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162: Incidence of Hypokalemia in Patients Presenting to the Emergency Department With Diabetic Ketoacidosis
Research Forum Abstracts sodium, creatinine and glucose were abstracted. A weighted scoring system proposed by Wong et al. was applied to both groups to determine the accuracy of the prediction rule. Results: A total of 27 charts over a 15 year period with the diagnosis of necrotizing fasciitis or gangrene were reviewed. A total of 8 charts had all the lab values available for scoring. A total of 275 charts with the diagnosis of cellulitis or soft tissue infection were reviewed with all lab values available in 75 charts. The laboratory risk indicator for necrotizing fasciitis (LRINEC) score was calculated for both groups. Using a cut off value of 6 or greater yielded a positive test in 7 of the necrotizing fasciitis and 11 in the cellulitis group. A 2-way contingency table analysis yielded a sensitivity of 87.5% (95% CI 55.8 - 97.7) and a specificity of 85.3% (95% CI 82.0 86.4). The positive predictive value was 38.9% (95% CI 24.8 - 43.4) and the negative predictive value was 98.5% (95% CI 94.6 - 99.7). The LRINEC score’s Likelihood ratio positive was 5.97 (95% CI 3.1 - 7.2) and Likelihood ratio negative was 0.146 (95% CI 0.026 - 0.539). Conclusion: The LRINEC scoring system may assist clinicians in excluding the presence of necrotizing fasciitis early in the emergency department course. Limitations of the study include the small sample size and the absence of the required laboratory parameters in a significant portion of the study population.
162
Incidence of Hypokalemia in Patients Presenting to the Emergency Department With Diabetic Ketoacidosis
Swartzberg J, Jang T, Naunheim R, Najand H, Chauhan V/University of California at Los Angeles, Los Angeles, CA; Washington University, Saint Louis, MO; St. Louis University, Saint Louis, MO
Background: Hypokalemia is reported to occur in approximately 3 to 4 percent of patients with diabetic ketoacidosis (DKA). To prevent complications of severe hypokalemia, the American Diabetes Association (ADA) treatment guidelines recommend ensuring that serum potassium levels are ⬎ 3.3 mEq/L prior to initiation of insulin in the treatment of DKA. Study Objectives: The purpose of this study was to assess the incidence of hypokalemia in patients presenting to the emergency department with hyperglycemia with or without DKA. Methods: This was a multicenter retrospective study at three urban academic EDs with a combined annual adult census of 150,000. Charts of patients who presented to the ED between January and December 2005 with hyperglycemia (defined as serum glucose ⬎ 200 mg/dL) or DKA (defined in accordance with ADA guidelines as serum glucose ⬎ 250 mg/dL, serum bicarbonate ⬍ 18 mEq/L or anion gap ⬎ 15, and evidence of ketonemia or ketonuria) were reviewed. Initial lab values on presentation were assessed for the incidence of hypokalemia. Results: 800 patients (494 with DKA) were diagnosed with hyperglycemia. The mean potassium level was 4.7 mEq/L (range 3.3 to 8.7, SD ⫹/⫺ 0.8). For those patients diagnosed with DKA, the mean potassium level was 4.9 mEq/L (range 3.3 to 8.7, SD ⫹/⫺ 0.8). Only seven cases of serum potassium ⬍ 3.5 mEq/L (none ⬍ 3.3) were found in our DKA patients (incidence of 1.4 percent). Discussion: Our results suggest that the incidence of hypokalemia in ED patients with DKA may be far less than 3 to 4 percent. As the demographics of DKA are changing (e.g. increasing numbers of older patients, patients with renal disease, and patients with congestive heart failure), our ability to depend on IV fluids alone as the initial therapy in DKA may be diminishing. Today’s DKA patients may be less likely to tolerate large fluid loads and are potentially more prone to hyperkalemia. The benefits of early insulin administration may outweigh the risk of causing severe hypokalemia. Conclusion: The incidence of hypokalemia among hyperglycemic patients presenting to the ED with or without DKA appears to be less than prior estimates. Further research is needed to better determine the risks and benefits of administering insulin before obtaining serum potassium values.
