From the publishers of The New England Journal of Medicine July 2008 Vol. 12 No. 7

Hypothermia for ated with an unfavorable outcome, the Hutchison JS et al. Hypothermia therapy odds ratio for an unfavorable outcome after traumatic brain injury in children. Traumatic Brain Injury with hypothermia therapy was 2.33. N Engl J Med 2008 Jun 5; 358:2447. in Children Death rates did not differ significantly nimal models and small studies in between the hypothermia and normo- A children and adults suggest a bene- thermia groups (21% vs. 12%). No evi- Corticosteroids Don’t fit for hypothermia therapy in the treat- dence of benefit was detected in analy- Reduce Mortality ment of severe traumatic brain injury. ses of any of eight subgroups, including patients who were treated early. in Children with In an international trial, researchers Bacterial Meningitis compared outcomes in children (age Comment: range, 1–17 years) with traumatic brain This study was remarkably ambitious, dministration of adjuvant cortico- injury who were randomized to either given the low incidence of eligible pa- A steroids mitigates hearing loss in hypothermia therapy for 24 hours tients (5 per month in 17 pediatric children with Haemophilus influenzae (32.0°C–33.0°C) or normothermia hospitals in 3 countries). Despite this type B (Hib) meningitis. However, the (36.5°C–37.5°C). Eligible patients had obstacle, the researchers showed un- introduction of vaccines against Hib in Glasgow Coma Scale scores 8 at the ≤ equivocally that hypothermia has no 1985 and against Streptococcus pneu- scene or in the emergency department, benefit. Although a greater proportion moniae in 2000 has greatly altered the needed mechanical ventilation, and had of children who were treated with hypo- landscape of bacterial meningitis in chil- evidence of acute brain injury on com- thermia than with normothermia had dren. In a retrospective cohort study, puted tomography scan. Patients who poor outcomes, the difference did not these authors reviewed data from 27 U.S. were screened more than 8 hours after reach statistical significance. Induced children’s hospitals to determine the injury or who had refractory shock, hypothermia is not indicated for treat- effect of adjuvant corticosteroid therapy nonaccidental injury, high cervical spinal ment of acute severe brain injury in on mortality and time to discharge in cord injury, or acute isolated epidural children. children younger than 18 years who were hematoma were excluded. — J. Stephen Bohan, MD, MS, discharged with a diagnosis of bacterial Of 1441 patients who were screened FACP, FACEP meningitis from 2001 through 2006. during more than 5 years, 327 met eli- gibility criteria and 225 were enrolled. Complete data were available for 91% TABLE OF CONTENTS of enrolled patients. Mean time from Hypothermia for Early Repolarization: injury to initiation of cooling was 6.3 Traumatic Brain Injury Maybe Not So Benign After All ...... 53 hours, and mean time to achieve hypo- in Children ...... 49 Femoral Vein Central Lines thermia was 3.9 hours. Significantly more Corticosteroids Don’t Reduce in Children: Another Case patients in the hypothermia group than Mortality in Children for Ultrasound Guidance ...... 53 in the normothermia group received vaso- with Bacterial Meningitis ...... 49 Death After Syncope: active drugs for hypotension, usually Facilitated PCI Is Not Effective Can We Predict It? ...... 53 during the rewarming period. for STEMI ...... 50 Noninvasive Ventilation Is Safe The proportion of patients with an Oral Prednisolone for Gout ...... 51 and Effective in Acute Decompensated Heart Failure ...... 54 unfavorable outcome — defined as severe Oligoanalgesia in Women with Abdominal Pain ...... 51 Needle-Free Powder Lidocaine Delivery ...54 disability, death, or persistent vegetative Bivalirudin During PCI in Patients Risk Factors for Delay state at 6 months (the primary outcome) with Acute MI ...... 51 in Presentation of AMI Patients ...... 54 — was 31% in the hypothermia group Clinical Performance Minimal Risk for Shock to Rescuers and 22% in the normothermia group, a of the Airway Scope ...... 52 During Biphasic Defibrillation ...... 55 nonsignificant difference (relative risk C-Spine Movement: Macintosh vs. Patient Outcomes for an unfavorable outcome with hypo- Airtraq Laryngoscope ...... 52 from Intensivist Care ...... 55 thermia therapy, 1.41). After adjustment Management of Cocaine-Associated Don’t Delay Transfer of Trauma for clinical factors that might be associ- Chest Pain and MI ...... 52 Patients to Specialty Centers ...... 56

Journal Watch (and its design) is a registered trademark of the Massachusetts Medical Society. An editorially independent literature-surveillance newsletter summarizing articles from major medical journals. ©2008 Massachusetts Medical Society. All rights reserved. Disclosure information about our authors can be found at http://emergency-medicine.jwatch.org/misc/board_disclosures.dtl Page 50 JOURNAL WATCH EMERGENCY MEDICINE Volume 12 Number 7

