Samuel M. Keim

Sepsis Bundles and Compliance With Clinical Guidelines

Realizing the vast medical benefits of validated protocols, recommendations and practice guidelines requires acceptance and implementation by frontline care providers. Knowledge translation is the science of accelerating the transfer of knowledge to practice by understanding and creatively addressing the barriers that prevent adoption of new professional standards. In an attempt to improve patient care and reduce mortality, the Surviving Sepsis Campaign and The Institute for Healthcare Improvement created the resuscitation and management bundles for patients with severe sepsis and septic shock. These bundles have been accepted as best practice by many clinicians since multiple clinical trials have produced similar positive results when they were implemented. However, transferring these research outcomes-based guidelines to the clinical practice arena has been associated with poor compliance due to important barriers to implementation. Delays in the adoption of sepsis bundles are not surprising since the time from validation to implementation of a new clinical practice is typically 17 years. Using sepsis bundles as a model, this article explores why guidelines are important, examines physician adherence to protocols, and reviews the literature on strategies to improve clinical compliance and enhance knowledge translation.

A Systematic Review and Meta-Analysis of Diagnostic Performance of MRI for Evaluation of Acute Appendicitis

OBJECTIVE A meta-analysis was performed to determine the accuracy of MRI in the diagnosis of acute appendicitis in the general population and in subsets of pregnant patients and children. MATERIALS AND METHODS A systematic search of the PubMed and EMBASE databases for articles published through the end of October 2014 was performed to identify studies that used MRI to evaluate patients suspected of having acute appendicitis. Pooled data for sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS A total of 30 studies that comprised 2665 patients were reviewed. The sensitivity and specificity of MRI for the diagnosis of acute appendicitis are 96% (95% CI, 95-97%) and 96% (95% CI, 95-97%), respectively. In a subgroup of studies that focused solely on pregnant patients, the sensitivity and specificity of MRI were 94% (95% CI, 87-98%) and 97% (95% CI, 96-98%), respectively, whereas in studies that focused on children, sensitivity and specificity were found to be 96% (95% CI, 95-97%) and 96% (95% CI, 94-98%), respectively. CONCLUSION MRI has a high accuracy for the diagnosis of acute appendicitis, for a wide range of patients, and may be acceptable for use as a first-line diagnostic test.

ROCURONIUM VS. SUCCINYLCHOLINE IN THE EMERGENCY DEPARTMENT: A CRITICAL APPRAISAL

BACKGROUND Two methods of paralysis are available for rapid sequence intubation (RSI) in the emergency department (ED): depolarizing agents such as succinylcholine, and non-depolarizing drugs such as rocuronium. Rocuronium is a useful alternative when succinylcholine is contraindicated. Contraindications to succinylcholine include allergy, history of malignant hyperthermia, denervation syndromes, and patients who are 24-48 h post burn or crush injury. Non-depolarizing drugs have the advantage of causing less pain due to post-paralysis myalgias. CLINICAL QUESTION Can rocuronium replace succinylcholine as the paralytic of choice for RSI in the ED? EVIDENCE REVIEW Four relevant studies were selected from an evidence search and a structured review performed. RESULTS For the outcomes of clinically acceptable intubation conditions and time to onset, the two agents were not statistically significantly different. Succinylcholine seems to produce conditions that have higher satisfaction scores. CONCLUSION Succinylcholine remains the drug of choice for ED RSI unless there is a contraindication to its usage.

THROMBOLYTIC THERAPY FOR ACUTE ISCHEMIC STROKE BEYOND THREE HOURS

BACKGROUND Ischemic cerebrovascular accidents remain a leading cause of morbidity and mortality. Thrombolytic therapy for acute ischemic stroke within 3h of symptom onset of highly select patients has been advocated by some groups since 1995, but trials have yielded inconsistent outcomes. One recent trial demonstrated significant improvement when the therapeutic window was extended to 4.5h. CLINICAL QUESTION Does the intravenous systemic administration of tPA within 4.5h to select patients with acute ischemic stroke improve functional outcomes? EVIDENCE REVIEW All randomized controlled trials enrolling patients within 4.5h were identified, in addition to a meta-analysis of these trial data. RESULTS The National Institute of Neurological Disorders and Stroke (NINDS) and European Cooperative Acute Stroke Study III (ECASS III) clinical trials demonstrated significantly improved outcomes at 3 months, with increased rates of intracranial hemorrhage, whereas ECASS II and the Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS) study showed increased hemorrhagic complications without improving outcomes. Meta-analysis of trial data from all ECASS trials, NINDS, and ATLANTIS suggest that thrombolysis within 4.5h improves functional outcomes. CONCLUSION Ischemic stroke tPA treatment within 4.5h seems to improve functional outcomes and increases symptomatic intracranial hemorrhage rates without significantly increasing mortality.

Etomidate for Procedural Sedation in the Emergency Department

Study Objective. To review our experience with etomidate in nonintubated patients in the emergency department.

The 2011 model of the clinical practice of emergency medicine

The 2011 Model of the Clinical Practice of Emergency Medicine.

