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Acute Periorbital Infections: Who Needs Emergent Imaging?
394
Abstracts
the 10,711 OHCA cases, 2881 were transported to CCMCs and 7502 were transported to NCCHs. The primary endpoint was “neurologically favorable outcome” defined by Cerebral Performance Categories score. Among patients with return of spontaneous circulation (ROSC) in the field, the authors found that neurologically favorable outcome was similar between the CCMC and NCCH groups (43% vs. 41%, respectively, adjusted odds ratio [OR] 1.09, 95% confidence interval [CI] 0.82e1.45; p = 0.554). Among patients without ROSC in the field, neurologically favorable outcome was very unlikely overall, however, slightly more likely in the CCMC group (1.7% vs. 0.5%, adjusted OR 3.39, 95% CI 2.17e5.29; p < 0.001) compared to the NCCH group. The authors conclude that patients without ROSC benefit from transfer to a CCMC. Factors such as cooling protocols, rapid access to percutaneous coronary intervention, and subspecialty support may be responsible for these differences. [Charles M Reynolds, MD Denver Health Medical Center, Denver, CO] Comment: This study suggests that outcomes of OHCA without ROSC are dependent upon in-hospital factors. If true, this could have implications for the transport of patients without ROSC after OHCA. However, there are several important limitations to the article, including the observational nature of the study, lack of randomization, and potential for selection bias among prehospital providers (Emergency Medical Services personnel chose their destination without support from a decision-making protocol) that necessitate caution in interpreting the results. , HEALTH CARE INSURANCE, FINANCIAL CONCERNS IN ACCESSING CARE, AND DELAYS TO HOSPITAL PRESENTATION IN ACUTE MYOCARDIAL INFARCTION. Smolderen KG, Spertus JA, Nallamothu BK, et al. JAMA 2010;303:1392e400. This was a prospective observational study that examined the associations between health insurance status and financial concerns related to accessing health care with delayed presentation to the hospital in patients with acute myocardial infarction. Participants were consecutively enrolled from the TRIUMPH study patient population from 24 urban hospitals within the United States. Patients older than 18 years who had elevated cardiac enzymes within 24 h of admission and other supporting evidence of acute myocardial infarction were considered for inclusion. Patients were excluded if they were incarcerated, refused to participate, were unable to consent, did not speak Spanish or English, transferred to the participating hospital more than 24 h after initial presentation, if they died, or if they were discharged before being contacted by researchers. Data were collected by chart abstraction and from interviews that were performed within 24e72 h of admission from 3271 included patients. Insurance status was divided into three categories: no insurance, insurance with financial concerns, and insurance without financial concerns. Patients were classified as having financial concerns if cost had caused them to avoid care in the past year, to be non-adherent to medications in the past year, or to have difficulty obtaining health care services. These data were compared to the time from symptom onset to hospital presentation, which was grouped into one of three categories: # 2 h,
2e6 h, or > 6 h. Time to presentation was compared to insurance status using multivariable hierarchical cumulative-logit models. To adjust for missing time data across all insurance categories, a non-parsimonious model was created and the reciprocal of the associations were used to weight the hierarchical cumulative-logit model. A secondary analysis was performed to analyze the association between delayed presentation and lower rates of treatment with percutaneous coronary intervention or thrombolytic therapy. Multiple differences were found in the baseline characteristics of patients with insurance without financial concerns, those with insurance with financial concerns, and those without insurance. Compared to patients with insurance and no financial concerns, patients who were uninsured or insured with financial concerns were more likely to be younger, nonwhite, single, and less likely to have completed high school. There were also significant differences between the groups with regard to pre-hospital delays to care. Among those with insurance without financial concerns, 36.6% presented within 2 h, as compared to 33.5% of insured patients with financial concerns and 27.5% of uninsured patients. Of patients with insurance without financial concerns, 39.3% presented > 6 h after symptom onset, as compared to 44.6% with insurance with financial concerns and 48.6% of uninsured patients. After adjustment for demographics, baseline health status, social factors, and psychiatric variables, insured patients with financial concerns were found to be more likely to delay care (odds ratio 1.21, 95% confidence interval 1.12e1.51). Among patients with ST elevation myocardial infarction, those with pre-hospital delays > 6 h were less likely to receive primary reperfusion therapy (83.9% of those with delays > 6 h, 92.5% for those with > 2e6-h delays, and 93.5% in those with < 2-h