Clinical Examination for Outcome Prediction in Nontraumatic Coma

206 sought to determine if the use of epinephrine in the prehospital cardiac arrest setting was associated with immediate and 1-month survival. A prospective observational model was used to evaluate data on all out-of-hospital cardiac arrests (OHCA) in Japan from 2005 through 2008. There were 417,188 OHCAs meeting criteria in the time frame. Data were collected on ROSC, survival rates, and, in those who survived, neurological outcome, as measured by the Glasgow-Pittsburgh Performance Category (CPC) and the Overall Performance Category (OPC). The four primary endpoints were ROSC before hospital arrival, 1-month survival, CPC category 1 or 2, and OPC category 1 or 2 at 1-month follow-up. Epinephrine use before hospital arrival was not randomized, so a propensity score was used to control for confounding and selection bias. There were 15,030 patients matched in each group. Data were abstracted from propensity-matched patients, and multiple conditional logistic regression models were fit with endpoints as dependent variables. Crude analysis of the data revealed a positive association between prehospital epinephrine and 1-month survival (odds ratio [OR] 1.15; p < 0.001), though adjustment for propensity score and all confounding variables revealed a significant negative association (OR 0.54, p < 0.001). Epinephrine use was, however, a significant positive predictor of ROSC before hospital arrival (OR 2.51, p < 0.001). Data for CPC and OPC yielded odds ratios < 1 in all analyses for association between prehospital epinephrine use and long-term neurological outcome (OR 0.21–0.41 and 0.23–0.43 respectively, p < 0.001 for all). The authors concluded that epinephrine in the prehospital setting was strongly predictive of short-term survival, though associated with decreased 1-month survival and neurological outcome. [Peter Emiley, MD Denver Health Medical Center, Denver, CO]

Abstracts months of age. Patients were excluded if they had a baseline O2 requirement before presentation. After diagnosis, patients were watched for 8 h within the ED; if, after 8 h, their O2 saturation was $ 90% on # 0.5 L O2, they had no other abnormal vital signs, and they were maintaining hydration, they were discharged home on home O2. Patients had a 24-h follow-up appointment either prearranged with their primary care provider or at the ED. Outcome measures consisted of the percentage of patients discharged on home O2 and the readmission rate for all patients, as well as adverse outcomes for those patients initially discharged on home O2. Secondary outcomes were cost savings as well as reasons for readmission. In total, 3983 patients were responsible for the 4194 acute illnesses included in the study. Fifty-seven percent (n = 2383) of patients were discharged to home on room air, 15% (n = 649) were discharged to home on O2 therapy and 28% (n = 1162) were admitted to the hospital or kept in the ED for at least 24 h of observation. Mean age for all patients was 7.6 6 4.8 months, and the mean age for patients discharged home on O2 was 8.9 6 4.4 months. Sixty percent of patients discharged home were boys. Mean O2 amount at discharge was 0.39 L/min (SD 0.1 L/min), and the mean lowest O2 saturation for patients discharged home was 84% (SD 3%). Four percent of patients discharged on room air were subsequently admitted (95% confidence interval [CI] 3.1–4.6), compared to 6% of patients discharged on O2 (95% CI 4.3–7.9). There were no adverse events, defined as intensive care unit admission or use of advanced airway management, in either group. Increased oxygen utilization and increased work of breathing were the most common causes for readmission. Overall admission rates dropped from 40% before initiation of this protocol to 31% over this 4-year period. There was an estimated $1262 savings per patient discharged home on O2. The authors conclude that a select group of pediatric patients with bronchiolitis can be discharged home on O2 safely with significant cost savings and decreased overall hospital admissions. [Austin Johnson, MD Denver Health Medical Center, Denver, CO]

Comments: Although limited by its retrospective design, this is yet another study that demonstrates the shortcomings of advanced cardiovascular life support research. Although diseaseoriented outcomes such as ROSC may suggest that epinephrine has utility for patients with OHCA, the dismal patient-oriented outcome of 1-month survival suggests quite the contrary. As providers and consumers of this kind of information, we must remember to balance the disease- and patient-oriented outcomes of the studies that we read.

