Helmets Still Uncommon Among Children in Bicycle Accidents.

Only 1 in 10 children involved in a bicycle accident was wearing a helmet, a review of emergency department records in Los Angeles County shows.

“We found decreased use among older children, minority groups, and those of lower socioeconomic status,” said Veronica Sullins, MD, from Harbor-UCLA Medical Center in Torrance, California.

Bicycle-related injuries are responsible for more than 250,000 visits to the emergency department and nearly 200 deaths a year. California has the second highest number of cyclist fatalities.

The use of a bicycle helmet reduces head injuries by 63% to 88%, but a small number of children younger than 15 years wear helmets, Dr. Sullins reported.

She presented the research here at the American Academy of Pediatrics 2013 National Conference and Exhibition.

Dr. Sullins and her team reviewed information from the Trauma and Emergency Medicine Information System for patients younger than 18 years. The median age of the children was 13 years, and 64% were male.

The primary end points were the association between helmet use and age, sex, insurance status, and race or ethnicity.

Only 11% Wore Helmets

Of the 1248 children identified, 11% were wearing helmets when their injuries occurred. Of these, 13.8% were younger than 12 years and 9.8% were 12 years or older.

Helmet use was 47% more likely in the younger age group (P < .03), was 10 times more likely in white children than in children from a minority group (P < .0001), and was twice as likely in children covered by private insurance as in those covered by public or no insurance (P < .0001).

There were no differences in any of the primary end points between the helmeted and unhelmeted groups. However, “we should note that of the 9 total deaths, 8 children were not wearing helmets,” Dr. Sullins said.

On multivariable logistic regression analysis, helmet use did not increase the need for emergency surgery, mortality, or length of hospital stay, after adjustment for age, race and ethnicity, and injury severity score.

Only injury severity score increased the risk for all outcomes. For every 1-point increase in injury severity score, length of stay increased by 0.4 days (P < .0001). Private insurance decreased the length of stay.

“Overall, less than 1% of patients died, few required emergency surgery (5.9%), permanent disability was very low (0.5%), but temporary disability was high (65.4%),” she said.

On the basis of the findings, Dr. Sullins and her team recommend that middle schools, high schools, low-income communities, and minority populations in Los Angeles County be targeted for bicycle safety programs.

Targeted Education

“This study picked up some remarkable trends in the difference in helmet use across different socioeconomic groups,” said Tanzid Shams, MD, who leads the concussion and brain injury program at the Floating Hospital for Children at Tufts Medical Center in Boston. “We need to look more closely at why this disparity exists.”

He told Medscape Medical News that “we want all children to wear helmets. One effective strategy would be to develop targeted campaigns that positively reinforce healthy habits.”

“The governing bodies for sports such as skateboarding and BMX can really get behind a campaign that encourages wearing helmets anytime one is riding a bicycle. I believe that a consistent message from role models can be highly effective,” said Dr. Shams.

He noted that in addition to emphasizing the value of helmets to parents, pediatricians should stress the importance of a proper fit.

“Very frequently, I see a child wearing a helmet that is loosely dangling off the head. When purchasing a bicycle helmet, one-size-fits-all may not be the best approach. The key is to go for a snug fit that does not constrict circulation or vision,” he explained.

“Several helmet manufacturers offer adjustable inner harnesses that allow for fit adjustments as the head of the child grows,” Dr. Shams said. “This feature is a good investment in terms of protecting the child from potential head trauma.”

Choosing Wisely: ACEP Lists 5 Tests to Question

The American College of Emergency Physicians (ACEP) issued a list of 5 tests and procedures that may not be cost-effective in some situations. The ACEP announced this list, which reflects its participation in the ABIM Foundation‘s Choosing Wisely campaign, at the opening session of their annual meeting in Seattle, Washington.

To lower healthcare costs and improve patient care, ACEP recommends that clinicians avoid these interventions when appropriate, after discussing that decision with patients and educating them regarding the rationale.

“ACEP needed a strategy to determine what emergency physicians could do to improve efficiency and reduce cost without affecting the quality of care we deliver,” ACEP Cost Effectiveness Task Force Chair David Ross, MD, an emergency physician in Colorado and medical director for more than 50 emergency medical services agencies in Colorado Springs, said in a news release. “The challenge also was to identify real cost savings, but also to develop consensus among emergency physicians.”

