Ethan Brandler

Does the current definition of contrast-induced acute kidney injury reflect a true clinical entity?

OBJECTIVES Contrast-induced acute kidney injury (CI-AKI) is defined as either a 25% increase in or an absolute elevation in serum creatinine (SCr) of 0.5 mg/dL, 48 to 72 hours after parenteral contrast exposure. The objective of this study was to compare the incidence and complications of AKI between patients exposed and those unexposed to intravenous (IV) contrast. METHODS This was a retrospective cohort study using the electronic medical record of adult patients (>18 years) with and without contrast-enhanced abdominal or chest computed tomography (CT) between May 2008 and April 2009. Inclusion criteria were emergency department (ED) patients with normal renal function who received either a contrast-enhanced abdominal or a contrast-enhanced chest CT, compared to those unexposed to IV contrast, with a repeat SCr within 48 to 72 hours. Exclusion criteria were contrast exposure within 7 days before the index visit. CI-AKI in the contrast-exposed group and AKI in the contrast-unexposed group were defined by the same changes in SCr 48 to 72 hours after contrast or ED admission. Data were described by proportions or medians with 95% confidence intervals (CIs) or interquartile ranges (IQR; 25% to 75%). Group comparisons were by Mann-Whitney U or Fishers exact test (α = 0.05, two tails). RESULTS The contrast-exposed (n = 773) and contrast-unexposed (n = 2,956) patients were evenly matched for initial demographic, renal, and metabolic parameters. The incidence of CI-AKI/AKI was significantly higher for the patients unexposed versus exposed to contrast (8.96% vs. 5.69%, p = 0.003). There was no significant difference in mortality rates between contrast-exposed and unexposed patients (9.09% vs. 6.79%, p = 0.533). CONCLUSIONS The definition of CI-AKI for ED patients with normal renal function may not represent a true clinical entity and the definition warrants revision.

Does the early administration of beta-blockers improve the in-hospital mortality rate of patients admitted with acute coronary syndrome?

OBJECTIVES Beta-blockade is currently recommended in the early management of patients with acute coronary syndromes (ACS). This was a systematic review of the medical literature to determine if early beta-blockade improves the outcome of patients with ACS. METHODS The authors searched the PubMed and EMBASE databases for randomized controlled trials from 1965 through May 2009 using a search strategy derived from the following PICO formulation of our clinical question: Patients included adults (18+ years) with an acute or suspected myocardial infarction (MI) within 24 hours of onset of chest pain. Intervention included intravenous or oral beta-blockers administered within 8 hours of presentation. The comparator included standard medical therapy with or without placebo versus early beta-blocker administration. The outcome was the risk of in-hospital death in the intervention groups versus the comparator groups. The methodologic quality of the studies was assessed. Qualitative methods were used to summarize the study results. In-hospital mortality rates were compared using a forest plot of relative risk (RR; 95% confidence interval [CI]) between beta-blockers and controls. Statistical analysis was done with Review Manager V5.0. RESULTS Eighteen articles (total N = 72,249) met the inclusion/exclusion criteria. For in-hospital mortality, RR = 0.95 (95% CI, 0.90-1.01). In the largest of these studies (n = 45,852), a significantly higher rate (p < 0.0001) of cardiogenic shock was observed in the beta-blocker (5.0%) versus control group (3.9%). CONCLUSIONS This systematic review failed to demonstrate a convincing in-hospital mortality benefit for using beta-blockers early in the course of patients with an acute or suspected MI.

Factors related to the sensitivity of emergency medical service impression of stroke.