Among 2780 children (median age, myocardial infarction (STEMI; excluding EDITOR-IN-CHIEF Ron M. Walls, MD, FRCPC, FACEP, FAAEM 9 months), 8.9% received adjuvant corti- localized inferior infarction) and who Chair, Department of Emergency Medicine, costeroid therapy. The leading bacterial presented within 6 hours of symptom Brigham and Women’s Hospital, Boston; pathogens were S. pneumoniae (18%) onset received one of three treatments: Professor of Medicine, Harvard Medical School and Neisseria meningitidis (10%). The (1) half-dose reteplase plus abciximab DEPUTY EDITOR overall mortality rate was 4.2%. Adjuvant started immediately after randomization John A. Marx, MD, FAAEM, FACEP Chair and Chief, Department of Emergency corticosteroid therapy did not reduce (combination-facilitated PCI), (2) abcix- Medicine, Carolinas Medical Center, Charlotte; mortality or time to discharge in any age imab alone started immediately after Adjunct Professor of Emergency Medicine, groups (<1 year, 1–5 years, or >5 years) randomization (abciximab-facilitated University of North Carolina, Chapel Hill or in subgroups of children with pneumo- PCI), or (3) abciximab started in the EXECUTIVE EDITOR coccal or meningococcal meningitis. catheterization lab (primary PCI). A Cara Adler, MS Massachusetts Medical Society Corticosteroid use increased signifi- larger enrollment had been planned, but ASSOCIATE EDITORS cantly from 5.8% in 2001 to 12.2% in 2006. the study was stopped early for a variety of reasons, including cost overruns and Aaron E. Bair, MD, MSc, FAAEM, FACEP Comment: Associate Professor, Department of Emergency concern in the U.S. that the random- Medicine, University of California, The putative beneficial effects of cortico- Davis Medical Center ization process interfered with the steroids are ascribed to reduction of 90-minute door-to-balloon goal. Jill M. Baren, MD, MBE, FACEP, FAAP the inflammatory response caused by Director, Pediatric Emergency Medicine Education, The combination-facilitated PCI Department of Emergency Medicine, antimicrobial-induced bacteriolysis. But group had significantly greater ST- Hospital of the University of Pennsylvania; corticosteroids also have adverse effects, segment resolution 60 to 90 minutes after Associate Professor of Emergency Medicine and including the possibility of decreasing Pediatrics, University of Pennsylvania School of initiation of treatment and significantly Medicine; Associate, University of Pennsylvania delivery of antibiotics into cerebrospinal lower creatine kinase (CK) levels (meas- Center for Bioethics, Philadelphia fluid. The findings of a Cochrane review ured during the first 24 hours after en- Diane M. Birnbaumer, MD, FACEP and a large clinical study both published rollment) than the other two groups. Associate Residency Director, Department of in 2007 are in line with those of this Emergency Medicine, Harbor-UCLA Medical Center, However, the incidence of the primary Torrance; Professor of Clinical Medicine, UCLA analysis. However, guidelines from the endpoint (a composite of all-cause J. Stephen Bohan, MD, MS, FACP, FACEP American Academy of Pediatrics state death, ventricular fibrillation occurring Executive Vice Chairman, Department of Emergency that “adjunctive therapy with dexameth- more than 48 hours after randomiza- Medicine, Brigham and Women’s Hospital, Boston; asone may be considered after weighing Assistant Professor, Harvard Medical School tion, cardiogenic shock, and congestive the potential benefits and risks.” Such Kristi L. Koenig, MD, FACEP heart failure within 90 days) was about Director of Public Health Preparedness; equivocal recommendations and the fail- 10% in all three groups. The incidence Professor of Clinical Emergency Medicine, ure of practitioners to appreciate the of major bleeding was significantly Department of Emergency Medicine, effect of vaccination have been partly University of California, Irvine higher in the combination-facilitated responsible for the increase in use of PCI group than in the primary PCI Tiffany M. Osborn, MD corticosteroids for children with menin- Assistant Professor, Department of Emergency group. The authors and an editorialist Medicine and Surgical/Trauma Critical Care, gitis. The findings of this study, the note that for patients undergoing PCI, University of Virginia, Charlottesville largest multicenter study of its kind, reducing door-to-PCI time might be Richard D. Zane, MD, FAAEM suggest that healthcare providers should more important than use of adjunctive Vice Chairman, Department of Emergency not administer adjuvant corticosteroids Medicine, Brigham and Women’s Hospital, Boston; pharmacologic therapy. Assistant Professor, Harvard Medical School to a child with suspected bacterial men- Comment: CONTRIBUTING EDITOR ingitis unless the child has not received Peter Rosen, MD, FACEP Hib vaccination. The finding that early ST-segment res- Department of Emergency Medicine, Beth Israel — John A. Marx, MD, FAAEM, FACEP olution and infarct-size reduction (as Deaconess Medical Center, Boston; measured by CK level) did not improve Senior Lecturer, Harvard Medical School Mongelluzzo J et al. Corticosteroids and mortality in children with bacterial outcome sounds a cautionary note for MASSACHUSETTS MEDICAL SOCIETY Joe Elia, Lyn Whinston-Perry, Staff Editors meningitis. JAMA 2008 May 7; 299:2048. us when interpreting studies that use Terri Autieri, Copy Editor surrogate measures as opposed to hard Sioux Waks, Layout outcomes. The message is to get STEMI Christopher R. Lynch, patients as rapidly as possible to the Vice President for Publishing Facilitated PCI Is Alberta L. Fitzpatrick, Publisher catheterization lab and not to bother Matthew O’Rourke, Director, Not Effective for STEMI with potentially time-wasting “adjunc- Editorial Operations and Development bciximab often is initiated immedi- tive” drug therapy. Art Wilschek, Christine Miller, Lew Wetzel, — Advertising Sales A ately before percutaneous coronary J. Stephen Bohan, MD, MS, William Paige, Publishing Services intervention (PCI) and then continued FACP, FACEP Bette Clancy, Customer Service for about 12 hours afterward. These Ellis SG et al. Facilitated PCI in patients Published 12 times a year. Subscription rates — U.S.: $129 per year; Residents/Students/Nurses/PAs: $69; Institutions: $179; authors hypothesized that initiating with ST-elevation myocardial infarction. individual print only: $99. Canada: C$163.81 per year; Residents/ abciximab earlier and in combination N Engl J Med 2008 May 22; 358:2205. Students/Nurses/PAs: C$96.19; Institutions: C$252.38. Intl: US$149 per year; Physicians in Training/Nurses/PAs: US$75; Institutions: with a lytic agent would improve out- Leopold JA. Does thrombolytic therapy US$216. Prices do not include GST, HST, or