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Increasing Critical Care Admissions from U.S. Emergency Departments, 2001–2009
The Journal of Emergency Medicine The authors state that routine administration of ipecac in the Emergency Department or at the site of ingestion should be avoided. [Mariah Bellinger, MD Denver Health Medical Center, Denver, CO] Comment: Although this study did not find any convincing evidence that would change prior recommendations concerning ipecac administration, ipecac should be reserved for very specific situations and should not be used routinely in the Emergency Department. , LITHIUM POISONING: THE VALUE OF EARLY DIGESTIVE TRACT DECONTAMINATION. Bretaudeau Deguigne M, Hamel JF, Boels D, Harry P. Clin Toxicol (Phila) 2013;51:243–8. Lithium is a medication commonly used to treat mood disorders. There are three different types of lithium poisoning. These include acute poisoning in patients not regularly taking lithium, acute poisoning in patients receiving long-term therapy (acuteon-chronic) and chronic poisoning. This study aimed to evaluate the effects of early gastrointestinal (GI) decontamination on severity of acute-on-chronic lithium poisoning. Although activated charcoal is a commonly used medication for GI decontamination, it does not adsorb lithium. Sodium polystyrene sulfonate has been demonstrated to reduce lithium toxicity as well as whole body irrigation (WBI). This observational and retrospective study examined acuteon-chronic lithium overdoses recorded by the French Angers Poisons and Toxicovigilance Centre between 2006 and 2010. Two groups were determined: patients who received decontamination by sodium polystyrene sulfonate or WBI and those in which decontamination was not performed or was delayed > 12 h. Patients who suffered acute ingestions but were not regularly taking lithium were excluded. Other exclusion criteria included chronic lithium ingestions as well as significant coingestions with other substances (co-ingestion with low doses of psychotropic drugs or alcohol were included in the study). The severity of poisoning was also assessed based on the final patient outcome using the Poisoning Severity Score (PSS). Statistical analysis was performed on 59 patients. Of these 59, 15 were decontaminated at < 12 h. The mean age and estimated ingestion dose did not differ significantly between the two groups. The study found that patients who were in the decontamination group had an overall lower PSS (1.07 vs 1.79, p = 0.001). The decontamination group also had lower maximum serum lithium levels (2.39 vs. 4.08 mEq/L; p = 0.001) and higher average Glasgow Coma Scale scores (14.93 vs. 13.3; p = 0.038). None of the patients who underwent early GI decontamination required dialysis. Multivariate analysis demonstrated that early GI decontamination was significantly associated with a lower risk of severe toxicity (odds ratio 0.21; 95% confidence interval 0.04–0.99; p = 0.049). The authors conclude that early GI decontamination is useful in treating acute-on-chronic lithium poisoning. One limitation to the study is that the physician in charge made the decision to carry out GI contamination. The authors also note it was not possible to separate patients receiving whole bowel irriga-
311 tion, sodium polystyrene sulfonate, or both. The authors state that further randomized controlled trials are needed to perform a separate assessment of these two techniques of GI decontamination in lithium toxicity. [Mariah Bellinger, MD Denver Health Medical Center, Denver, CO] Comment: This study has supporting evidence demonstrating the importance of early GI decontamination in acute-onchronic lithium toxicity in the Emergency Department if mental status is not depressed. , INCREASING CRITICAL CARE ADMISSIONS FROM U.S. EMERGENCY DEPARTMENTS, 2001–2009. Herring A, Ginde A, Fahimi J, et al. Crit Care Med 2013; 41:1197–204. The aim of this study was to analyze the difference in the number of critical care-based Emergency Department (ED) visits, critical care admissions, and ED lengths of stay from 2001 to 2009. Further, this study investigates several characteristics of critically ill patients in the ED. Data were analyzed from the National Hospital Ambulatory Medical Care Survey between 2001 and 2009. The primary outcome was total annual hours of ED care provided to patients admitted to the intensive care unit (ICU). The study found that annual ED visits by critically ill patients increased by 79% (1.2 million to 2.2 million) in the United States from 2001 to 2009. The percentage of ED visits resulting in ICU admission increased by 75% (0.9% to 1.6%, p < 0.001). The median ED length-of-stay for patients admitted to the ICU increased by 60 min (185 to 245 min, p < 0.03). The total number of critical care hours provided by EDs increased from 3.2 to 10.1 million h (p < 0.001). The study also found that increased visits among Blacks (+250%, p = 0.001) and Hispanics (+328, p < 0.001) were larger than those among Whites (+86%, p < 0.001). The increased ED critical care hours primarily affected EDs in the urban setting. There are several consequences and implications related to increased critical care hours in an already