Comments: Although limited by its retrospective design, this study does provide some evidence for the safety and efficacy of a home oxygen program for the management of patients with bronchiolitis who present to the ED. Clearly, prospective studies would further delineate the true measures of success of such a program.

, DISCHARGED ON SUPPLEMENTAL OXYGEN FROM AN EMERGENCY DEPARTMENT IN PATIENTS WITH BRONCHIOLITIS. Halstead S, Roosevelt G, Deakyne S, Bajaj L. Pediatrics 2012;129:e605–10. Bronchiolitis is a frequent cause of hospital admission for pediatric patients in the Emergency Department (ED). One of the most common causes of admission within this patient population is persistent hypoxia within the ED. Although two small prospective studies demonstrated good outcomes for home O2 therapy, their small sample size and low incidence of complications precluded a thorough analysis of overall safety. This retrospective chart review of 4194 ED visits over a 4-year period in a large academic ED attempted to determine the safety of home O2 therapy vs. hospital admission for the hypoxic infant with bronchiolitis. All patients within the study group were between 1 and 18

, CLINICAL EXAMINATION FOR OUTCOME PREDICTION IN NONTRAUMATIC COMA. Greer DM, Yang J, Scripko PD, et al. Crit Care Med 2012;40:1150–6. In this prospective observational study of 500 non-traumatic coma patients, the authors substantiate the importance of the clinical neurologic examination in predicting patient outcomes. Data were collected at a single academic medical center over the course of 7 years. Patients were enrolled in the Emergency Department, the neuroscience Intensive Care Unit (ICU), the medical ICU, or the cardiac ICU. Methods were reflective of the seminal article on the topic published by Levy et al. in 1981. Inclusion criteria defined non-traumatic coma as ‘‘.complete lack of awareness of the environment, no eye opening in response to external stimuli.sounds emitted could not reflect response to need/discomfort.no blink to visual threat, no grimace to

The Journal of Emergency Medicine noxious stimulation on the cranium or body, and no purposeful movement to noxious stimulations.’’ Cause of coma included subarachnoid hemorrhage (n = 80), ischemic stroke (n = 54), intracerebral hemorrhage (n = 112), hypoxia-ischemia (n = 202), hepatic encephalopathy (n = 10), and miscellaneous (n = 42). Clinical data were collected on hospital days 0, 1, 3, and 7. Outcomes were assessed at 6 months by a modified Rankin Scale (mRS). Good outcomes were defined and analyzed on two different levels; a mRS # 3 as well as one # 4. Pupillary reflex was predictive of good outcome regardless of hospital day or set point of the mRS (mean odds ratio [OR] 12.51, range 6.01–22.56 for mRS # 3; mean OR 19.26, range 5.38–42.26 for mRS # 4). Oculocephalic reflex was also an important determinant (mean OR 62.61, range 2.24–177 for mRS # 3; mean OR 34.13, range 4.95–89.93 for mRS # 4). Motor response predicted outcome only on day 0 (OR 2.35, 95% confidence interval [CI] 0.64– 5.74 for mRS # 3; OR 2.1, 95% CI 0.81–4.24 for mRS # 4). [Mike Miller, MD Denver Health Medical Center, Denver, CO] Comments: This study helps to remind us of the importance of a good clinical examination in the evaluation of patients with nontraumatic coma. The findings of such an examination may be helpful in determining prognosis and advising family members. It would be useful to know if the use of therapeutic hypothermia would alter the results of this study and if the results would remain similar for patients with coma from a traumatic cause. , CT/CT ANGIOGRAPHY AND MRI FINDINGS PREDICT RECURRENT STROKE AFTER TRANSIENT ISCHEMIC ATTACK AND MINOR STROKE: RESULTS OF THE PROSPECTIVE CATCH STUDY. Coutts SB, Modi J, Patel SK, et al. Stroke 2012; 43:1013–7. Acute stroke is a common and frequently disabling condition worldwide. Fifteen to thirty percent of disabling strokes are preceded by transient ischemic attacks (TIAs). After suffering a TIA there is significant risk (10%) of recurrent neurologic event in the following week, most frequently within 48 h. Magnetic resonance imaging with diffusion-weighted imaging (DWI) is known to identify patients with high risk of recurrent event after TIA. This study investigated the viability of computed tomography (CT) and CT angiography (CTA) in identifying those same patients through assessment of the intracranial and extracranial vasculature with high spatial resolution for occlusion or stenosis. The primary outcome was the first recurrent stroke event within 90 days. The secondary outcome was comparison of DWI to CT/CTA. Five hundred ten patients were enrolled in the study, of whom 237 had ischemic strokes and 232 TIAs; 11 were lost to follow-up. There were 36 primary outcome events with mean onset of 1 day. Positive CT/CTA metric was present in 24 of 36 patients with recurrent event and in 147 of 463 patients without recurrent event (hazard ratio [HR] 4.0, 95% confidence interval [CI] 2.0–8.0). Positive DWI was present in 27 of 36 patients with recurrent event and in 57 of 463 patients without recurrent event (HR 2.2, 95% CI 1.05–4.7). There was no significant difference in diagnostic accuracy between the two modalities. The authors concluded that early assessment of intracranial and extracranial vasculature with CT/CTA predicts recurrent stroke and outcome in patients with TIA and minor