United States-Mexico Border Crossing: Experiences and Risk Perceptions of Undocumented Male Immigrants

Undocumented immigrants crossing the US–Mexico border face many hazards as they attempt to enter the United States, including heat and cold injury, dehydration, and wild animal encounters. In the Tucson sector of the US–Mexico border, there are over 100 deaths a year from heat-related injuries alone. Public awareness campaigns have been undertaken to disseminate information on the dangers inherent in crossing. Little is known, however, about the ways in which undocumented immigrants actually receive information regarding the risks of crossing the border, how such information impacts their preparation for crossing or how the journey itself effects their motivation to cross again in the future. A qualitative descriptive method was used to describe and analyze information from adult males who had attempted to illegally cross the US–Mexico Border and had recently been returned to Mexico. Semi-structured interviews were conducted, and responses were classified into several broad themes. Interviews were conducted and analyzed iteratively until thematic saturation was achieved. The responses validated the established risks as being commonplace. A total of eight (8) male undocumented immigrants participated in the interviews. Individuals sought information prior to crossing from the media, their families and friends, and acquaintances in border towns. They did not appear to value any particular information source over any other. New areas of risk were identified, such as traveling with others who might have new or existing medical problems. There was also substantial concern for the family unit as both a source of inspiration and motivation. The family emerged as an additional at-risk unit due to the destabilization and financial strain of having one of its members leave to attempt to immigrate to the US for work. While many planned to cross again, the majority of the men in our sample had no intention of seeking permanent residence in the US, instead planning to work and then return to their families in Mexico. This preliminary study found that individuals crossing the US–Mexico border appear willing to put themselves and their families at substantial perceived risk in order to seek economic opportunity. Future public awareness campaigns may choose to shift focus solely from the individual risk of the crossing to the additional risks to family and community.

Intravenous Opioids for Severe Acute Pain in the Emergency Department

Objective: To review clinical trials of intravenous opioids for severe acute pain in the emergency department (ED) and to provide an approach for optimization of therapy. Data Sources: Articles were identified through a search of Ovid/MEDLINE (1948-August 2010), PubMed (1950-August 2010), Cochrane Central Register of Controlled Trials (1991-August 2010), and Google Scholar (1900-August 2010). The search terms used were pain, opioid, and emergency department. Study Selection and Data Extraction: The search was limited by age group to adults and by publication type to comparative studies. Studies comparing routes of administration other than intravenous or using non-opioid comparators were not included. Bibliographies of all retrieved articles were reviewed to obtain additional articles. The focus of the search was to identify original research that compared intravenous opioids used for treatment of severe acute pain for adults in the ED. Data Synthesis: At equipotent doses, randomized controlled trials have not shown clinically significant differences in analgesic response or adverse effects between opioids studied. Single opioid doses less than 0.1 mg/kg of intravenous morphine, 0.015 mg/kg of intravenous hydromorphone, or 1 μg/kg of intravenous fentanyl are likely to be inadequate for severe, acute pain and the need for additional doses should be anticipated. In none of the randomized controlled trials did patients develop respiratory depression requiring the use of naloxone. Future trials could investigate the safety and efficacy of higher doses of opioids. Implementation of nurse-initiated and patient-driven pain management protocols for opioids in the ED has shown improvements in timely provision of appropriate analgesics and has resulted in better pain reduction. Conclusions: Currently, intravenous administration of opioids for severe acute pain in the ED appears to be inadequate. Opioid doses in the ED should be high enough to provide adequate analgesia without additional risk to the patient. EDs could implement institution-specific protocols to standardize the management of pain.

BRAIN NATRIURETIC PEPTIDE IN THE EVALUATION OF EMERGENCY DEPARTMENT DYSPNEA: IS THERE A ROLE?

BACKGROUND Acute decompensated congestive heart failure (ADCHF) is a common etiology of dyspnea in emergency department (ED) patients. Delayed diagnosis of ADCHF increases morbidity and mortality. Two cardiac biomarkers, N-terminal-pro brain natriuretic peptide (NT-proBNP) and brain natriuretic peptide (BNP) have demonstrated excellent sensitivity in diagnostic accuracy studies, but the clinical impact on patient-oriented outcomes of these tests remains in question. CLINICAL QUESTION Does emergency physician awareness of BNP or NT-proBNP level improve ADCHF patient-important outcomes including ED length of stay, hospital length of stay, cardiovascular mortality, or overall health care costs? EVIDENCE REVIEW Five trials have randomized clinicians to either knowledge of or no knowledge of ADCHF biomarker levels in ED patients with dyspnea and some suspicion for heart failure. In assessing patient-oriented outcomes such as length-of-stay, return visits, and overall health care costs, the randomized controlled trials fail to provide evidence of unequivocal benefit to patients, clinicians, or society. CONCLUSION Clinician awareness of BNP or NT-proBNP levels in ED dyspnea patients does not necessarily improve outcomes. Future ADCHF biomarker trials must assess patient-oriented outcomes in conjunction with validated risk-stratification instruments.

Estimating the incidence of heat-related deaths among immigrants in Pima County, Arizona

Widespread media reports have described an increase in heat-related deaths among illegal immigrant border crossers in Southern Arizona in recent years. We conducted a retrospective case series review of heat-related deaths reported by a large border county medical examiner office in an attempt to estimate the occurrence and distribution of these deaths for the years 1998–2003. United States Border Patrol apprehension data were also collected and used in the analysis to estimate the size of the population of border crossers. An increase in the total heat-related deaths has occurred since 1999 in Pima County Arizona and has continued to date. Precise estimates of rates are not possible but appear to have increased as well. Implications for understanding the complexity of researching this public health issue including the definition of cases and population at risk are discussed.