over-capacitated ED. Some studies have shown that prolonged ED stays by critically ill patients are associated with increased mortality. This study estimates that the total amount of critical care time proved in the ED more than tripled in the United States (US) from 2001 to 2009. One limitation to this study is that it was difficult to distinguish if the time spent in the ED by critically ill patients was a result of active care or boarding. Also, identifying critically ill patients was based on disposition alone. The authors conclude that there is now increasing critical care being provided in US EDs, and this will become a rising burden in already over-crowed departments. [Mariah Bellinger, MD Denver Health Medical Center, Denver, CO] Comment: This study points out important implications in the increasing number of critical care visits and ICU patient length-of-stay in the ED. More studies need to be conducted to identify barriers on moving these patients to the ICU and
312 recognizing specific consequences of longer ICU patient lengthof-stay in the department. , BODY CT SCANNING IN YOUNG ADULTS: EXAMINATION INDICATIONS, PATIENT OUTCOMES, AND RISK OF RADIATION-INDUCED CANCER. Zondervan RL, Hahn PF, Sadow CA, et al. Radiology 2013;267:460–9. Due to the increasing use of computed tomography (CT) in the United States, there has been increasing concern for the safety of those scanned with regards to radiation-induced cancers. CT use now accounts for over 50% of the population’s radiation exposure, as approximately 80 million CT scans were performed in 2010 alone. The aim of this study was to specifically address cancer risk from body CT in young adults. This was a retrospective multicenter study targeting patients aged 18–35 years who had one or more chest or abdominopelvic CT scans performed during a 5-year period. Patients were placed into the following five groups based on the frequency of CT scans performed in the study period: very rarely scanned (1–2 scans), rarely scanned (3–5 scans), moderately scanned (6–15 scans), and frequently scanned (> 15 scans). Patients were placed into cancer or non-cancer groups based upon information from their medical record. The Biologic Effects of Ionizing Radiation VII method was used to predict cancer incidence and death. A total of 16,804 patients were included in the analysis, and accounted for 16,851 chest CT and 24,112 abdominopelvic CT scans. Overall, 7.1% and 3.9% of patients who underwent chest or abdominopelvic CT, respectively, died at follow-up. The lowest death rate was in those very rarely scanned (4.7% chest and 2.6% abdominopelvic). Including all patients undergoing chest CT, 5 patients (0.1%) were predicted to have died of a radiationinduced cancer, and only 3 patients (0.05%) among the very rarely scanned group. Including all patients undergoing abdominopelvic CT, 11 patients (0.1%) were predicted to have died of a radiation-induced cancer, and only 7 patients (0.1%) among the very rarely scanned group. Combined, the death rate among any scanning frequency group was higher compared to that of the general population (3.9% vs 1.1%, respectively). Of these deaths, 0.1% were predicted to be due to a radiation-induced cancer. The most common indications for chest CT were cancer, trauma, and cardiorespiratory complaints. The most common indications for abdominopelvic CT were abdominal pain, cancer, trauma, and bowel/bladder-related complaints. In those very rarely scanned, trauma and abdominal pain were the most common indications for chest and abdominopelvic CT, respectively. The authors concluded that in young patients undergoing chest or abdominopelvic CT, the risk of radiation-induced cancer was far outweighed (by one order of magnitude) by the risk of intercurrent death from their acute medical condition or underlying medical comorbidities, regardless of scanning frequency. [David Bosch, DO Denver Health Medical Center, Denver, CO]
Abstracts Comment: When considering radiation concerns, the patient’s underlying medical morbidity has an overall greater impact on adverse outcomes than the risk of radiation-induced cancer. , UNINTENTIONAL DOMESTIC NON-FIRE RELATED CARBON MONOXIDE POISONING: DATA FROM MEDIA REPORTS, UK/REPUBLIC OF IRELAND 1986–2011. Fisher DS, Bowskill S, Saliba L, Flanagan RJ. Clin Toxicol (Phila) 2013;51:409–16. Carbon monoxide (CO) poisoning is difficult to diagnose when the context of exposure is not known, as is the case in most unintentional poisonings excluding fires. This article sought to collect data from media databases over a 25-year period to assess trends in accidental CO poisonings. Investigators retrospectively analyzed data from publicly available information. Their search included Newsbank and 332 other United Kingdom (UK) and Republic of Ireland media databases for reports of unintentional (excluding homicide/ suicide) and non-fire-related domestic CO poisonings from 1986–2011. A total of 880 victims were identified with reference to 348 separate incidences. Overall, there was a steady increase in reports of fatal incidents from 1990 to 2005, with a decreasing trend from 2005 to 2011. The report of non-fatal incidents showed more year-to-year variation across