VAT. Remittance comes. In a pharmaceutical company– facilitate or foil primary PCI? N Engl to Journal Watch Emergency Medicine, P.O. Box 9085, J Med 2008 May 22; 358:2277. Waltham, MA 02454-9085 or call 1-800-843-6356. E-mail inquiries sponsored, randomized, double-blind or comments via the Contact Us page at www.jwatch.org. international study, 2452 patients older Information on our conflict-of-interest policy can be found at www.jwatch.org/misc/conflict.dtl than 60 who had ST-segment-elevation July 2008 JOURNAL WATCH EMERGENCY MEDICINE Page 51 Oral Prednisolone for Gout sented to a single emergency department ceived either bivalirudin or unfraction- with non–pregnancy-related abdominal ated heparin plus a GP IIb/IIIa inhibitor. urrent standard treatments for gout pain of less than 72 hours’ duration. All patients underwent coronary angi- C (colchicine and nonsteroidal anti- Among 981 patients (65% women), ography and received aspirin and clo- inflammatory drugs [NSAIDs]) can have men and women had similar mean pain pidogrel at enrollment and for at least significant side effects. In a randomized, scores. Women were less likely than men 6 months thereafter. double-blind trial, Dutch researchers com- to receive any analgesia (60% vs. 67%) At 30 days, the bivalirudin group had pared treatment with either oral na- and opioids (45% vs. 56%). In logistic significantly lower rates of adverse proxen (500 mg twice daily) or oral regression analysis that controlled for clinical events (major bleeding, death, prednisolone (35 mg once daily plus pla- potential confounders, women were 13% reinfarction, stroke, and target-vessel cebo) for 5 days in 120 patients (89% men; to 25% less likely than men to receive revascularization for ischemia) than the mean age, 57) with microscopically con- opioids, although the two sexes were heparin group (9.2% vs. 12.1%), includ- firmed monoarticular gout. Patients were equally likely to receive nonopioid anal- ing death from cardiac causes (1.8% vs. referred by their family doctors within gesic medications. Among patients who 2.9%) and death from all causes (2.1% 24 hours of initial presentation. Another received analgesia, women waited a vs. 3.1%). The authors attributed the 96 patients with microscopically con- median of 16 minutes longer than men lower death rates in the bivalirudin firmed gout were excluded, mostly be- to receive medication (median time to group to significantly lower rates of cause of current use of NSAIDs or colchi- administration, 65 vs. 49 minutes). thrombocytopenia (1.3% vs. 3.8%) cine or contraindications to NSAIDs. and major bleeding (4.9% vs. 8.3%). Comment: At 90 hours, mean reductions in pain An editorialist notes that bleeding (assessed on a validated visual analog Use of a nonopioid medication might be might be a marker, as opposed to a scale [VAS]) were similar in the naproxen appropriate in women with pain related mediator, of mortality risk; thus, the and prednisolone groups. Mean reduc- to a gynecologic condition, but the time mechanism by which bivalirudin im- tions in disability related to use of the delay to administration in this study is proves outcomes is not clear. The edito- affected joint and related to walking cause for concern. Although more time rialist concludes that the new evidence (both scored on unvalidated VASs) also might be required to assess abdominal from this study indicates that bivaliru- were similar in the two groups. Adverse pain in women because of the need to din “warrants consideration among the effects during treatment were minor and perform a pelvic examination, this should alternatives for ancillary antithrombotic comparable between groups. At 3-week not delay the administration of pain therapy” in patients with STEMI who follow-up, all patients reported com- medication. Prompt administration of undergo primary PCI. plete resolution of pain and disability. analgesics to both women and men should be a treatment priority. Comment: Comment: — Diane M. Birnbaumer, MD, FACEP Ever since therapeutic phlebotomy A 5-day course of prednisolone is as Chen EH et al. Gender disparity in anal- and use of leeches passed into history, effective as traditional treatment with gesic treatment of emergency department the common wisdom has been the less an NSAID (in this case, naproxen) for patients with acute abdominal pain. bleeding the better. Thus, an editorialist acute gout. Prednisolone is both a sound Acad Emerg Med 2008 May; 15:414. correctly advises that bivalirudin “war- alternative for patients with an NSAID rants consideration among the alterna- contraindication and an alternative tives” for facilitated PCI. The FDA likely first-line therapy. Bivalirudin During PCI will agree with him that more-rigorous, — Kristi L. Koenig, MD, FACEP in Patients with Acute MI blinded study is needed before bivaliru- Janssens HJEM et al. Use of oral prednis- din alone can be approved as a replace- olone or naproxen for the treatment of ivalirudin alone has been shown to ment for heparin and GP IIb/IIIa in- gout arthritis: A double-blind, randomised be as effective as and safer than hibitors. However, less death and less equivalence trial. Lancet 2008 May 31; B heparin plus a glycoprotein (GP) IIb/ 371:1854. bleeding (even if they do not exist in a IIIa inhibitor for suppressing ischemia cause-and-effect relation) have innate Rainer TH and Graham CA. A significant in patients with unstable angina and step forward for gout. Lancet 2008 May 31; appeal. — J. Stephen Bohan, MD, MS, 371:1816. non–ST-segment-elevation myocardial FACP, FACEP infarction (NSTEMI) who undergo percutaneous coronary intervention (PCI; JW Cardiol Jan 2007, p.4, and Oligoanalgesia in Women N Engl J Med 2006; 355:2203). To assess with Abdominal Pain bivalirudin’s efficacy and safety in pa- tients with STEMI who undergo PCI, re- esearch shows that ethnic minorities searchers conducted a randomized, open- are less likely than other people to beta.jwatch.org R label, multicenter, international trial receive opioid analgesics for acutely pain- Participate in the next funded by the maker of bivalirudin. ful conditions. To determine whether a Some 3600 patients who presented generation of Journal Watch. sex disparity exists in the administration within 12 hours of symptom onset and of pain medication for acute abdominal who had ST-segment elevation 1 mm pain, these authors conducted a second- ≥ in two contiguous leads, new left bundle ary analysis of data from a prospective branch block, or true posterior MI re- cohort study in adult patients who pre- Page 52 JOURNAL WATCH EMERGENCY MEDICINE Volume 12 Number 7