163
Emergency Department Tachypnea Predicts InHospital Adverse Outcomes
Gies JW, Zubrow MT, Jurkovitz C, Kolm P, Mascioli S, Mahoney D, O’Connor RE/ Christiana Care Health System, Newark, DE
Study Objectives: Survival to discharge from in-hospital cardiac arrest is poor and has increased very little over the past three decades A clinical antecedent not only preceding cardiac arrest but preceding clinical deterioration would be infinitely valuable and would allow practitioners to identify patients at risk for deterioration
S52 Annals of Emergency Medicine
and in need of further resuscitation or increased support. Our objective was to determine if vital sign abnormalities detected in the emergency department can be used to forecast clinical deterioration occurring shortly after admission. Methods: We performed a matched case control study in the setting of a tertiary emergency department, census ⱖ140,000 visits per year. Cases were ⱖ18 years, admitted to the general floor though the emergency department who required a rapid response team activation and transfer to higher level of care in the first 24 hours of hospital admission. Controls were ⱖ18 years, admitted to the floor though the emergency department, never required rapid response team activation or transfer to an intensive care unit and matched to cases by risk of mortality. Risk of mortality was determined by using a logistic regression model using patient demographic and medical record coding information to assign risk. Multilevel logistic regression was used to model the probability of an adverse outcome as a function of respiration rate, heart rate, systolic and diastolic blood pressure, race and gender at emergency department discharge. Likelihood ratio statistics were used to compare nested models beginning with all variables in the model and then eliminating variables one at a time. Linearity of continuous variables was assessed by restricted cubic splines. Results: A total of 74 cases and 246 matched controls were used. Respiratory rate (OR 1.11, P⫽0.003), heart rate (OR 1.01, P⫽0.079), diastolic blood pressure (OR 0.98, P⫽0.022) and non-white race (OR 2.3, P⫽0.013) all contributed significantly to the prediction of adverse outcome. Systolic blood pressure and gender did not (P⬎0.1 for both). Conclusion: Emergency department respiratory rate preceding floor transfer appears to have a dose-response relationship to in-hospital adverse outcome. Patients with persistent emergency department tachypnea need ongoing evaluation with resuscitation, if required, and should be considered for admission to a higher level of care.
164
Nasogastric Tube Placement Verification: Use of an Esophageal Detector Device
Moghadam D, Hsu CK, Leber M/The Brooklyn Hospital Center, Brooklyn, NY
Background: An esophageal detector device (EDD) is a bulb that is placed in-line with an endotracheal tube (ET). If the tube is placed appropriately in the lung, it will expand freely. If the ET tube is placed in the esophagus, delayed or no expansion of the EDD will occur. Study Objective: To determine if an EDD can be used to confirm placement of a nasogastric (NG) tube in the esophagus. Methods: Yorkshire swine were obtained postmortem from an IACUC approved procedure lab. A commercially available EDD was placed in line with a NG Tubes which were alternatively placed in the stomach or airway. Placement of the NG tube was verified by direct palpation in the esophagus or trachea through a thoracotomy. A blinded observer determined whether there was expansion after each placement. The observer looked for no expansion, delayed expansion or aspiration of stomach content into the bulb Vs free and immediate expansion of the EDD bulb. Results: Forty determinations were pooled from 4 swine. Stomach Placement: 16/20 (80%) were correctly determined to be in the stomach. Placement in Trachea: 20/20 (100%) were correctly determined to be place in the trachea. Sen 0.786CI (0.574, 0.909) Spec: (0.976) CI (0.808, 0.998). PPV 0.971 CI (0.771, 0.997). NPV: 0.820 CI (0.631, 0.924). LR(⫹) 33 LR(⫺) 0.22. Conclusions: An EDD may be used to determine placement of an NG tube. Specificity is high for placement in the airway.