the data collection period and showed no increasing/decreasing trends. Incidents showed seasonal variation and were most frequent in autumn and winter months. The most common source of CO production was described as a ‘‘boiler,’’ which included permanently installed gas, coal, and wood fires. The most common location of CO poisoning was in private residences (49%), although incidents occurring in tents, boats, caravans, hotels, sheds, outhouses, or hostels maintained much higher overall death rates. Of the 298 reported deaths, 269 patients (90%) were found dead, and the male-to-female ratio was 1.36:1. Survival rates decreased with increasing age for both sexes. Limitations to this retrospective review of media-reported CO poisonings are many. Reporting bias by media, in addition to countless unknown/unreported diagnoses/exposures by health care professionals or maintenance workers would affect the total number of cases reported. In addition, the more frequent use of electronic media since 1990 may have lead to an increased availability of reported incidents. The authors concluded that deaths and permanent injuries from unintentional domestic non-fire-related CO poisoning most commonly occur at home due to permanently installed gas, coal, or wood fire boilers. Survival rates were high if CO poisoning was diagnosed clinically. [David Bosch, DO Denver Health Medical Center, Denver, CO] Comment: Although implementing and maintaining CO detectors may reduce morbidity and mortality in private residences, inappropriate use or inadequate maintenance of combustion devices will likely continue to cause death and disability.
311 tion, sodium polystyrene sulfonate, or both. The authors state that further randomized controlled trials are needed to perform a separate assessment of these two techniques of GI decontamination in lithium toxicity. [Mariah Bellinger, MD Denver Health Medical Center, Denver, CO] Comment: This study has supporting evidence demonstrating the importance of early GI decontamination in acute-onchronic lithium toxicity in the Emergency Department if mental status is not depressed. , INCREASING CRITICAL CARE ADMISSIONS FROM U.S. EMERGENCY DEPARTMENTS, 2001–2009. Herring A, Ginde A, Fahimi J, et al. Crit Care Med 2013; 41:1197–204. The aim of this study was to analyze the difference in the number of critical care-based Emergency Department (ED) visits, critical care admissions, and ED lengths of stay from 2001 to 2009. Further, this study investigates several characteristics of critically ill patients in the ED. Data were analyzed from the National Hospital Ambulatory Medical Care Survey between 2001 and 2009. The primary outcome was total annual hours of ED care provided to patients admitted to the intensive care unit (ICU). The study found that annual ED visits by critically ill patients increased by 79% (1.2 million to 2.2 million) in the United States from 2001 to 2009. The percentage of ED visits resulting in ICU admission increased by 75% (0.9% to 1.6%, p < 0.001). The median ED length-of-stay for patients admitted to the ICU increased by 60 min (185 to 245 min, p < 0.03). The total number of critical care hours provided by EDs increased from 3.2 to 10.1 million h (p < 0.001). The study also found that increased visits among Blacks (+250%, p = 0.001) and Hispanics (+328, p < 0.001) were larger than those among Whites (+86%, p < 0.001). The increased ED critical care hours primarily affected EDs in the urban setting. There are several consequences and implications related to increased critical care hours in an already over-capacitated ED. Some studies have shown that prolonged ED stays by critically ill patients are associated with increased mortality. This study estimates that the total amount of critical care time proved in the ED more than tripled in the United States (US) from 2001 to 2009. One limitation to this study is that it was difficult to distinguish if the time spent in the ED by critically ill patients was a result of active care or boarding. Also, identifying critically ill patients was based on disposition alone. The authors conclude that there is now increasing critical care being provided in US EDs, and this will become a rising burden in already over-crowed departments. [Mariah Bellinger, MD Denver Health Medical Center, Denver, CO] Comment: This study points out important implications in the increasing number of critical care visits and ICU patient length-of-stay in the ED. More studies need to be conducted to identify barriers on moving these patients to the ICU and