Abstract Objectives. To examine factors related to sensitivity of emergency medical services (EMS) stroke impression. Methods. We reviewed ambulance and hospital records of all patients transported to Long Island College Hospital between January 1, 2009 and January 1, 2011 by the hospital-based EMS with a discharge diagnosis of stroke or a confounding diagnosis, and compared EMS impression to hospital discharge diagnosis. We examined relationships between EMS diagnostic sensitivity and age, gender, ethnicity, NIH Stroke Scale (NIHSS), motor signs, aphasia, neglect, lesion side, circulation, stroke type, EMS provider level, and documented Cincinnati Pre-hospital Stroke Scale (CPSS) with contingency analysis and logistic regression. Results. Stroke was validated in 18% (56/310) of patients and 50% (28/56) of these were missed by EMS. EMS diagnostic sensitivity was 50% (95% CI: 36–64%), and was related to NIHSS quartile (p = 0.014), with higher sensitivities in 2nd (69%; 95% CI: 44–86%) and 3rd (75%; 95% CI: 47–91%) vs. 1st (20%; 95% CI: 7–45%) and 4th (45%; 95% CI: 21–72%) quartiles, motor signs (62 vs. 14%, p = 0.002), and documented CPSS (84 vs. 32%, p = 0.0002). EMS impression was independently related to NIHSS quartile (1st vs. 2nd adjusted OR = 9.61, 1.13–122.03, p = 0.038) and CPSS (adjusted OR = 12.58, 2.22–111.06, p = 0.003). Conclusion. Stroke was missed more frequently when CPSS was not documented, in patients without motor signs, and in patients with moderate–severe stroke. The sensitivity of prehospital screening for patients with moderate–severe stroke might be improved by including additional non-motor signs and by stressing indications for when screens should be performed.

Emergency medical services in India: the present and future.

India is the second most populous country in the world. Currently, India does not have a centralized body which provides guidelines for training and operation of Emergency Medical Services (EMS). Emergency Medical Services are fragmented and not accessible throughout the country. Most people do not know the number to call in case of an emergency; services such as Dial 108/102/1298 Ambulances, Centralized Accident and Trauma Service (CATS), and private ambulance models exist with wide variability in their dispatch and transport capabilities. Variability also exists in EMS education standards with the recent establishment of courses like Emergency Medical Technician-Basic/Advanced, Paramedic, Prehospital Trauma Technician, Diploma Trauma Technician, and Postgraduate Diploma in EMS. This report highlights recommendations that have been put forth to help optimize the Indian prehospital emergency care system, including regionalization of EMS, better training opportunities, budgetary provisions, and improving awareness among the general community. The importance of public and private partnerships in implementing an organized prehospital care system in India discussed in the report may be a reasonable solution for improved EMS in other developing countries.

A review and meta-analysis of studies on the effect and timing of β-blocker administration in patients with ST-segment elevation myocardial infarction.

Abstract The utility of β-blockers during an evolving ST-segment elevation myocardial infarction (STEMI) has substantial theoretic physiological backing. This coupled with early successes using β-blockers in STEMI promulgated multiple guidelines expanding the use of this class of medication to all patients with acute coronary syndromes. However, recent studies have questioned the utility of β-blockers in the emergency department in these patients. The purpose of this article is to review the evidence behind the use of β-blockers in the emergency department for STEMI patients.

Using a joint triage model for multi-hospital response to a mass casualty incident in New York city.

This paper defines a specific plan which allows two separate institutions, with different capabilities, to function as a single receiving entity in the event of a mass casualty incident. The street between the two institutions will be closed to traffic and a two-phase process initiated. Arriving ambulances will first be quickly screened to expedite the most critical patients followed by formal triage and directing patients to one of the two facilities. Preparation for this plan requires prior coordination between local authorities and the administrations of both institutions. This plan can serve as a general model for disaster preparedness when two or more institutions with different capabilities are located in close proximity.

Immediate β-Blockade in Patients With Myocardial Infarctions: Is There Evidence of Benefit?

STUDY OBJECTIVE The American Heart Association recommends the initiation of β-blockade to all patients with an ST-segment elevation myocardial infarction (STEMI) without contraindications to β-blocking agents. The present study seeks to systematically review the medical literature to determine the efficacy of treating STEMI patients with a β-blocker within the first 24 hours. METHODS We searched databases for articles through MEDLINE with the PubMed interface and from 1966 through May 2009 and EMBASE from 1980 to August 2009 with the Ovid Technologies interface, using a search strategy derived from the following PICO (Patient-Intervention-Comparator-Outcome) clinical question: In patients presenting with STEMI (P), does immediate treatment with β-blockers (I) followed by standardized care beginning on day 2 or 3 compared with placebo or no treatment followed by standardized care on day 2 or 3 (C) reduce the risk of death, reinfarction, or cardiogenic shock (O)? The methodological quality of the studies was assessed. RESULTS From more than 2,000 references identified in the search, only a single randomized trial met the inclusion criteria. There were no statistically significant differences in mortality; the relative risk for the combined endpoint (mortality and reinfarction) was 0.67 (95% confidence interval 0.44 to 1.03) at 6 days and 0.74 (95% confidence interval 0.53 to 1.06) at 6 weeks. Outcomes for cardiogenic shock were not reported. CONCLUSION Evidence from a single randomized trial failed to demonstrate a reduction in mortality or reinfarction with administration of β-blocker within the first 24 hours after STEMI.

