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4th May 2023
Low back pain (LBP) is responsible for nearly 5% of all emergency department visits. Opioids and NSAIDs are useful emergency department (ED) treatments for acute LBP. Moreover, skeletal muscle relaxants, including diazepam (DP) and methocarbamol (MC) can serve as viable alternatives. Despite this, there is insufficient evidence to identify whether any one class of medication has a net advantage.
This lack of evidence led to researchers to undertake the current study. This double-blind RCT set out to compare intravenous DP with MC in acute non-traumatic musculoskeletal LBP. Both groups of patients also received morphine. Pain assessment was performed using a simple numeric rating scale, NRS, ranging from 0 (no pain) to 10 (worst possible pain). The primary outcome was the difference in pain relief post-intervention after 60 minutes.
Diazepam and post-intervention pain relief
There were 101 patients with 51 who received diazepam. Pain scores were lower with both treatments in comparison to baseline levels (p < 0.001). After 60 minutes, pain score reductions were slightly greater with DP (p = 0.048). The length of stay in the ED was similar between the two groups (MC = 5.9 hours vs DP = 4.8 hours, p=0.365). However, patients receiving diazepam were more likely to report drowsiness (4% vs 15% , p = 0.001).
These findings led the authors to concluded that DP and MC gave rise to similar pain relief after 60 minutes. Nevertheless, DP use may be associated with more drowsiness.
Upper gastrointestinal (GI) bleeding mortality is 5-10% largely due to peptic ulcers and portal hypertensive gastropathy. A common scoring system to evaluate patients with upper GI bleeding is the Glasgow-Blatchford Score (GBS). In fact, the European Society of Gastrointestinal Endoscopy suggests that a GBS score of <1 prior to endoscopy, indicates a low risk of re-bleeding. Both GBS and a modified version appear to be moderately accurate for decision-making in those with an upper GI bleed. CANUKA has a similar performance to the GBS and more accurately identifies those with a low risk for adverse outcomes. Nevertheless, currently, there is a lack of comparative data on these three systems.
Recently, researchers sought to compare the effectiveness of each system for identifying patients at low risk of death or the need for a subsequent intervention. Using a retrospective approach, the team considered emergency department patients with an upper GI bleed. They explored the need for blood transfusion, endoscopic haemostasis or re-bleeding within seven days. The scoring system sensitivity, specificity, positive and negative predictive values were used as outcome measures. Cut-off thresholds for low risk of the GBS, the modified version (mGBS) and CANUKA were set at <1, 0 and <2 respectively.
GBS and CANUKA identification of low-risk upper GI bleeding patients
There were 386 patients with a median age of 60 years (65.3% male) with sufficient data to calculate the three scores.
Using the threshold levels for GBS, mGBS and CANUKA, 24.9%, 18.2% and 18.9% of patients respectively, were at low risk. Furthermore, with these cut-off levels, only 2.2%, 4.6% and 0% respectively, required a further intervention. Sensitivity values with these cut-offs were broadly similar (98.2% to 100% for CANUKA). The negative predictive values ranged from 97.8% (GBS) to 100% for CANUKA. In addition, no deaths occurred for patients identified as being at low risk.
These findings led the authors to conclude that a Glasgow-Blatchford score of <1 and a CANUKA score of <2 appears to be safe for identifying patients at low risk of death or the need for an intervention following an upper GI bleed.
Raised cardiac troponin in acute dyspnoea could be a useful prognostic marker in those without an acute myocardial infarction (MI).
Acute dyspnoea is a common complaint within an emergency department (ED). Dyspnoea is also a common symptom of an acute myocardial infarction (MI), affecting nearly two-thirds of patients. This consequently necessitates prompt patient assessment.
High-sensitivity cardiac troponin T (CTT) can quickly assess patients with chest pain to rule out an MI. Nevertheless, elevated cardiac troponin T levels can also occur in those experiencing chest pain without an MI.
In the current study, researchers set out to determine role of CTT in ED patients presenting with acute dyspnoea not due to an acute MI. Adult patients with acute dyspnoea were included and CTT levels measured together with their clinical history. CTT levels were divided into three levels: <15, 15-100 and >100 µg/l. An analysis provided the three-month relative risk of mortality with adjustment to models for a patient’s clinical history.
Cardiac troponin and three-month mortality risk
A sample of 1001 patients had usable data. With CTT levels < 15 set as the reference point, a CTT level between 15 and 100 gave rise to a more than three-fold higher mortality risk (Hazard ratio, HR = 3.68 (95% CI 1.72-7.84). The mortality risk was even higher with levels above 100 µg/l (HR = 10.523, 95% CI 4.46-24.80).
Patients with higher cardiac troponin levels were generally older, had a higher number of co-morbidities and more severe symptoms. The researchers felt that the data highlighted the value of CTT as an important risk factor in acute dyspnoea without a cardiac cause.
