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Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction
The Journal of Emergency Medicine were well matched with the exception of more white patients were enrolled in the prednisone group when compared to other ethnicities. Outcomes were measured at 3, 6, and 52 weeks. At 3 weeks, the prednisone-treated group had a larger unadjusted reduction in ODI score with an unadjusted mean that was 5.6 points greater reduction, and this held true in the adjusted model with a mean difference of 6.4 points (P = 0.006). In the responder analysis, looking at the patients that were classified only as ‘‘responders’’ to the treatment, the prednisone-treated group demonstrated a greater relative likelihood of achieving a 50% improvement on the ODI at 3 weeks (relative risk 1.8 and number needed to treat 7.6). While the primary outcome demonstrated a difference in ODI scores, the secondary outcomes demonstrated no differences, including no statistical difference in pain score between the groups and no differences in the number of spine surgery at the one year follow up. Also of importance, the prednisone-treatment group did have a statistically significant greater number of adverse events (49.2% compared to 23.9% in placebo), although most of these were minor. The most common adverse events in the prednisone-treated group were insomnia, nervousness, and increased appetite. The authors concluded that there is a small, statistically significant improvement in overall function in patients with acute lumbar radiculopathy treated with prednisone as measured by the ODI score. The authors suggest that the administration of a short course of oral prednisone is a reasonable option for treatment of acute lumbar radiculopathy, but the decision to pursue this treatment should be made on an individual patient basis. [Angela Wright, MD Denver Health Medical Center, Denver, CO] Comment: Due to the significant number of Emergency Department visits for acute lumbar radiculopathy, evaluation of different treatment options of these patients is essential to care. These data suggest that a short course of oral steroids may benefit patients with clinically diagnosed sciatica if there are no contraindications to prednisone. Interestingly, this study demonstrated that patients receiving prednisone had an improvement in function, not necessarily pain, which is an important consideration when treating this patient population.
, VALIDATION OF A PREDICTION TOOL FOR ABUSIVE HEAD TRAUMA. Cowley LE, Morris CB, Maguire SA, et al. Pediatrics. 2015;136:290-298 Healthcare providers encounter pediatric cases that raise concerns about non-accidental trauma. Because of this, and the social and clinical repercussions of missing an abusive head trauma, a clinical decision rule was derived to aid in the identification of nonaccidental head trauma. This study was conducted to externally validate the clinical prediction tool for nonaccidental head trauma. The clinical decision rule includes six features to help identify abusive head trauma, including head or neck bruising, seizures, apnea, rib fractures, long bone fracture, and retinal
827 hemorrhage. In order to externally validate these findings and examine the sensitivity, specificity, and area under the curve, the authors looked at two separate data sets. The first data set was a retrospective data collection of 60 children, and an additional 143 cases that are part of an ongoing prospective study. The majority of the children included in the study were less than two years of age, and the proportion of those that were found to have an intracranial injury that was ultimately determined to be abusive in nature was 33%. When the clinical decision tool was applied, it was correct for 82% of the cases that were determined to be accidental in nature, and found to be correct in 66% of the abuse cases. It was noted however, that many of the abusive cases that the tool ‘‘missed’’ were those with missing data that was needed for the application of the tool. After statistical analysis, it was determined that when greater than or equal to three of the six features that were examined were present, the probability of abusive head trauma was 81.5%. When applied to these two data sets, the sensitivity of the tool was 72.3% and the specificity was 85.7%. The positive predictive value was 71.2% and the negative predictive value 86.3%. The authors concluded that their abusive head trauma prediction tool performed well and can aid in decision making in potential abusive head trauma cases. [Angela Wright, MD Denver Health Medical Center, Denver, CO] Comment: Non-accidental trauma is of great clinical significance. The development and validation of tools that will aid healthcare providers in the timely and accurate recognition of patients with nonaccidental trauma is especially important. Additional studies are needed to prospectively assess the performance of the rule to predict nonaccidental head trauma in clinical practice and compare its predictive ability to physician gestalt regarding the likelihood of nonaccidental trauma. , AIR VERSUS OXYGEN IN ST-SEGMENT-ELEVATION MYOCARDIAL INFARCTION. Stub, D, Smith, K, Bernard, S. et al. Resuscitation. 2015;131:2143-2150 The use of supplemental oxygen has been a standard part of pre-hospital and hospital care of the acute myocardial infarction (AMI) patient. The current reported estimate is that 90% of patients with suspected AMI are given supplemental oxygen with the belief that increased oxygen delivered to ischemic myocardium could reduce the extent of the myocardial damage. Some literature notes the possibility of harm from oxygen administration due to reduced coronary blood flow, increased vascular resistance, and reactive oxygen species. The purpose of the study was to compare myocardial injury size in normoxic patients with ST elevation myocardial infarction (STEMI) who received supplemental oxygen use with no oxygen therapy. This multicenter, prospective, open-label, randomized trial was conducted in Australia from 10/2011-7/2014,