Stone GW et al. Bivalirudin during pri- Dr. Bair teaches The Difficult Airway Course: Hirabayashi Y et al. A comparison of cervi- mary PCI in acute myocardial infarction. Emergency; and Journal Watch Emergency cal spine movement during laryngoscopy N Engl J Med 2008 May 22; 358:2218. Medicine Editor-in-Chief Dr. Walls is a teacher using the Airtraq® or Macintosh laryngo- Morrow DA. Antithrombotic therapy to and director of the course, which receives scopes. Anaesthesia 2008 Jun; 63:635. support primary PCI. N Engl J Med 2008 equipment support from manufacturers of May 22; 358:2280. airway devices, but not the manufacturer (Pentax) of the Airway Scope. Suzuki A et al. The Pentax-AWS® rigid Management of Cocaine- indirect video laryngoscope: Clinical Associated Chest Pain Clinical Performance assessment of performance in 320 cases. and MI of the Airway Scope Anaesthesia 2008 Jun; 63:641. he American Heart Association he Airway Scope is a rigid, indirect T (AHA) has published a review of T video laryngoscope that provides C-Spine Movement: recent literature and recommendations a non–line-of-sight view of the glottis for management of patients with cocaine- by way of a camera and a color screen. Macintosh vs. Airtraq associated chest pain and myocardial Previous small trials have suggested that Laryngoscope infarction. Cocaine use leads to in- the Airway Scope is easy to use and is as- creased cardiac demand and accelerated sociated with less upper cervical spine he Airtraq is a single-use, indirect laryngoscopic device with an im- atherosclerosis and coronary vaso- motion than the Macintosh laryngoscope T spasm. The AHA recommendations indi- ( JW Emerg Med Nov 2007, p. 85, and age transfer channel that transmits a view of the glottis without the need to cate that treatment of cocaine-associated Anaesthesia 2007; 62:1050). In the cur- myocardial ischemia differs in several rent study, the authors evaluated the per- align the oral, pharyngeal, and tracheal axes. Previous research suggests that important ways from treatment of non– formance of the Airway Scope in clinical cocaine-associated ischemia. anesthesia practice and compared glottic the Airtraq is easy to use ( JW Emerg • Aspirin and nitrates continue to be visualization between the Airway Scope Med Dec 2006, p. 94, and Anaesthesia strongly recommended as they are for and the Macintosh laryngoscope. 2006; 61:1093). The authors of this non–cocaine-associated acute coro- During a 1-year period, 320 adult pa- unsponsored study compared cervical nary syndrome (ACS), but β-blockers tients who were scheduled for elective spine (C-spine) motion during laryngos- (including agents with mixed surgery underwent laryngoscopy, first copy using the Airtraq and Macintosh α-adrenergic antagonist effects, such with the Macintosh laryngoscope and laryngoscopes. as labetolol) are considered contrain- then with the Airway Scope. All intuba- Twenty adult patients who required dicated, despite a relatively weak evi- tions were performed by anesthesiolo- routine intubation for elective gyneco- dence base. Theoretically, β-blockade gists skilled in both techniques. Com- logic surgery in the operating suite un- might induce or worsen hypertension pared with the Macintosh, the Airway derwent laryngoscopy with both the and vasospasm. Scope significantly improved the laryn- Airtraq and Macintosh devices, in ran- geal view: 46 patients with poor views dom order. Patients with a history of dif- • If cocaine intoxication is suspected, (Cormack-Lehane grade 3 or 4) with the ficult intubation or C-spine injury were benzodiazepines are recommended Macintosh had excellent views (grade 1 excluded. All laryngoscopies were per- as the primary treatment for anxiety, or 2) with the Airway Scope. All intuba- formed by a single anesthesiologist who tachycardia, and hypertension. was skilled in both techniques. Lateral tions with the Airway Scope were suc- • Calcium channel blockers are not radiographs were taken at baseline with cessful (96% on the first attempt and 4% recommended. Some evidence from the patient in a neutral position and dur- on the second). Mean time to intubation studies of patients with non–cocaine- ing laryngoscopy when the best view of with the Airway Scope was 20 seconds. associated ACS suggests that calcium the larynx was obtained. Two radiolo- The Intubation Difficulty Scale score channel blockers increase mortality gists reviewed the radiographs to meas- with the Airway Scope ranged from 0 rates when used as a first-line agent ure the degree of vertebral body dis- to 2 (a score >5 indicates moderate-to- for control of hypertension. major difficulty). The authors conclude placement. C-spine extension was • Early percutaneous coronary inter- that the Airway Scope is useful in routine significantly less with the Airtraq than vention is particularly preferred over practice and might confer advantages with the Macintosh: 29% less at the fibrinolysis in patients with cocaine- over the Macintosh laryngoscope in occiput–C4 segment and 44% less at associated MI because of increased cases involving difficult intubation. the C3–C4 segment. risk for intracranial hemorrhage after Comment: Comment: administration of