The ACEP board of directors approved the following 5 Choosing Wisely recommendations for patients seen in the emergency department:

1.      For patients with minor head injury who are deemed to be at low risk for skull fractures or hemorrhage, based on validated decision rules, clinicians should avoid head computed tomography scans. The majority of minor head injuries do not result in brain hemorrhage.

2.      For stable patients who can urinate on their own, clinicians should avoid placing indwelling urinary catheters for either urine output monitoring or patient or staff convenience.

3.      For patients likely to benefit from palliative and hospice care services, clinicians should not delay in engaging such services when available. Early referral from the emergency department can improve quality, as well as quantity, of life.

4.      For patients with uncomplicated skin and soft tissue abscesses successfully treated with incision and drainage, clinicians should provide adequate medical follow-up but avoid antibiotics and wound cultures.

5.      For children with mild to moderate, uncomplicated dehydration, clinicians should avoid giving intravenous fluids before a trial of oral rehydration therapy.

“Emergency physicians are dedicated to improving emergency care and to reducing health care costs,” ACEP President Alex Rosenau, DO, said in a news release. “These recommendations are evidence-based and developed with significant input from experts.”

An expert panel of emergency physicians and the ACEP board of directors reviewed pertinent research and input, including a survey of all ACEP members, before developing the recommendations.

In its Choosing Wisely campaign, the ABIM Foundation aims to facilitate discussion among physicians and patients about appropriate use of tests and treatments and avoidance of these interventions when the harms may outweigh the benefits.

More than 80 national, regional, and state medical specialty societies and consumer groups have joined Choosing Wisely since the campaign began in April 2012, but ACEP held off until February 2013. The delay resulted from potential conflicts of the Choosing Wisely strategy with the unique goals of emergency medicine and from concerns that the campaign does not advocate for medical liability reform.

“Overuse of medical tests is a serious problem, and health care reform is incomplete without medical liability reform,” said Dr. Rosenau. “Millions of dollars in defensive medicine are driving up the costs of health care for everyone. We will continue to encourage the ABIM Foundation and its many partners in this campaign to lend their influential voices to the need for medical liability reform.”

Source: American College of Emergency Physicians.

Propofol Procedural Sedation Is Safe.

No adverse outcomes occurred among 1000 adult propofol procedural sedation episodes.

To determine the safety of propofol for emergency department (ED) procedural sedation, researchers retrospectively applied a sedation adverse-event reporting tool to 1008 consecutive patients (age range, 15 to 97 years) who underwent procedural sedation at a single ED in the U.K. over a 5-year period. Sentinel events included oxygen saturation <75% for any length of time or <90% for more than 60 seconds, apnea lasting longer than 60 seconds, aspiration event, need for intubation, cardiovascular collapse, permanent neurologic disability, and death. Most patients were sedated for orthopedic procedures (77%) and cardioversion (9%). Monitoring included pulse oximetry, non-invasive blood pressure measurement, respiratory rate, and electrocardiography; nasal capnography was adopted near the end of the study period.

A total of 73 adverse events were reported: 11 sentinel, 34 moderate, 25 minor, and 3 minimal risk. Sentinel events included six episodes of prolonged hypotension (>60 seconds) requiring brief vasopressor support, and five episodes of hypoxia, all but one of which resolved with assisted ventilation. One patient with unstable ventricular tachycardia underwent cardioversion, vomited, and became hypoxic, necessitating intubation for airway protection and altered mentation. He was found to have a saddle pulmonary embolism and distal aortic thrombus; he survived to hospital discharge. No adverse outcomes related to procedural sedation were identified.

Comment: Several patients with sentinel adverse events had significant underlying medical comorbidities. Fortunately, no patients suffered any adverse outcomes related to the procedural sedation, but this study reminds us that proper monitoring, including capnography, and careful patient selection are crucial to ensure the safety of this procedure. Patients at high risk for adverse events, such as those with significant cardiopulmonary comorbidity, and those with difficult airways should be evaluated for possible sedation in the operating room.


Source: Journal Watch Emergency Medicine


Man vs. Machine for CPR.