delays). The authors conclude that financial concerns or a lack of health insurance are important causes of delays to accessing care for patients with myocardial infarction. Unless the financial aspect of access to health care is addressed, patients may continue to delay care. [Colleen Foster, MD PGY-2 Denver Health Medical Center Emergency Medicine Residency Program, Denver, CO] Comments: The authors provide a compelling argument about the influence of financial concerns for patients in accessing health care when they need it most. What could not be answered by this study was whether or not that delay resulted in worse outcomes. Nonetheless, if the desire is to have patients present as early as possible in the course of a myocardial infarction, the financial barriers, or at least the perceptions of them, must be addressed. , ACUTE PERIORBITAL INFECTIONS: WHO NEEDS EMERGENT IMAGING? Rudloe TF, Harper MB, Prabhu SP, Rahbar R, Vanderveen D, Kimia AA. Pediatrics 2010;125:e719e26. With the emphasis on reducing pediatric exposure to radiation, providers often find themselves debating whether their patient needs a computed tomography (CT) scan. This study examined factors that identified those children with signs or symptoms of periorbital infection who were candidates for early imaging of the orbit. Included were all children presenting to
The Journal of Emergency Medicine a single urban pediatric tertiary care emergency department over a 14-year period with suspected acute clinical periorbital or orbital cellulitis. Of these 918 patients, 298 underwent CT scan and 111 were identified as having an abscess. The authors studied the association between abscess and classic clinical examination findings (i.e., proptosis, pain with external ocular movement [EOM], and ophthalmoplegia) as well as other predictive variables (age, gender, height of fever, duration of symptoms, previous upper respiratory infection/sinusitis symptoms, absolute neutrophil count [ANC], absence of infectious conjunctivitis, C-reactive protein level, erythrocyte sedimentation rate, degree of edema, and previous antibiotic therapy). The authors found that 56 (50.5%) patients with an abscess did not experience proptosis, pain with EOM, or ophthalmoplegia. Moderate-to-severe periorbital edema, ANC of > 10,000 cells per mL, absence of conjunctivitis, age > 3 years, and previous antibiotic use were identified as predictors of an orbital abscess. Using these data, they created a recursive partitioning model that identified all high-risk (risk = 44%) patients needing emergent imaging, as well as a low-risk (risk = 0.4e2%) group. [Sara Medendorp Denver Health Medical Center, Denver, CO] Comments: This retrospective study is limited by all of the problems inherent to these types of studies. It does, however, demonstrate how difficult it is to reduce imaging in patients for a potentially dangerous disease that has inconsistent presenting complaints and findings.
, SURVIVAL AFTER APPLICATION OF AUTOMATIC EXTERNAL DEFIBRILLATORS BEFORE ARRIVAL OF THE EMERGENCY MEDICAL SYSTEM: EVALUATION IN THE RESUSCITATION OUTCOMES CONSORTIUM POPULATION OF 21 MILLION. Weisfeldt ML, Sitlani CM, Ornato JP, et al. J Am Coll Cardiol 2010;55:1713e20. Public and community response to out-of-hospital cardiac arrest is crucial to patient survival. Prior studies suggest that automated external defibrillator (AED) use could potentially double survival when trained individuals utilize the devices in prehospital settings for cardiac arrest. To further understanding of how public AEDs impact real-world survival, this large prospective multicenter multiregional cohort study enrolled patients with out-of-hospital non-traumatic cardiac arrest. Patients with emergency medical services (EMS)-witnessed arrests, hospitalized patients, and patients in whom resuscitation was not attempted were excluded from the trial. A total of 13,769 patients were included. Of these patients, 4403 had bystander cardiopulmonary resuscitation (CPR) performed but no AED applied, and 289 had an AED applied before EMS arrival. The primary outcome measured was survival to hospital discharge. Overall survival for all enrolled patients was 7%, with a survival of 9% for patients who received CPR before EMS arrival. Survival of patients with AED application before EMS arrival was 24%, with survival increased to 38% for patients with a shock delivered by AED. In a multivariate logistic regression analysis, the variables researchers controlled for included age, gender, receipt of bystander CPR, EMS response time, and initial rhythm. Use of AED before EMS arrival in this