fibrinolytic agents This study provides even more evidence How much C-spine movement is clini- in cocaine users. of the value of video laryngoscopy in cally significant still is not known. How- Comment: routine operating room practice. Video ever, with acute spine injury, any reduc- laryngoscopy clearly is superior to con- tion in movement is desirable. While we Early aggressive treatment continues to ventional laryngoscopy, and emergency await reports of experience with the be the mainstay of therapy for patients physicians should familiarize them- Airtraq in the emergency department, we with suspected ACS. However, treat- selves with this new technology. can add this study to the others that will ment for cocaine-associated ACS differs eventually help to put the Macintosh — Aaron E. Bair, MD, MSc, in several important ways from treat- laryngoscope out to pasture. FAAEM, FACEP ment for non–cocaine-associated ACS. — Aaron E. Bair, MD, MSc, Clarifying whether cocaine was recently FAAEM, FACEP July 2008 JOURNAL WATCH EMERGENCY MEDICINE Page 53 used is important before administering findings who are symptomatic (i.e., syn- nal jugular central venous lines is safer β-blockers. — Aaron E. Bair, MD, cope, palpitations, chest pain) require and more effective than using external MSc, FAAEM, FACEP close monitoring, with particular atten- landmarks alone. This study extends McCord J et al. Management of cocaine- tion to intermittent increases in J-point those findings to children, although associated chest pain and myocardial elevation. lines were not actually placed in the infarction: A scientific statement from the study subjects. The results suggest that Comment: American Heart Association Acute Cardiac the femoral artery overlies the femoral Care Committee of the Council on Clinical Although ventricular fibrillation is un- vein either partially or completely in up Cardiology. Circulation 2008 Apr 8; 117:1897. common in young people, this study to 12% of children younger than 9 and suggests that we make two important that ultrasound can determine this rela- changes in our approach to “benign” tion, thereby allowing the operator to Early Repolarization: early repolarization. First, an ECG that choose an approach that will avoid inad- Maybe Not So Benign shows early repolarization should not be vertent arterial puncture. considered as normal in patients who — Diane M. Birnbaumer, MD, FACEP After All have had syncope or symptoms of dys- Warkentine FH et al. The anatomic rela- xperimental evidence suggests that rhythmia. Second, patients undergoing tionship of femoral vein to femoral artery E early repolarization is associated electrocardiography in the emergency in euvolemic pediatric patients by ultra- with ventricular dysrhythmias, but no department for unrelated reasons who sonography: Implications for pediatric fem- clinical evidence is available. In a case- have findings of early repolarization oral central venous access. Acad Emerg Med 2008 May; 15:426. control study, researchers reviewed data abnormality should be told about the from 22 dysrhythmia centers in several symptoms of dysrhythmia and advised countries to evaluate the prevalence of to seek care if these symptoms should early repolarization and its association arise. — J. Stephen Bohan, MD, MS, Death After Syncope: with dysrhythmia in patients younger FACP, FACEP Can We Predict It? than 60 who had idiopathic (no evi- Haïssaguerre M et al. Sudden cardiac ar- dence of structural heart disease) sud- rest associated with early repolarization. yncope has myriad causes, ranging den cardiac arrest and had received N Engl J Med 2008 May 8; 358:2016. S from benign to serious, but the implantable defibrillators. Wellens HJ. Early repolarization revisited. causes are difficult to distinguish be- The researchers identified 206 cases N Engl J Med 2008 May 8; 358:2063. cause presentations often are similar. In (60% men; median age, 36) and com- a prospective cohort study of 1418 con- pared them with 412 matched controls secutive patients (mean age, 62) who who had not had cardiac arrest and did Femoral Vein Central presented to a single emergency depart- not have evidence of heart disease. Early Lines in Children: ment with syncope during a 45-month repolarization (defined as a J-point ele- period, the researchers who derived the vation ≥1 mm) was significantly more Another Case for San Francisco Syncope Rule assessed frequent in the cardiac-arrest group Ultrasound Guidance whether the rule can predict death than in the control group (31% vs. 5%) within 1 year. xternal landmarks typically are used and, when present, was significantly For patients who died, the researchers to guide placement of femoral cen- greater in magnitude in the cardiac- E determined the cause of death, judged tral venous catheters in adults and chil- arrest group (2.0 vs. 1.2 mm). Nearly 30% whether the cause was related to the dren. In this study, researchers used ultra- of patients in the cardiac-arrest group cause of syncope, and retrospectively ap- sound to determine the depth, location, had a history of syncope. Defibrillator plied the rule. The rule, which has previ- and diameter of the femoral vein and its interrogation (in 18 patients) showed ously been shown to predict short-term relation to the femoral artery in children. that dysrhythmias were preceded by an outcome, stratifies patients into low- and A single pediatric fellow performed increase in J-point elevation. In the one high-risk categories based on presence of femoral artery and vein ultrasonography third of cardiac-arrest patients who had any of five risk factors: history of conges- in a convenience sample of 84 euvo- early repolarization and had pre-arrest tive heart failure, hematocrit <30%, ab- lemic children younger than 9 years. The electrocardiograms available, the pre- normal electrocardiogram, shortness of femoral artery and vein were identified