312 recognizing specific consequences of longer ICU patient lengthof-stay in the department. , BODY CT SCANNING IN YOUNG ADULTS: EXAMINATION INDICATIONS, PATIENT OUTCOMES, AND RISK OF RADIATION-INDUCED CANCER. Zondervan RL, Hahn PF, Sadow CA, et al. Radiology 2013;267:460–9. Due to the increasing use of computed tomography (CT) in the United States, there has been increasing concern for the safety of those scanned with regards to radiation-induced cancers. CT use now accounts for over 50% of the population’s radiation exposure, as approximately 80 million CT scans were performed in 2010 alone. The aim of this study was to specifically address cancer risk from body CT in young adults. This was a retrospective multicenter study targeting patients aged 18–35 years who had one or more chest or abdominopelvic CT scans performed during a 5-year period. Patients were placed into the following five groups based on the frequency of CT scans performed in the study period: very rarely scanned (1–2 scans), rarely scanned (3–5 scans), moderately scanned (6–15 scans), and frequently scanned (> 15 scans). Patients were placed into cancer or non-cancer groups based upon information from their medical record. The Biologic Effects of Ionizing Radiation VII method was used to predict cancer incidence and death. A total of 16,804 patients were included in the analysis, and accounted for 16,851 chest CT and 24,112 abdominopelvic CT scans. Overall, 7.1% and 3.9% of patients who underwent chest or abdominopelvic CT, respectively, died at follow-up. The lowest death rate was in those very rarely scanned (4.7% chest and 2.6% abdominopelvic). Including all patients undergoing chest CT, 5 patients (0.1%) were predicted to have died of a radiationinduced cancer, and only 3 patients (0.05%) among the very rarely scanned group. Including all patients undergoing abdominopelvic CT, 11 patients (0.1%) were predicted to have died of a radiation-induced cancer, and only 7 patients (0.1%) among the very rarely scanned group. Combined, the death rate among any scanning frequency group was higher compared to that of the general population (3.9% vs 1.1%, respectively). Of these deaths, 0.1% were predicted to be due to a radiation-induced cancer. The most common indications for chest CT were cancer, trauma, and cardiorespiratory complaints. The most common indications for abdominopelvic CT were abdominal pain, cancer, trauma, and bowel/bladder-related complaints. In those very rarely scanned, trauma and abdominal pain were the most common indications for chest and abdominopelvic CT, respectively. The authors concluded that in young patients undergoing chest or abdominopelvic CT, the risk of radiation-induced cancer was far outweighed (by one order of magnitude) by the risk of intercurrent death from their acute medical condition or underlying medical comorbidities, regardless of scanning frequency. [David Bosch, DO Denver Health Medical Center, Denver, CO]
Abstracts Comment: When considering radiation concerns, the patient’s underlying medical morbidity has an overall greater impact on adverse outcomes than the risk of radiation-induced cancer. , UNINTENTIONAL DOMESTIC NON-FIRE RELATED CARBON MONOXIDE POISONING: DATA FROM MEDIA REPORTS, UK/REPUBLIC OF IRELAND 1986–2011. Fisher DS, Bowskill S, Saliba L, Flanagan RJ. Clin Toxicol (Phila) 2013;51:409–16. Carbon monoxide (CO) poisoning is difficult to diagnose when the context of exposure is not known, as is the case in most unintentional poisonings excluding fires. This article sought to collect data from media databases over a 25-year period to assess trends in accidental CO poisonings. Investigators retrospectively analyzed data from publicly available information. Their search included Newsbank and 332 other United Kingdom (UK) and Republic of Ireland media databases for reports of unintentional (excluding homicide/ suicide) and non-fire-related domestic CO poisonings from 1986–2011. A total of 880 victims were identified with reference to 348 separate incidences. Overall, there was a steady increase in reports of fatal incidents from 1990 to 2005, with a decreasing trend from 2005 to 2011. The report of non-fatal incidents showed more year-to-year variation across the data collection period and showed no increasing/decreasing trends. Incidents showed seasonal variation and were most frequent in autumn and winter months. The most common source of CO production was described as a ‘‘boiler,’’ which included permanently installed gas, coal, and wood fires. The most common location of CO poisoning was in private residences (49%), although incidents occurring in tents, boats, caravans, hotels, sheds, outhouses, or hostels maintained much higher overall death rates. Of the 298 reported deaths, 269 patients (90%) were found dead, and the male-to-female ratio was 1.36:1. Survival rates decreased with increasing age for both sexes. Limitations to this retrospective review of media-reported CO poisonings are many. Reporting bias by media, in addition to countless unknown/unreported diagnoses/exposures by health care professionals or maintenance workers would affect the total number of cases reported. In addition, the more frequent use of electronic media since 1990 may have lead to an increased availability of reported incidents. The authors concluded that deaths and permanent injuries from unintentional domestic non-fire-related CO poisoning most commonly occur at home due to permanently installed gas, coal, or wood fire boilers. Survival rates were high if CO poisoning was diagnosed clinically. [David Bosch, DO Denver Health Medical Center, Denver, CO] Comment: Although implementing and maintaining CO detectors may reduce morbidity and mortality in private residences, inappropriate use or inadequate maintenance of combustion devices will likely continue to cause death and disability.