395 analysis was associated with an odds ratio of survival of 1.75 (95% confidence interval 1.23e2.5, p < 0.002). Several other analyses, including stratified propensity score analysis, generalized estimating equation, and generalized linear mixed model analyses, provided similar results. The authors of this study conclude that given the significant improvement in survival with AED application, increased implementation of community and public AEDs in strategic locations would have a significant public health benefit. [Janetta Iwanicki, MD Denver Health Medical Center, Denver, CO] Comment: It is interesting to note the large proportion of patients (9077) who did not have CPR performed or AED applied before EMS arrival. This highlights the importance of continued public health education efforts not only to provide AED training but also public awareness of importance of early CPR. Additionally, a disproportionately large number of patients in the AEDapplied group had a shockable rhythm compared to patients in the no-AED-applied group with rhythm analysis on EMS arrival. Although this may indicate one reason for the improved survival in the AED group, this may also indicate that some patients who did not have an AED applied may have had degeneration of their initial potentially shockable rhythm into an unshockable rhythm by the time of EMS arrival. , ADDITIONAL VALUE OF PROCALCITONIN FOR DIAGNOSIS OF INFECTION IN PATIENTS WITH FEVER AT THE EMERGENCY DEPARTMENT. de Kruif MD, Limper M, Gerritsen H, et al. Crit Care Med 2010;38:457e63. This observational study out of Amsterdam examined the role of procalcitonin (PCT) as a biomarker of bacterial infections in febrile patients. Associated with this primary objective, a scoring system was introduced that included PCT to distinguish bacterial infections from non-bacterial causes of infection. Finally, the authors looked at C-reactive protein (CRP) in comparison with PCT with respect to clinical outcomes of febrile patients. The study included 211 consecutively enrolled patients at a single hospital who presented either with fever or who developed fever within 36 h of admission. Patients were categorized in one of the following four groups: infection confirmed (n = 73), infection likely (n = 58), infection not excluded (n = 46), and no infection (n = 34). Using univariate and multivariate analysis, CRP and chills were identified to be most commonly associated with bacterial infection. Adding PCT to a derived decision rule including these predictors resulted in an area under the curve of 0.83, and a sensitivity of 79% and specificity of 71%. This decision rule was better at predicting bacterial infection than clinician judgment or systemic inflammatory response syndrome criteria. Second, PCT was found to be associated more closely than CRP to clinical outcomes (need for higher level of care, duration of antibiotics and duration of hospital stay). Based on the above analysis, the authors concluded that PCT is potentially a valuable diagnostic biomarker in clinical decision-making. [Whitney Barrett, MD Denver Health Medical Center, Denver, CO]
Abstracts
the 10,711 OHCA cases, 2881 were transported to CCMCs and 7502 were transported to NCCHs. The primary endpoint was “neurologically favorable outcome” defined by Cerebral Performance Categories score. Among patients with return of spontaneous circulation (ROSC) in the field, the authors found that neurologically favorable outcome was similar between the CCMC and NCCH groups (43% vs. 41%, respectively, adjusted odds ratio [OR] 1.09, 95% confidence interval [CI] 0.82e1.45; p = 0.554). Among patients without ROSC in the field, neurologically favorable outcome was very unlikely overall, however, slightly more likely in the CCMC group (1.7% vs. 0.5%, adjusted OR 3.39, 95% CI 2.17e5.29; p < 0.001) compared to the NCCH group. The authors conclude that patients without ROSC benefit from transfer to a CCMC. Factors such as cooling protocols, rapid access to percutaneous coronary intervention, and subspecialty support may be responsible for these differences. [Charles M Reynolds, MD Denver Health Medical Center, Denver, CO] Comment: This study suggests that outcomes of OHCA without ROSC are dependent upon in-hospital factors. If true, this could have implications for the transport of patients without ROSC after OHCA. However, there are several important limitations to the article, including the observational nature of the study, lack of randomization, and potential for selection bias among prehospital providers (Emergency Medical Services personnel chose their destination without support from a decision-making protocol) that necessitate caution in interpreting the results. , HEALTH CARE INSURANCE, FINANCIAL CONCERNS IN ACCESSING CARE, AND DELAYS TO HOSPITAL PRESENTATION IN ACUTE MYOCARDIAL INFARCTION. Smolderen KG, Spertus JA, Nallamothu BK, et al. JAMA 2010;303:1392e400. This was a prospective observational study that examined the associations between health insurance status and financial concerns related to accessing health care with delayed presentation to the hospital in patients with acute myocardial infarction. Participants were consecutively enrolled from the TRIUMPH study patient population from 24 urban hospitals within the United States. Patients older than 18 years who had elevated cardiac enzymes within 24 h of admission and other supporting evidence of acute myocardial infarction were considered for inclusion. Patients were excluded if they were incarcerated, refused to participate, were unable to consent, did not speak Spanish or English, transferred to the participating hospital more than 24 h after initial presentation, if they died, or if they were discharged before being contacted by researchers. Data were collected by chart abstraction and from interviews that were performed within 24e72 h of admission from 3271 included patients. Insurance status was divided into three categories: no insurance, insurance with financial concerns, and insurance without financial concerns. Patients were classified as having financial concerns if cost had caused them to avoid care in the past year, to be non-adherent to medications in the past year, or to have difficulty obtaining health care services. These data were compared to the time from symptom onset to hospital presentation, which was grouped into one of three categories: # 2 h,