arrest ECGs showed early repolarization. breath, or systolic blood pressure <90 according to specific criteria. The femo- During a mean follow-up of 61 months, mm Hg ( JW Emerg Med Aug 2006, p. 57, ral artery partially overlapped the femo- the three patients with the highest J- and Ann Emerg Med 2006; 47:448). ral vein in 4% of cases and completely point elevation (>5 mm) together had All-cause mortality rates were 1.4% overlapped the vein in 8%. Depth of the more than 50 episodes of ventricular fi- at 1 month, 2.9% at 3 months, 4.3% at femoral vein increased with age, rang- brillation (VF), resulting in the death of 6 months, and 7.6% at 1 year. Syncope- ing from a mean of 6.5 mm in neonates one patient. Few patients in the cardiac- related mortality rates were 1.3% at to 11.2 mm in 9-year-olds. Mean diam- arrest group were athletes or blacks, 1 month, 1.8% at 3 months, 2.3% at eter also increased with age, ranging groups in which repolarization abnor- 6 months, and 3.8% at 1 year. At 6 from 4.1 mm in young infants to mality is most common. months, the rule predicted overall mor- 10.9 mm in 9-year-olds. An editorialist notes that while re- tality with a sensitivity of 89% and a polarization abnormality is common, Comment: specificity of 53% and predicted syncope- related mortality with a sensitivity of sudden cardiac arrest is not, and that Studies have shown that using ultra- 100% and a specificity of 52%. At 1 year, patients with the characteristic ECG sound for guidance when placing inter- Page 54 JOURNAL WATCH EMERGENCY MEDICINE Volume 12 Number 7 sensitivities and specificities were 83% Comment: The lidocaine and placebo groups had and 54% for all-cause mortality and 93% According to the medical literature, use similar patient and procedural charac- and 53% for syncope-related mortality. of NIV can prevent more than half of an- teristics at baseline. Pain scores were significantly lower in the lidocaine Comment: ticipated intubations in patients with acute decompensated heart failure. Al- group than in the placebo group, as In this single-hospital study, the San Fran- though lack of randomization in this assessed by patients on both the faces cisco Syncope Rule was sensitive for pre- study might have introduced bias (less- scale (1.8 vs. 2.1) and the VAS (22.6 vs. dicting 1-year mortality in patients who ill patients might have received NIV), 32.0) and by parents on the VAS (21.4 presented with syncope. As initially con- the findings support use of NIV instead vs. 28.7). Differences in treatment effect ceived and studied, the rule was meant of intubation as initial treatment. NIV across age categories were similar in to predict which patients (without any of should be considered early in the course both groups. Treatment-related adverse the 5 risk factors) could be safely dis- of treating patients with acute decom- events were rare in both groups, and all charged from the ED and worked up as pensated heart failure, unless the clini- resolved without sequelae; most adverse outpatients. Pending validation of these cian judges that the patient will not tol- events were attributed to minor dermal findings in a multicenter study, a reason- erate it (because the patient is unstable, reactions at the administration site. able approach is to consider discharge uncooperative, or claustrophobic). only for patients who have none of the Comment: — Diane M. Birnbaumer, MD, FACEP five San Francisco criteria and are judged Children should receive local anesthesia to have a benign presentation by the Tallman TA et al. Noninvasive ventilation before venipuncture, whenever possi- outcomes in 2,430 acute decompensated attending emergency physician. ble. Existing topical anesthetics can re- heart failure patients: An ADHERE registry — Richard D. Zane, MD, FAAEM analysis. Acad Emerg Med 2008 Apr; 15:355. quire as long as 1 hour to achieve a de- Quinn J et al. Death after emergency de- sired effect, and their use often requires partment visits for syncope: How common multiple clinician assessments to deter- and can it be predicted? Ann Emerg Med mine patient readiness; this device 2008 May; 51:585. Needle-Free Powder avoids both drawbacks. This study Lidocaine Delivery shows that the needle-free system is ef- fective and safe, and, although the study eedle insertion can be one of the was limited to hospitalized children, the Noninvasive Ventilation most painful and distressing pro- N device seems perfect for the ED setting. Is Safe and Effective in cedures for a child and often leaves a The measured benefit as scored on the traumatic, lasting impression. Topical Acute Decompensated faces scale was modest and perhaps of anesthetic creams that are used to amelio- no clinical significance, but the differ- Heart Failure rate the pain of a needlestick often are ences on the VAS exceeded 25% and lthough noninvasive ventilation impractical in an emergency depart- likely were real. Although cost data (NIV) is frequently used to treat ment because of the delay between ap- A were not provided by the authors, a patients with acute decompensated plication and analgesic effect. In a multi- higher cost could easily be justified heart failure, its efficacy and safety have center, randomized, double-blind, sham– by the benefits. — Jill M. Baren, MD, remained controversial. To evaluate the placebo-controlled trial, researchers MBE, FACEP, FAAP safety and efficacy of NIV, researchers evaluated the efficacy and safety of a retrospectively analyzed data from the needle-free powder lidocaine delivery Zempsky WT et al. Needle-free powder lido- caine delivery system provides rapid effec- Acute Decompensated Heart Failure Na- device in 597 hospitalized children (age tive analgesia for venipuncture or cannu- tional Registry (ADHERE) for patients range, 3–18 years) who were undergo- lation pain in children: Randomized, who were admitted from emergency de- ing venipuncture or