In this meta-analysis, return of spontaneous circulation was more likely when chest compressions were delivered by a mechanical device than manually.

When applied properly, mechanical devices provide consistent and effective chest compressions; no risk for provider fatigue; and the opportunity for concurrent defibrillation, thereby reducing time to shock. Investigators performed a meta-analysis of controlled (randomized, historical, or case-control) trials in humans to compare prehospital cardiopulmonary resuscitation (CPR) using a mechanical chest compression device versus manual compressions.

Of 12 studies meeting entry criteria, 8 involved load-distributing band CPR and 4 used piston-driven CPR, with a total of 6538 patients and 1824 instances of return of spontaneous circulation (ROSC). ROSC was defined as a measurable blood pressure sustained for at least 1 minute. Use of a mechanical device was superior to manual compressions for achieving ROSC (odds ratio, 1.53 overall, 1.62 for load-distributing band CPR, and 1.25 for piston-driven CPR).

Comment: Compression devices have become more lightweight and portable, making them a more attractive option for prehospital resuscitation, where it may be more difficult to achieve consistently adequate manual compressions. Such devices can be expected to similarly outperform humans in the emergency department and hospital settings, too, making a convincing argument for their routine use during resuscitation.


Source: Journal Watch Emergency Medicine

Do All Patients with Major Blunt Trauma Need C-Spine CT?

Clinical factors show promise for predicting fractures, but until they’re validated, all such patients should undergo C-spine computed tomography.

Both the National Emergency X-Radiography Utilization Study (NEXUS) and Canadian cervical spine (C-spine) rules have demonstrated that clinical exam is sufficient to clear the cervical spine for certain trauma patients. However, the sensitivity and specificity of these rules for patients with major trauma are not adequate, and many centers perform C-spine computed tomography (CT) for all patients with major trauma. In this prospective single-site study, investigators evaluated the correlation between findings on C-spine CT and presence of any of 18 combined NEXUS and Canadian C-spine criteria in 5812 trauma patients.

All patients met criteria for major trauma requiring trauma team activation, which included Glasgow Coma Scale (GCS) score <14, systolic blood pressure <90 mm Hg, respiratory rate <10 or >20 per minute, significant obvious anatomic injury (e.g., flail chest; two or more long-bone fractures; crushed, degloved, or mangled extremity; amputation; pelvic fractures; open or depressed skull fractures; paralysis), and significant mechanism of injury (e.g., falls >20 feet, high-risk motor vehicle collision).

Fracture incidence was 6.3%. Clinical exam had 100% sensitivity and 0.62% specificity for detecting fractures. Seven NEXUS/Canadian C-spine criteria were independent predictors of fracture: midline tenderness, GCS score <15, paresthesias, rollover motor vehicle collision, ejection from a motor vehicle, age 65, and not being able to sit up in the emergency department. Use of these seven factors increased specificity nearly 20-fold, to 11.6%.

Comment: Prospective multicenter validation of these factors is needed before practice changes. Until then, C-spine computed tomography should continue be the study of choice to evaluate patients with major trauma for possible cervical spine fracture.


Source: Journal Watch Emergency Medicine


Chest Pain: What Happens After the Emergency Department?

Patients who follow up with cardiologists do best.


Researchers examined patterns of follow-up care and outcomes in high-risk patients with chest pain who presented to Ontario emergency departments (EDs) from 2004 to 2010. High risk was defined as having a prior diagnosis of cardiovascular disease, diabetes, or both. The primary outcome was a composite of all-cause death and hospitalization for myocardial infarction within 1 year after the index visit.

Of nearly 57,000 patients, 17% followed up with a cardiologist (with or without a visit to primary care) within 30 days after ED discharge, 57% followed up with a primary care practitioner only, and 25% did not have a visit to a physician recorded. After adjustment for clinical, demographic, and hospital characteristics, the cardiologist group had a significantly lower hazard ratio for the composite outcome (HR, 0.79; P<0.001) than the no–follow-up group and the PCP-only group (HR, 0.85; P<0.001). PCP-only follow-up was significantly beneficial compared to no follow-up (HR, 0.93; P<0.023). Patients seen by cardiologists underwent more testing and received more evidence-based therapies within 100 days after discharge.