165
Are Prescribing Patterns For Treatment of Pain Different by Physician Assistants With and Without DEA Registration?
Sabatino M, Dvorkin R, Levy D, Glantz S/Good Samaritan Hospital Medical Center, West Islip, NY
Study Objectives: To study whether the lack of a Drug Enforcement Administration (DEA) registration is associated with differences in the treatment of pain for patients seen by physician’s assistants (PAs). We hypothesize that if a PA lacks DEA registration they will write fewer prescriptions for controlled substances in their treatment of painful conditions. Methods: In our emergency department, physician assistants are not required to
Volume , . : September
162
Incidence of Hypokalemia in Patients Presenting to the Emergency Department With Diabetic Ketoacidosis
Swartzberg J, Jang T, Naunheim R, Najand H, Chauhan V/University of California at Los Angeles, Los Angeles, CA; Washington University, Saint Louis, MO; St. Louis University, Saint Louis, MO
Background: Hypokalemia is reported to occur in approximately 3 to 4 percent of patients with diabetic ketoacidosis (DKA). To prevent complications of severe hypokalemia, the American Diabetes Association (ADA) treatment guidelines recommend ensuring that serum potassium levels are ⬎ 3.3 mEq/L prior to initiation of insulin in the treatment of DKA. Study Objectives: The purpose of this study was to assess the incidence of hypokalemia in patients presenting to the emergency department with hyperglycemia with or without DKA. Methods: This was a multicenter retrospective study at three urban academic EDs with a combined annual adult census of 150,000. Charts of patients who presented to the ED between January and December 2005 with hyperglycemia (defined as serum glucose ⬎ 200 mg/dL) or DKA (defined in accordance with ADA guidelines as serum glucose ⬎ 250 mg/dL, serum bicarbonate ⬍ 18 mEq/L or anion gap ⬎ 15, and evidence of ketonemia or ketonuria) were reviewed. Initial lab values on presentation were assessed for the incidence of hypokalemia. Results: 800 patients (494 with DKA) were diagnosed with hyperglycemia. The mean potassium level was 4.7 mEq/L (range 3.3 to 8.7, SD ⫹/⫺ 0.8). For those patients diagnosed with DKA, the mean potassium level was 4.9 mEq/L (range 3.3 to 8.7, SD ⫹/⫺ 0.8). Only seven cases of serum potassium ⬍ 3.5 mEq/L (none ⬍ 3.3) were found in our DKA patients (incidence of 1.4 percent). Discussion: Our results suggest that the incidence of hypokalemia in ED patients with DKA may be far less than 3 to 4 percent. As the demographics of DKA are changing (e.g. increasing numbers of older patients, patients with renal disease, and patients with congestive heart failure), our ability to depend on IV fluids alone as the initial therapy in DKA may be diminishing. Today’s DKA patients may be less likely to tolerate large fluid loads and are potentially more prone to hyperkalemia. The benefits of early insulin administration may outweigh the risk of causing severe hypokalemia. Conclusion: The incidence of hypokalemia among hyperglycemic patients presenting to the ED with or without DKA appears to be less than prior estimates. Further research is needed to better determine the risks and benefits of administering insulin before obtaining serum potassium values.