2e6 h, or > 6 h. Time to presentation was compared to insurance status using multivariable hierarchical cumulative-logit models. To adjust for missing time data across all insurance categories, a non-parsimonious model was created and the reciprocal of the associations were used to weight the hierarchical cumulative-logit model. A secondary analysis was performed to analyze the association between delayed presentation and lower rates of treatment with percutaneous coronary intervention or thrombolytic therapy. Multiple differences were found in the baseline characteristics of patients with insurance without financial concerns, those with insurance with financial concerns, and those without insurance. Compared to patients with insurance and no financial concerns, patients who were uninsured or insured with financial concerns were more likely to be younger, nonwhite, single, and less likely to have completed high school. There were also significant differences between the groups with regard to pre-hospital delays to care. Among those with insurance without financial concerns, 36.6% presented within 2 h, as compared to 33.5% of insured patients with financial concerns and 27.5% of uninsured patients. Of patients with insurance without financial concerns, 39.3% presented > 6 h after symptom onset, as compared to 44.6% with insurance with financial concerns and 48.6% of uninsured patients. After adjustment for demographics, baseline health status, social factors, and psychiatric variables, insured patients with financial concerns were found to be more likely to delay care (odds ratio 1.21, 95% confidence interval 1.12e1.51). Among patients with ST elevation myocardial infarction, those with pre-hospital delays > 6 h were less likely to receive primary reperfusion therapy (83.9% of those with delays > 6 h, 92.5% for those with > 2e6-h delays, and 93.5% in those with < 2-h delays). The authors conclude that financial concerns or a lack of health insurance are important causes of delays to accessing care for patients with myocardial infarction. Unless the financial aspect of access to health care is addressed, patients may continue to delay care. [Colleen Foster, MD PGY-2 Denver Health Medical Center Emergency Medicine Residency Program, Denver, CO] Comments: The authors provide a compelling argument about the influence of financial concerns for patients in accessing health care when they need it most. What could not be answered by this study was whether or not that delay resulted in worse outcomes. Nonetheless, if the desire is to have patients present as early as possible in the course of a myocardial infarction, the financial barriers, or at least the perceptions of them, must be addressed. , ACUTE PERIORBITAL INFECTIONS: WHO NEEDS EMERGENT IMAGING? Rudloe TF, Harper MB, Prabhu SP, Rahbar R, Vanderveen D, Kimia AA. Pediatrics 2010;125:e719e26. With the emphasis on reducing pediatric exposure to radiation, providers often find themselves debating whether their patient needs a computed tomography (CT) scan. This study examined factors that identified those children with signs or symptoms of periorbital infection who were candidates for early imaging of the orbit. Included were all children presenting to
The Journal of Emergency Medicine a single urban pediatric tertiary care emergency department over a 14-year period with suspected acute clinical periorbital or orbital cellulitis. Of these 918 patients, 298 underwent CT scan and 111 were identified as having an abscess. The authors studied the association between abscess and classic clinical examination findings (i.e., proptosis, pain with external ocular movement [EOM], and ophthalmoplegia) as well as other predictive variables (age, gender, height of fever, duration of symptoms, previous upper respiratory infection/sinusitis symptoms, absolute neutrophil count [ANC], absence of infectious conjunctivitis, C-reactive protein level, erythrocyte sedimentation rate, degree of edema, and previous antibiotic therapy). The authors found that 56 (50.5%) patients with an abscess did not experience proptosis, pain with EOM, or ophthalmoplegia. Moderate-to-severe periorbital edema, ANC of > 10,000 cells per mL, absence of conjunctivitis, age > 3 years, and previous antibiotic use were identified as predictors of an orbital abscess. Using these data, they created a recursive partitioning model that identified all high-risk (risk = 44%) patients needing emergent imaging, as well as a low-risk (risk = 0.4e2%) group. [Sara Medendorp Denver Health Medical Center, Denver, CO] Comments: This retrospective study is limited by all of the problems inherent to these types of studies. It does, however, demonstrate how difficult it is to reduce imaging in patients for a potentially dangerous disease that has inconsistent presenting complaints and findings.