828 and included Emergency Medical Service (EMS) agencies that transported to the 9 centers that provided 24-hr percutaneous coronary artery intervention. The study included patients over the age of 18 years, with chest pain less than 12 hours, and prehospital ECG with evidence of STEMI (as determined by paramedics). If a patient’s ECG was deemed non-STEMI by physician assessment on arrival to the emergency department the patient was subsequently excluded from the study. The following patients were excluded: individuals with oxygen saturation below 94%, bronchospasm requiring nebulized salbutamol/oxygen, oxygen administration prior to randomization, altered mental status, or transport to a non-participating hospital. Patients were randomized using computer-generated block randomization. The treating EMS and hospital treatment teams were unblinded to the treatment arm in the study. Follow up coordinators and investigators analyzing data were blinded. The primary outcome was myocardial injury measured by peak cTnI and CK. The secondary end points measured at hospital discharge and 6 months were electrocardiogram STsegment resolution, mortality, major adverse cardiac events, and myocardial infarction size on contrast enhanced cardiac magnetic resonance imaging. There wasn’t a statistically significant difference in myocardial injury with cTnI between the supplemental oxygen and non-oxygen groups. However, when using CK as the biomarker for myocardial injury the oxygen administration group had a geometric mean peak at 1948 U/L compared to the non-oxygen group at 1543 U/L with a ratio of oxygen to no oxygen of 1.26 (p=0.01). Repeated CK values in the oxygen treatment group throughout the patients’ time course were consistently 20% higher than the geometric mean CK in the non-oxygen group which maintained its significance when collapsed over time (p=0.007). In the supplemental oxygen group, there was a statistically significant increase in the rate of in-hospital recurrent myocardial infarctions (p=0.006) and major cardiac dysrhythmias (p=0.05). In-hospital mortality and 6-month adverse outcomes did not differ significantly between the supplemental oxygen and non-oxygen groups. Cardiac MRI was only able to be performed in 32% of patients at 6 months with findings of median infarct size increase in the oxygen group at 20.3 grams compared to 13.1 grams in the non-oxygen group (p=0.04). However, when the infarct was expressed as a proportion of the left ventricular mass there was no statistically significant difference between the supplemental oxygen and non-oxygen groups. The authors concluded that routine supplemental oxygen in AMI patients may cause harm as noted with the increase in CK and the larger infarct size noted on 6 month cardiac MRI. [Katie McCabe, MD Denver Health Medical Center, Denver, CO] Comment: This study is especially important to emergency care providers as it evaluated supplemental oxygen, a commonly administered therapy, in the management of AMI patients. However, without primary clinical endpoints and a very small portion of participants obtaining the 6 month cardiac im-
Abstracts aging follow up, the study lacks the strength necessary to change a clinical practice as pervasive as supplemental oxygen in AMI.
, A NATIONAL ASSESSMENT OF PEDIATRIC READINESS OF EMERGENCY DEPARTMENTS. Gausche-Hill M, Ely M, Schmuhl P, et al. JAMA Pediatrics. 2015;169:27-534 Pediatric readiness in Emergency Departments (EDs) is especially important and directly impacts patient safety and overall care. Previous investigations have demonstrated poor adherence to published guidelines for pediatric readiness and wide variations in Emergency Department readiness to care for the emergent pediatric patient. The goal of this investigation was to measure adherence to the 2009 national guidelines for care of children in EDs, identify gaps and barriers to adherence, and evaluate the effect of nurse or physician pediatric emergency care coordinators (PECCs). This was accomplished through the National Pediatric Readiness Project (NPRP) which was a 55 question internet based assessment sent to ED nurse managers from 1/2013-8/2013. Hospitals in the 50 United States (U.S.), 8 U.S. territories and Washington, D.C. that had EDs open 24 hours per day, 7 days a week were included in the study. The hospitals were then classified by location, volume, and hospital configuration (ie; staffing and how the ED was built into the larger hospital system). Prisons and Veterans Affairs hospitals were excluded from participation in the study. Of the 5017 ED assessments that were sent, 82.7% were completed. Among the 55 questions, 24 were used to form a weighted pediatric readiness score (WPRS). The mean WPRS was 68.9. Low volume EDs mean WPRS was 61.4 and high volume EDs mean WPRS was 89.8. (Kruskal-Wallis p=0.001). PECCs, either nurse or physician, raised the WRPS, irrespective of the ED pediatric volume. EDs were 4 times more likely to have quality improvement plans for children if one PECC was present. The most frequent barriers to guideline adherence and implementation noted by respondents were cost of training (54.4%) and lack of educational resources (49.0%). The authors concluded that an improvement in pediatric ED readiness has occurred when compared to previously published investigations. The presence of a physician and nurse ED PECC was the most important process change that resulted in improved compliance with national guidelines. [Katie McCabe, MD Denver Health Medical Center, Denver, CO] Comment: This investigation included data on 88.9% of all annual pediatric ED visits in the United States at 24-hour access emergency departments. With such high capture rate in a study that includes diverse facility configurations and volume types, the results are readily applicable to most EDs that care for children. Most importantly, the report provides evidence and actionable information on how to improve pediatric ED readiness, most significantly with the implementation of a nurse or physician PECC.