Comment: These robust results demonstrate that what happens after the emergency department visit is as important as what happens during the ED visit, and that postdischarge care for patients with high-risk chest pain should include timely assessment by a cardiologist.


Source: Journal Watch Emergency Medicine

Routine Propofol Sedation Increases Risk During Colonoscopy In a large database study, anesthesia assistance was associated with an elevated risk for perforation, splenic injury, or aspiration pneumonia. The use of anesthesiologist-administered propofol sedation for colonoscopy is increasing in the U.S. (JW Gastroenterol April 13 2012 and JW Gastroenterol Feb 17 2012). Propofol use during colonoscopy is associated with shorter recovery time and higher patient satisfaction but also an estimated 20% increase in health care costs. Whereas most studies on the use of propofol sedation during colonoscopy have focused on its economic cost, researchers now explore another possible disadvantage — increased risk for complications. Using a database of linked U.S. Medicare and cancer registry data, investigators identified patients without cancer who underwent diagnostic colonoscopy between 2000 and 2009, assessed whether they received anesthesiology services, and determined whether they were hospitalized during the 30 days following colonoscopy for perforation, splenic injury, or aspiration pneumonia. Data on the type of anesthetic agent used were unavailable, but investigators assumed that anesthesiologist-administered propofol was used most often. Of 165,527 colonoscopy examinations in 100,359 patients, 35,128 procedures (21.2%) were performed with anesthesia assistance. Complications of aspiration, perforation, or splenic injury occurred more frequently in patients who received anesthesia assistance than in those who did not (0.22% vs. 0.16%, P<0.001; odds ratio, 1.46; 95% confidence interval, 1.09–1.94). This difference was mostly attributable to the difference in risk for aspiration (0.14% vs. 0.10%; P=0.02). The risks for perforation and splenic injury were similar between groups. Other independent risk factors for these complications were older age, male sex, increased comorbidity, and undergoing the procedure in a hospital. Comment: Although the overall rate of complications was very low, the use of anesthesia services for diagnostic colonoscopy resulted in a higher risk for complications. These findings might result in part from confounding if patients who received anesthesia assistance were sicker or more prone to complications and were chosen to receive anesthesia for those reasons. Also, the data were from a period when propofol was sometimes administered by trained nurses rather than anesthesiologists, and the relative safety of this approach compared to anesthesia-administered services cannot be determined. Finally, these findings might be more pronounced in the types of patients included in this trial ( 65 years old), and whether the observed increased risk is present in younger or more healthy patients remains to be determined.

In a simulation study, percent adequate chest compressions performed by in-hospital providers fell below 70% within 120 seconds in child and adult manikins.


The American Heart Association defines effective chest compression during cardiopulmonary resuscitation (CPR) as >100 compressions per minute at a depth >38 mm. In a prospective randomized crossover study, investigators compared quality of compressions and the work required to perform them on a 5-year old manikin and an adult manikin. Forty-five in-hospital healthcare providers performed single-rescuer continuous compressions for up to 10 minutes on both the child and adult manikins. A HeartStart MRx Monitor/Defibrillator was used to quantify compression rate and compression depth at 30-second intervals.

Mean chest compression rate remained above 100 per minute for both manikins. Mean compression depth decreased over the 10-minute period for both the child (41 to 34 mm) and adult (42 to 36 mm) manikins. Measured energy expended during CPR was comparable to that expended during running or swimming, and was about 15% greater for the adult than the child manikin. Over the 10-minute period, the percentage of adequate compressions fell from 85% to less than 40% for both manikins. Fewer than 70% of compressions were adequate by 90 seconds in the child and 120 seconds in the adult. Self-reported fatigue during the first 2 minutes was low in comparison to the decrease in compression quality.

Comment: Whether due to fatigue, declining vigilance, or other causes, providers perform high-quality CPR for only a brief period of time. These data support switching the person providing chest compressions every 2 minutes during resuscitation in adults and children.


Source: Journal Watch Emergency Medicine


Head CT Not Useful for Evaluating Acute Dizziness in the ED.

Magnetic resonance imaging has a higher diagnostic yield.

In a retrospective chart review, investigators determined the diagnostic yield (acute and subacute findings) of head computed tomography (CT) in 448 adult patients who presented to a single urban academic emergency department (ED) with acute dizziness (vertigo, lightheadedness, disequilibrium, presyncope).