intravenous cannu- double-blind Comparison of Venipuncture partments. Among patients with com- lation on the dorsal hand or antecubital and Venous Cannulation Pain After Fast- plete data, 34,942 did not receive NIV fossa. The device manufacturer provided Onset Needle-Free Powder Lidocaine or Pla- or endotracheal intubation (no ventila- the devices and funded the research, cebo Treatment trial. Pediatrics 2008 May; tion), 1688 received NIV and did not re- and one author was an employee of the 121:979. quire any other airway support (suc- manufacturer. cessful NIV), 72 received NIV but The device uses helium-generated ultimately required intubation (failed pressure to deliver 0.5 mg of lidocaine Risk Factors for NIV), and 670 received only intubation. hydrochloride powder to the anticipated Delay in Presentation Rates of in-hospital mortality were 3.2% needle insertion site, where the particles in the no-ventilation group, 7.9% in the penetrate the epidermis. In this study, of AMI Patients successful-NIV group, 13.9% in the failed- the device was used to deliver lidocaine ith widespread attention to NIV group, and 15.4% in the intubation powder or no powder approximately 1 to W “door-to-balloon time” brought group. After adjustment for risk factors for 3 minutes before the venous access pro- about by Medicare’s national standards, mortality (e.g., age, history of heart dis- cedure. Patients rated the pain of the time to treatment of acute myocardial ease), the likelihood of in-hospital death subsequent needlestick using a modified infarction after patient arrival at the was significantly less in the successful- Wong-Baker Faces Pain Rating Scale (0 = hospital is improving. The problem that NIV group than in the intubation group no pain to 5 = worst pain), and patients persists, however, is getting patients to (odds ratio, 0.51) but did not differ signifi- aged 8 to 18 years also used a 100-mm come to the hospital promptly after cantly between the failed-NIV group and visual analog scale (VAS). Parents used symptom onset. Two research groups the intubation group (OR, 1.43). the VAS to rate their child’s pain. used different methods to determine July 2008 JOURNAL WATCH EMERGENCY MEDICINE Page 55 factors that might contribute to delays physicians should support and partici- interruption of compressions requires in presentation. pate in programs that promote aware- significant time to reestablish forward In one study, 3522 patients from the ness of symptoms of ischemia and the flow. Based on these findings, there U.S., Australia, and New Zealand who importance of getting to the hospital seems to be no reason to discontinue had a preexisting diagnosis of ischemic quickly. — J. Stephen Bohan, MD, MS, chest compressions for biphasic defibril- heart disease were surveyed about their FACP, FACEP lation during CPR. — Aaron E. Bair, knowledge, attitudes, and beliefs about Dracup K et al. Acute coronary syndrome: MD, MSc, FAAEM, FACEP coronary heart disease. On a standard- What do patients know? Arch Intern Med Lloyd MS et al. Hands-on defibrillation: An ized instrument that included questions 2008 May 26; 168:1049. analysis of electrical current flow through about perceived vulnerability to a fu- Ting HH et al. Factors associated with longer rescuers in direct contact with patients ture acute coronary syndrome event, a time from symptom onset to hospital pre- during biphasic external defibrillation. score of 70% or higher was judged to re- sentation for patients with ST-elevation Circulation 2008 May 13; 117:2510. flect “adequate knowledge.” The mean myocardial infarction. Arch Intern Med 2008 May 12; 168:959. knowledge score was 71%, and 44% of patients scored lower than 70%. Female Patient Outcomes from sex, being under the care of a cardiolo- Intensivist Care gist, and participation in a cardiac reha- Minimal Risk for Shock bilitation program were associated with to Rescuers During rior studies consistently have higher scores. No specific factors in the Biphasic Defibrillation P shown better patient outcomes clinical history (e.g., coronary artery by- when critical care specialists are sub- pass graft [CABG]) or cardiac risk fac- voiding interruption of chest com- stantially involved in care of patients in tors predicted knowledge scores. Over- A pressions during cardiopulmonary intensive care units (ICUs), but these all, 43% of this study’s high-risk pop- resuscitation potentially can improve studies all had methodological limita- ulation considered their risk for AMI patient outcomes by supporting contin- tions. These authors reviewed data from during the next 5 years to be the same uous coronary and cerebral circulation. a national ICU database to compare hos- as or lower than that of other people of However, in the absence of automated pital mortality rates in more than the same age. Characteristics signifi- resuscitation systems, a “hands-off” pe- 100,000 patients who were cared for cantly associated with perception of riod during delivery of shocks is recom- either entirely by intensivists or entirely low risk were history of CABG and age mended to protect rescuers from poten- by nonintensivist physicians. Intensiv- younger than 80. tially dangerous electrical discharge. In ists were defined as physicians who In the other study, researchers re- the current era, with use of conforming were board certified in critical care viewed data for nearly 500,000 patients pre-gelled electrodes and advanced bi- medicine, trained in a critical care fel- enrolled in the National Registry of Myo- phasic defibrillators, the risk to the res- lowship, or recognized by the institu- cardial Infarction from 1995 through cuer might be minimal. tion as critical care specialists (e.g., 2004 to identify risk factors for delay. In this study, researchers measured burn surgeons). The mean time from symptom onset leakage voltage and current through The standardized mortality