Needle Aspiration of Spontaneous Pneumothorax

A 25-year-old man with a medical history of mild intermittent asthma and daily tobacco use presented to the emergency department with 6 hours of sudden-onset dyspnea and rightsided pleuritic chest pain. He had no fevers, chills, cough, or recent trauma. He was in no respiratory distress and was alert and oriented to person, place, and time. His vital signs were temperature 98.2 F, heart rate 56 beats ⁄min, respiratory rate 18 breaths ⁄min, blood pressure 112 ⁄ 71 mm Hg, and oxygen saturation 99% while breathing room air. Upright end-expiratory chest radiography demonstrated a small right-sided pneumothorax (Figure 1). Noncontrast computed tomography (CT) demonstrated a moderate right-sided pneumothorax and multiple small peripheral blebs (Figure 2). Given the patient’s underlying structural lung disease evident on CT, a tube thoracostomy was planned. The patient, however, requested that an attempt at needle aspiration be performed. Before the procedure, the emergency physician performed a bedside lung ultrasound using a 10–5 MHz linear array transducer (SonoSite MTurbo, Bothell, WA). Examination of the right anterior chest wall demonstrated absent pleural sliding (Video Clip S1). After written informed consent was obtained, the patient underwent aspiration of the right-sided pneumothorax using a single-lumen catheter with a three-way stopcock and syringe (Video Clip S2). During the procedure, a repeat ultrasound examination demonstrated partial resolution of the pneumothorax, with visualization of the ‘‘lung point’’ sign (Video Clip S3); pleural sliding was visualized along one side of an interspace, with absent pleural sliding on the other side of the same interspace (representing the border of the pneumothorax). After repositioning of the catheter and aspiration of an additional 100 mL of air, ultrasound examination confirmed return of normal pleural sliding anteriorly (Video Clip S4). Chest radiography was performed 30 minutes after completion of the procedure and demonstrated reaccumulation of the pneumothorax. A tube thoracostomy was performed, resulting in complete resolution of the pneumothorax, and the patient was admitted to the cardiothoracic surgery service for further management. While primary spontaneous pneumothorax can be managed with needle aspiration or tube thoracostomy with similar results, patients with secondary spontaneous pneumothoraces (pneumothoraces associated with underlying structural lung disease) are more likely to have persistent air leaks that result in recurrence of their

The cost-efficiency of mobile stroke units Where the rubber meets the road

In the vanguard of acute stroke care, the pursuit of ultra-early diagnosis and treatment has led to the development of mobile stroke units (MSU): ambulances equipped with portable CT imaging and other advanced diagnostics capable of administering IV thrombolysis in the prehospital setting. Since initial reports of feasibility, separate research groups have demonstrated the effectiveness of MSUs to facilitate earlier treatment with IV tissue plasminogen activator (tPA).1,2

Early dual antiplatelet therapy in stroke: should we take the CHANCE?

Patients with stroke or transient ischemic attack (TIA) are at high risk of recurrence. Approximately 10-20% of patients have another stroke within the first 3 months of the index event. Recurrent strokes can be disabling for patients, sometimes resulting in fatal consequences. The role of aspirin has been established in the acute phase as well as in secondary prevention of future ischemic strokes. Clopidogrel, an inhibitor of adenosine diphosphate (ADP) receptor on platelet cell membranes, along with aspirin synergistically prevents platelet activation and further ischemic events. Beneficial effects of this dual antiplatelet therapy (DAPT) in acute coronary syndromes have been established, without any increased risk of bleeding, however the same cannot be said about secondary prevention of stroke. In the acute phase, ischemic strokes are prone to hemorrhagic transformation spontaneously and a recently published meta-analysis of five randomized controlled trials, which enrolled patients with acute ischemic stroke or TIA, reported an increase in major bleeding with the combination therapy.