, VALIDATION OF A PREDICTION TOOL FOR ABUSIVE HEAD TRAUMA. Cowley LE, Morris CB, Maguire SA, et al. Pediatrics. 2015;136:290-298 Healthcare providers encounter pediatric cases that raise concerns about non-accidental trauma. Because of this, and the social and clinical repercussions of missing an abusive head trauma, a clinical decision rule was derived to aid in the identification of nonaccidental head trauma. This study was conducted to externally validate the clinical prediction tool for nonaccidental head trauma. The clinical decision rule includes six features to help identify abusive head trauma, including head or neck bruising, seizures, apnea, rib fractures, long bone fracture, and retinal
827 hemorrhage. In order to externally validate these findings and examine the sensitivity, specificity, and area under the curve, the authors looked at two separate data sets. The first data set was a retrospective data collection of 60 children, and an additional 143 cases that are part of an ongoing prospective study. The majority of the children included in the study were less than two years of age, and the proportion of those that were found to have an intracranial injury that was ultimately determined to be abusive in nature was 33%. When the clinical decision tool was applied, it was correct for 82% of the cases that were determined to be accidental in nature, and found to be correct in 66% of the abuse cases. It was noted however, that many of the abusive cases that the tool ‘‘missed’’ were those with missing data that was needed for the application of the tool. After statistical analysis, it was determined that when greater than or equal to three of the six features that were examined were present, the probability of abusive head trauma was 81.5%. When applied to these two data sets, the sensitivity of the tool was 72.3% and the specificity was 85.7%. The positive predictive value was 71.2% and the negative predictive value 86.3%. The authors concluded that their abusive head trauma prediction tool performed well and can aid in decision making in potential abusive head trauma cases. [Angela Wright, MD Denver Health Medical Center, Denver, CO] Comment: Non-accidental trauma is of great clinical significance. The development and validation of tools that will aid healthcare providers in the timely and accurate recognition of patients with nonaccidental trauma is especially important. Additional studies are needed to prospectively assess the performance of the rule to predict nonaccidental head trauma in clinical practice and compare its predictive ability to physician gestalt regarding the likelihood of nonaccidental trauma. , AIR VERSUS OXYGEN IN ST-SEGMENT-ELEVATION MYOCARDIAL INFARCTION. Stub, D, Smith, K, Bernard, S. et al. Resuscitation. 2015;131:2143-2150 The use of supplemental oxygen has been a standard part of pre-hospital and hospital care of the acute myocardial infarction (AMI) patient. The current reported estimate is that 90% of patients with suspected AMI are given supplemental oxygen with the belief that increased oxygen delivered to ischemic myocardium could reduce the extent of the myocardial damage. Some literature notes the possibility of harm from oxygen administration due to reduced coronary blood flow, increased vascular resistance, and reactive oxygen species. The purpose of the study was to compare myocardial injury size in normoxic patients with ST elevation myocardial infarction (STEMI) who received supplemental oxygen use with no oxygen therapy. This multicenter, prospective, open-label, randomized trial was conducted in Australia from 10/2011-7/2014,
828 and included Emergency Medical Service (EMS) agencies that transported to the 9 centers that provided 24-hr percutaneous coronary artery intervention. The study included patients over the age of 18 years, with chest pain less than 12 hours, and prehospital ECG with evidence of STEMI (as determined by paramedics). If a patient’s ECG was deemed non-STEMI by physician assessment on arrival to the emergency department the patient was subsequently excluded from the study. The following patients were excluded: individuals with oxygen saturation below 94%, bronchospasm requiring nebulized salbutamol/oxygen, oxygen administration prior to randomization, altered mental status, or transport to a non-participating hospital. Patients were randomized using computer-generated block randomization. The treating EMS and hospital treatment teams were unblinded to the treatment arm in the study. Follow up coordinators and investigators analyzing data were blinded. The primary outcome was myocardial injury measured by peak cTnI and CK. The secondary end points measured at hospital discharge and 6 months were electrocardiogram STsegment resolution, mortality, major adverse cardiac events, and myocardial infarction