207 stroke. They also note possible advantages of CT/CTA over DWI being no difference in diagnostic accuracy, CT’s widespread availability, and time to performance of study. [Peter Emiley, MD Denver Health Medical Center, Denver, CO] Comments: The authors of this study suggest that the use of this type of imaging could prove useful in evaluating patients with TIAs to predict which of those patients are most at risk for developing a stroke in the time period immediately afterwards. The problem is that looking at their own data, I am unsure that they have made their case very convincingly. A very small number of patients actually had a recurrent event, and of those, the sensitivity of the test being advocated for was only 67%. Furthermore, almost a third without recurrent events were identified as being at risk. Would this have led to unnecessary work-ups or treatments? It is unclear that this kind of imaging is really of value for these patients based on this one study. , VARIATION IN USE OF HEAD COMPUTED TOMOGRAPHY BY EMERGENCY PHYSICIANS. Prevedello LM, Raja AS, Zane RD, et al. Am J Med 2012;125:356–64. A recent Centers of Medicare and Medicaid Services (CMS) measure has been approved to track and assess the use of head computed tomography (CT) in the Emergency Department (ED) for patients presenting with atraumatic headaches. This retrospective chart review from a large urban teaching hospital measured head CT rates for all patients presenting to the ED in an effort to measure inter-physician use of head CT. There were 55,286 patients included in the final analysis, and rates of head CT use were calculated across the 38 attending physicians within the ED. The mean age of patients within the study was 48 6 19.6 years, 60% were female, and the mean Emergency Severity Index (ESI) score was 2.8 6 0.8. Among attending physicians, 11 (29%) were female and the post-residency years of training ranged from 0 to 30 years (interquartile range 3–10 years). Of the 55,281 patients included in the study, 4919 patients had a head CT performed. Unadjusted rates of head CTs varied from 4.4% to 16.9% per physician for patients presenting with any chief complaint. Logistic regression analysis demonstrated that older patients, male patients, and patients presenting with head trauma were more likely to obtain a head CT scan. When controlling for patient demographics, ESI, and final diagnosis, an adjusted model demonstrated significant inter-physician variability in head CT orders (6.5% to 13.5%). Among patients presenting with an atraumatic headache, rates of head CT ordering ranged from 15.2% to 61.7% between physicians. When controlling for the above variables, there was an approximate threefold variation of head CT ordering rates between physicians (21.2– 60.1%). The authors conclude that there is significant variation in head CT ordering rates among Emergency Physicians. [Austin Johnson, MD Denver Health Medical Center, Denver, CO] Comments: This study demonstrated wide variation in Emergency Physician use of head CT. Further studies to determine if such variations in practice patterns are associated with