The overall diagnostic yield of head CT was 2.2%, with emergent findings detected on only 1.6% of the scans. Of the 448 patients, 104 underwent follow-up imaging, most often with magnetic resonance imaging or angiography (MRI/A; 78.7%). Seventeen patients (13%) had findings on follow-up imaging that changed or confirmed the diagnosis; most of the changes in diagnosis were ischemic stroke that was not identified on initial CT. MRI was the follow-up modality that most often led to a change in diagnosis (16% of the time).

Comment: These findings are consistent with the recommendation from the American College of Radiology and American College of Emergency Physicians that head CT be used in the evaluation of acute dizziness only when hemorrhage is the suspected cause. When an intracranial cause of dizziness is suspected (unless the patient presents with trauma or severe headache suspicious for hemorrhage), MRI is the test of choice.

Source: Journal Watch Emergency Medicine

McGrath Series 5 Video Laryngoscope Outperforms Macintosh.

In healthy adult patients with manual cervical spine immobilization, glottic views were better and intubations more successful.


Researchers randomized 88 healthy adults undergoing elective surgery at an academic center in Canada to intubation with a Macintosh laryngoscope or McGrath Series 5 video laryngoscope. Attending anesthesiologists who practiced with the McGrath Series 5 on a manikin until comfortable with its use evaluated glottic visualization using both devices, and intubated the trachea using the second device. Manual cervical spine immobilization was applied to simulate difficult intubation. Laryngeal manipulation maneuvers were not permitted. Patients with reactive airway disease, gastroesophageal reflux, ischemic heart disease, recent stroke or myocardial infarction, or cervical spine instability were excluded.

Baseline characteristics were similar between groups. All McGrath intubations were successful compared with 59% of Macintosh intubations. Intubation failures were due to inability to view the glottis. The McGrath group had significantly more Cormack-Lehane grade I or II glottic views (100% vs. 51%) and higher mean percentage of glottic opening (82% vs. 13%). The McGrath video laryngoscope improved the glottic view, compared with the Macintosh, in 66 patients (75%): by one grade in 36%, by two grades in 53%, and by three grades in 11%. Mean intubation time was longer with the McGrath (36 vs. 22 seconds). Rates of complications, all minor, were similar in the two groups.

Comment: The McGrath Series 5 video laryngoscope had a higher intubation success rate and improved glottic visualization in patients with cervical spine immobilization, compared with the Macintosh laryngoscope. The McGrath’s longer intubation time is not clinically significant, and if the study design had allowed for laryngeal manipulation, Macintosh intubations would likely have been more successful but also taken more time. With so many studies showing superiority of video laryngoscopes over direct laryngoscopes, perhaps it is time to halt these types of comparisons and move on to comparisons of one video laryngoscope with another.


Source: Journal Watch Emergency Medicine


Normalization of Vital Signs Does Not Reduce Risk for Acute Pulmonary Embolism.

Up to one third of patients whose abnormal triage vital signs reverted to normal values had PE.

In a prospective single-center study, researchers evaluated whether normalization of vital signs in patients who present with symptoms of pulmonary embolism (PE) reduces the probability of the disease. Patients at an urban academic emergency department (ED) in North Carolina were enrolled if they were older than 17 years and had at least one predefined sign or symptom and one risk factor for PE.

Of 192 patients, 35 (18%) were diagnosed with PE by computed tomography in the ED. In patients whose abnormal triage vital signs normalized at any time during their ED visit, incidence of PE was not lower than for patients whose vital signs did not normalize. The incidence of PE for patients with abnormal pulse rate, respiratory rate, shock index, or pulse oximetry at triage that subsequently normalized was 18%, 14%, 19%, and 33%, respectively.

Comment: Just as a normal blood gas value does not rule out acute pulmonary embolism, this study shows that normalization of initially abnormal vital signs also does not reduce the likelihood of PE. The best approach for patients presenting with signs and symptoms of PE is to note abnormal vital signs occurring at any time after symptom onset and use these vital sign numbers in the determination of pretest probability of PE, even if they subsequently normalized.

Source:Journal Watch Emergency Medicine