, SURVIVAL AFTER APPLICATION OF AUTOMATIC EXTERNAL DEFIBRILLATORS BEFORE ARRIVAL OF THE EMERGENCY MEDICAL SYSTEM: EVALUATION IN THE RESUSCITATION OUTCOMES CONSORTIUM POPULATION OF 21 MILLION. Weisfeldt ML, Sitlani CM, Ornato JP, et al. J Am Coll Cardiol 2010;55:1713e20. Public and community response to out-of-hospital cardiac arrest is crucial to patient survival. Prior studies suggest that automated external defibrillator (AED) use could potentially double survival when trained individuals utilize the devices in prehospital settings for cardiac arrest. To further understanding of how public AEDs impact real-world survival, this large prospective multicenter multiregional cohort study enrolled patients with out-of-hospital non-traumatic cardiac arrest. Patients with emergency medical services (EMS)-witnessed arrests, hospitalized patients, and patients in whom resuscitation was not attempted were excluded from the trial. A total of 13,769 patients were included. Of these patients, 4403 had bystander cardiopulmonary resuscitation (CPR) performed but no AED applied, and 289 had an AED applied before EMS arrival. The primary outcome measured was survival to hospital discharge. Overall survival for all enrolled patients was 7%, with a survival of 9% for patients who received CPR before EMS arrival. Survival of patients with AED application before EMS arrival was 24%, with survival increased to 38% for patients with a shock delivered by AED. In a multivariate logistic regression analysis, the variables researchers controlled for included age, gender, receipt of bystander CPR, EMS response time, and initial rhythm. Use of AED before EMS arrival in this
395 analysis was associated with an odds ratio of survival of 1.75 (95% confidence interval 1.23e2.5, p < 0.002). Several other analyses, including stratified propensity score analysis, generalized estimating equation, and generalized linear mixed model analyses, provided similar results. The authors of this study conclude that given the significant improvement in survival with AED application, increased implementation of community and public AEDs in strategic locations would have a significant public health benefit. [Janetta Iwanicki, MD Denver Health Medical Center, Denver, CO] Comment: It is interesting to note the large proportion of patients (9077) who did not have CPR performed or AED applied before EMS arrival. This highlights the importance of continued public health education efforts not only to provide AED training but also public awareness of importance of early CPR. Additionally, a disproportionately large number of patients in the AEDapplied group had a shockable rhythm compared to patients in the no-AED-applied group with rhythm analysis on EMS arrival. Although this may indicate one reason for the improved survival in the AED group, this may also indicate that some patients who did not have an AED applied may have had degeneration of their initial potentially shockable rhythm into an unshockable rhythm by the time of EMS arrival. , ADDITIONAL VALUE OF PROCALCITONIN FOR DIAGNOSIS OF INFECTION IN PATIENTS WITH FEVER AT THE EMERGENCY DEPARTMENT. de Kruif MD, Limper M, Gerritsen H, et al. Crit Care Med 2010;38:457e63. This observational study out of Amsterdam examined the role of procalcitonin (PCT) as a biomarker of bacterial infections in febrile patients. Associated with this primary objective, a scoring system was introduced that included PCT to distinguish bacterial infections from non-bacterial causes of infection. Finally, the authors looked at C-reactive protein (CRP) in comparison with PCT with respect to clinical outcomes of febrile patients. The study included 211 consecutively enrolled patients at a single hospital who presented either with fever or who developed fever within 36 h of admission. Patients were categorized in one of the following four groups: infection confirmed (n = 73), infection likely (n = 58), infection not excluded (n = 46), and no infection (n = 34). Using univariate and multivariate analysis, CRP and chills were identified to be most commonly associated with bacterial infection. Adding PCT to a derived decision rule including these predictors resulted in an area under the curve of 0.83, and a sensitivity of 79% and specificity of 71%. This decision rule was better at predicting bacterial infection than clinician judgment or systemic inflammatory response syndrome criteria. Second, PCT was found to be associated more closely than CRP to clinical outcomes (need for higher level of care, duration of antibiotics and duration of hospital stay). Based on the above analysis, the authors concluded that PCT is potentially a valuable diagnostic biomarker in clinical decision-making. [Whitney Barrett, MD Denver Health Medical Center, Denver, CO]