ratio (ra- to presentation decreased significantly four investigators who served as mock tio of actual mortality to expected mor- during the study period from 123 to 113 rescuers during elective cardioversion tality measured by the Simplified Acute minutes. Older age, female sex, black in 43 patients. With a gloved hand, the Physiology Score) was 1.09 for patients race, Latino ethnicity, and presence of rescuer applied pressure to the patient’s who were managed by intensivists and diabetes were associated with longer chest adjacent to the anterior chest elec- 0.91 for those who were managed by times to presentation. Analysis of com- trode. Leakage voltage and current and nonintensivists. A significant difference binations of these risk factors for delay peak potential differences in the rescuer persisted after logistic regression analy- showed, for example, that black women were monitored during delivery of sis that included adjustment for illness aged 70 and older with diabetes arrived shocks. No shocks were perceptible to severity (odds ratio for death, 1.40). The an average of 64 minutes later than rescuers (even during delivery of 360 J). authors note that the startling results white men younger than 70 without The current measured in the rescuer’s could be explained by the confounding diabetes (mean time to arrival, 170 vs. body ranged from 19 to 907 µA. In most effects of unrecognized, unmeasured 106 minutes, respectively). cases, the leakage current measured be- contributors to illness severity or that, low recommended safety standards. The alternatively, the findings could be accu- Comment: authors conclude that pausing CPR for rate and reflect, for example, that inten- The decline in time from symptom on- delivery of shocks might not be neces- sivists’ greater use of procedures might set to presentation during the 10-year sary because the risk to the rescuer is lead to more complications, with in- study period probably reflects increas- minimal. creased morbidity and mortality. ing public awareness of symptoms of Editorialists emphasize the substantial AMI and the importance of getting to Comment: evidence showing that patients cared the hospital quickly, but the message is The current recommendations regard- for by intensivists have better outcomes not reaching all segments of the popula- ing cardiac arrest strongly support mini- and note the mechanistic explanations tion equally. The discrepancy indicates mizing any interruption in chest com- for the improved outcomes, whereas the that both the content and delivery method pression. Keeping the “pump primed” authors of the current study provide no of the message needs to be targeted to has been shown to improve circulation evidence to support an explanation for vulnerable audiences. Emergency by maintaining valve function, and any their findings. The editorialists also note No part of this newsletter may be reproduced or otherwise incorporated into any information retrieval system without the written permission of the Massachusetts Medical Society. Printed in the USA. ISSN 1521-6535.

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Page 56 JOURNAL WATCH EMERGENCY MEDICINE Volume 12 Number 7 that the specialty of the caregiver might Don’t Delay Transfer fer stayed in the initial hospital signifi- not be as important as the mode in cantly longer than those who did not which the care is delivered (e.g., use of Trauma Patients to undergo CT (mean, 238 vs. 148 min- of protocols). Specialty Centers utes). The authors note that the time difference is longer than the time re- Comment: rauma systems improve survival. A fundamental principle of trauma quired to perform a CT scan. Common wisdom takes a real hit from T care is that rapid transport of patients this study, so much so that the results Comment: to appropriate facilities allows timely are hard to believe. The findings are as This study was retrospective and from identification and treatment of life- stunning as if a similar retrospective data- a single trauma center, but it emphasizes threatening injuries. To determine base study of emergency departments a valuable take-home point: The only whether obtaining a computed tomog- identified decreased mortality when reason to perform tests before transfer raphy (CT) scan before transfer affects nonemergency physicians provided to a trauma center is if the results will length of stay in the initial hospital, re- emergency care. As an emergency phy- inform a critical management decision searchers reviewed medical records of sician, I breathe easier knowing that (e.g., whether to perform laparotomy 249 consecutive adult trauma patients when I admit a patient to our ICU, a before transport) or will form the basis who were transferred to a regional qualified intensivist is on the receiving of the decision to transfer (e.g., CT trauma center in Canada during a end. — J. Stephen Bohan, MD, MS, scanning identifies an intracranial hem- 2-year period. FACP, FACEP orrhage or spinal column injury in an About one third of patients under- otherwise-stable patient). If the results Levy MM et al. Association between critical went CT before transfer. Mean injury se- care physician management and patient of a test will not change your manage- verity scores were similar between pa- mortality in the intensive care unit. Ann ment or disposition decisions, why do tients who did and did not undergo CT. Intern Med 2008 Jun 3; 148:801. the test? In no case was the CT result used to de- Rubenfeld GD and Angus DC. Are inten- — Kristi L. Koenig, MD, FACEP sivists safe? Ann Intern Med 2008 Jun 3; termine whether to transfer a patient, Onzuka J et al. Is computerized tomogra- 148:877. and in no case did it lead to a decision phy of trauma patients associated with a to perform surgery before transfer. Pa- transfer delay to a regional trauma centre? tients who underwent CT before trans- CJEM 2008 May; 10:205.