163
Emergency Department Tachypnea Predicts InHospital Adverse Outcomes
Gies JW, Zubrow MT, Jurkovitz C, Kolm P, Mascioli S, Mahoney D, O’Connor RE/ Christiana Care Health System, Newark, DE
Study Objectives: Survival to discharge from in-hospital cardiac arrest is poor and has increased very little over the past three decades A clinical antecedent not only preceding cardiac arrest but preceding clinical deterioration would be infinitely valuable and would allow practitioners to identify patients at risk for deterioration
S52 Annals of Emergency Medicine
and in need of further resuscitation or increased support. Our objective was to determine if vital sign abnormalities detected in the emergency department can be used to forecast clinical deterioration occurring shortly after admission. Methods: We performed a matched case control study in the setting of a tertiary emergency department, census ⱖ140,000 visits per year. Cases were ⱖ18 years, admitted to the general floor though the emergency department who required a rapid response team activation and transfer to higher level of care in the first 24 hours of hospital admission. Controls were ⱖ18 years, admitted to the floor though the emergency department, never required rapid response team activation or transfer to an intensive care unit and matched to cases by risk of mortality. Risk of mortality was determined by using a logistic regression model using patient demographic and medical record coding information to assign risk. Multilevel logistic regression was used to model the probability of an adverse outcome as a function of respiration rate, heart rate, systolic and diastolic blood pressure, race and gender at emergency department discharge. Likelihood ratio statistics were used to compare nested models beginning with all variables in the model and then eliminating variables one at a time. Linearity of continuous variables was assessed by restricted cubic splines. Results: A total of 74 cases and 246 matched controls were used. Respiratory rate (OR 1.11, P⫽0.003), heart rate (OR 1.01, P⫽0.079), diastolic blood pressure (OR 0.98, P⫽0.022) and non-white race (OR 2.3, P⫽0.013) all contributed significantly to the prediction of adverse outcome. Systolic blood pressure and gender did not (P⬎0.1 for both). Conclusion: Emergency department respiratory rate preceding floor transfer appears to have a dose-response relationship to in-hospital adverse outcome. Patients with persistent emergency department tachypnea need ongoing evaluation with resuscitation, if required, and should be considered for admission to a higher level of care.
164
Nasogastric Tube Placement Verification: Use of an Esophageal Detector Device
Moghadam D, Hsu CK, Leber M/The Brooklyn Hospital Center, Brooklyn, NY
Background: An esophageal detector device (EDD) is a bulb that is placed in-line with an endotracheal tube (ET). If the tube is placed appropriately in the lung, it will expand freely. If the ET tube is placed in the esophagus, delayed or no expansion of the EDD will occur. Study Objective: To determine if an EDD can be used to confirm placement of a nasogastric (NG) tube in the esophagus. Methods: Yorkshire swine were obtained postmortem from an IACUC approved procedure lab. A commercially available EDD was placed in line with a NG Tubes which were alternatively placed in the stomach or airway. Placement of the NG tube was verified by direct palpation in the esophagus or trachea through a thoracotomy. A blinded observer determined whether there was expansion after each placement. The observer looked for no expansion, delayed expansion or aspiration of stomach content into the bulb Vs free and immediate expansion of the EDD bulb. Results: Forty determinations were pooled from 4 swine. Stomach Placement: 16/20 (80%) were correctly determined to be in the stomach. Placement in Trachea: 20/20 (100%) were correctly determined to be place in the trachea. Sen 0.786CI (0.574, 0.909) Spec: (0.976) CI (0.808, 0.998). PPV 0.971 CI (0.771, 0.997). NPV: 0.820 CI (0.631, 0.924). LR(⫹) 33 LR(⫺) 0.22. Conclusions: An EDD may be used to determine placement of an NG tube. Specificity is high for placement in the airway.
165
Are Prescribing Patterns For Treatment of Pain Different by Physician Assistants With and Without DEA Registration?
Sabatino M, Dvorkin R, Levy D, Glantz S/Good Samaritan Hospital Medical Center, West Islip, NY
Study Objectives: To study whether the lack of a Drug Enforcement Administration (DEA) registration is associated with differences in the treatment of pain for patients seen by physician’s assistants (PAs). We hypothesize that if a PA lacks DEA registration they will write fewer prescriptions for controlled substances in their treatment of painful conditions. Methods: In our emergency department, physician assistants are not required to
Volume , . : September