size on contrast enhanced cardiac magnetic resonance imaging. There wasn’t a statistically significant difference in myocardial injury with cTnI between the supplemental oxygen and non-oxygen groups. However, when using CK as the biomarker for myocardial injury the oxygen administration group had a geometric mean peak at 1948 U/L compared to the non-oxygen group at 1543 U/L with a ratio of oxygen to no oxygen of 1.26 (p=0.01). Repeated CK values in the oxygen treatment group throughout the patients’ time course were consistently 20% higher than the geometric mean CK in the non-oxygen group which maintained its significance when collapsed over time (p=0.007). In the supplemental oxygen group, there was a statistically significant increase in the rate of in-hospital recurrent myocardial infarctions (p=0.006) and major cardiac dysrhythmias (p=0.05). In-hospital mortality and 6-month adverse outcomes did not differ significantly between the supplemental oxygen and non-oxygen groups. Cardiac MRI was only able to be performed in 32% of patients at 6 months with findings of median infarct size increase in the oxygen group at 20.3 grams compared to 13.1 grams in the non-oxygen group (p=0.04). However, when the infarct was expressed as a proportion of the left ventricular mass there was no statistically significant difference between the supplemental oxygen and non-oxygen groups. The authors concluded that routine supplemental oxygen in AMI patients may cause harm as noted with the increase in CK and the larger infarct size noted on 6 month cardiac MRI. [Katie McCabe, MD Denver Health Medical Center, Denver, CO] Comment: This study is especially important to emergency care providers as it evaluated supplemental oxygen, a commonly administered therapy, in the management of AMI patients. However, without primary clinical endpoints and a very small portion of participants obtaining the 6 month cardiac im-
Abstracts aging follow up, the study lacks the strength necessary to change a clinical practice as pervasive as supplemental oxygen in AMI.
, A NATIONAL ASSESSMENT OF PEDIATRIC READINESS OF EMERGENCY DEPARTMENTS. Gausche-Hill M, Ely M, Schmuhl P, et al. JAMA Pediatrics. 2015;169:27-534 Pediatric readiness in Emergency Departments (EDs) is especially important and directly impacts patient safety and overall care. Previous investigations have demonstrated poor adherence to published guidelines for pediatric readiness and wide variations in Emergency Department readiness to care for the emergent pediatric patient. The goal of this investigation was to measure adherence to the 2009 national guidelines for care of children in EDs, identify gaps and barriers to adherence, and evaluate the effect of nurse or physician pediatric emergency care coordinators (PECCs). This was accomplished through the National Pediatric Readiness Project (NPRP) which was a 55 question internet based assessment sent to ED nurse managers from 1/2013-8/2013. Hospitals in the 50 United States (U.S.), 8 U.S. territories and Washington, D.C. that had EDs open 24 hours per day, 7 days a week were included in the study. The hospitals were then classified by location, volume, and hospital configuration (ie; staffing and how the ED was built into the larger hospital system). Prisons and Veterans Affairs hospitals were excluded from participation in the study. Of the 5017 ED assessments that were sent, 82.7% were completed. Among the 55 questions, 24 were used to form a weighted pediatric readiness score (WPRS). The mean WPRS was 68.9. Low volume EDs mean WPRS was 61.4 and high volume EDs mean WPRS was 89.8. (Kruskal-Wallis p=0.001). PECCs, either nurse or physician, raised the WRPS, irrespective of the ED pediatric volume. EDs were 4 times more likely to have quality improvement plans for children if one PECC was present. The most frequent barriers to guideline adherence and implementation noted by respondents were cost of training (54.4%) and lack of educational resources (49.0%). The authors concluded that an improvement in pediatric ED readiness has occurred when compared to previously published investigations. The presence of a physician and nurse ED PECC was the most important process change that resulted in improved compliance with national guidelines. [Katie McCabe, MD Denver Health Medical Center, Denver, CO] Comment: This investigation included data on 88.9% of all annual pediatric ED visits in the United States at 24-hour access emergency departments. With such high capture rate in a study that includes diverse facility configurations and volume types, the results are readily applicable to most EDs that care for children. Most importantly, the report provides evidence and actionable information on how to improve pediatric ED readiness, most significantly with the implementation of a nurse or physician PECC.