5th April 2023
Neutrophil CD64 level measurement in emergency department (ED) patients with a suspected bacterial infection, has a both a high specificity and positive predictive value for diagnosing a bacterial infection. However, low levels cannot be used to rule out these infections, according to the findings of a study by the COVPACH study group.
Infections are a common ED presentation that require diagnostic biomarkers to enable the differentiation between those of a bacterial or viral origin. C-Reactive Protein (CRP) is one such marker that appears to act as a surveillance molecule for altered self and certain pathogens. Levels of CRP increase very rapidly in response to trauma, inflammation, and infection although CRP has been found to be neither sufficiently sensitive or specific to identify bacterial infections, particularly with lower respiratory tract infections. Although other markers such as the white blood cell (WBC) count and erythrocyte sedimentation rate can be used, the WBC count has a low sensitivity and specificity for a bacterial infection. An alternative marker is the neutrophil CD64 level with one meta-analysis concluding that it could be a promising and meaningful biomarker for diagnosing bacterial infection. In addition, while neutrophil CD64 demonstrates moderate performance in diagnosing sepsis in critically ill patients, whether it helps to diagnose bacterial infections within the ED where an answer is rapidly needed, is less clear and was the purpose of the current study.
Researchers examined the value of neutrophil CD64 (nCD64) in a study with COVID-19 suspected patients who visited the ED and for which a definitive diagnosis was made. Blood samples were analysed within 2 hours after presentation and patients categorised as having either a bacterial, viral, and non-infectious disease. The team then determined the diagnostic value of nCD64 and compared this to those of CRP and WBC counts.
Neutrophil CD64 as a biomarker for bacterial infections
A total of 182 patients with a median age of 63 years (52.7% male) were included and of whom, 43% had a confirmed bacterial infection and 35% a viral infection.
The median nCD64 level was higher in bacterial compared to viral infection (p = 0.004) and the non-infectious group (p < 0.0001). However when analysing the area under the receiver operating characteristics curve, there were no significant differences between the three biomarkers.
Using a cut-off of 9.4 units for nCD64, the corresponding positive predictive value was 1.00 and the specificity was 1.00 although the sensitivity was only 27%.
The authors concluded that nCD64 had a high specificity and positive predictive value for diagnosing a bacterial infection but noted how a low nCD64 could not be used to rule out a bacterial infection. They added that nCD64 should be combined with additional tests to form an algorithm that adequately diagnoses infectious diseases.
Citation
van de Ven NLM et al. Point-of-care neutrophil CD64 as a rule in diagnostic test for bacterial infections in the emergency department. BMC Emerg Med 2023
Among patients presenting at an emergency department (ED) with cannabis intoxication, almost half presented with cardiovascular (CV) symptoms according to the findings of a retrospective analysis by researchers from Amsterdam, the Netherlands.
In a study with 10,000 students, cannabis was rated as the most favourable most commonly used tobacco product the past 30 days and also perceived as the least harmful when compared to electronic cigarettes and cigarettes themselves. However, cannabis use is not without risks and one systematic review found that the data from 29 observational studies, suggested an association between cannabis-based product use and cardiovascular disease, with the strongest evidence for ischaemic heart disease. There is also data to suggest that cannabis use is associated with an increased risk of cardiac dysrhythmia, which is rare but may be life-threatening. As a result, there remains some uncertainty over whether patients who present at an ED with cannabis intoxication should undergo a full cardiovascular evaluation.
In the current study, the Dutch team retrospectively analysed data on a convenience sample of all self-reported cannabis-intoxicated adult patients who presented at an Amsterdam ED. Individuals who were intoxicated due to mixed recreational drug use were excluded and presenting symptoms were categorised as either CV-related (e.g., palpitations, chest pain and syncope) or non-cardiovascular (like nausea and vomiting).
Cardiovascular symptoms and cannabis intoxication
A total of 1689 individuals with a mean age of 31.9 years (62.4% male) were included in the study.
Overall, 47.2% presented with cardiovascular symptoms and which included palpitations (57.6%), chest pain (12.9%) and syncope (36.8%). Among those with CV-related symptoms, 8 had complications including ST elevation myocardial infarction, non-ST elevation myocardial infarction, atrial fibrillation and AV-nodal re-entrant tachycardia. Other ECG abnormalities observed were ischaemic ECG changes, first-degree atrioventricular block, premature atrial complexes, ventricular extrasystoles, prolonged corrected QT interval, and a Brugada type 1 pattern. Fortunately, all of these resolved spontaneously during the observational period.
The authors concluded that while the clinical relevance of cardiovascular symptoms is largely unknown, cannabis-intoxicated patients should have a cardiac evaluation, and symptoms should not just be considered benign.
Citation
Gresnigt F et al. Incidence of cardiovascular symptoms and adverse events following self-reported acute cannabis intoxication at the emergency department: a retrospective study. Emerg Med J 2023
Administration of intra-vesical tranexamic acid to a Foley catheter in patients with gross haematuria, prior to continuous bladder irrigation, reduced both the length of stay in the emergency department (ED) and the duration of catheter placement, according to a before and after study by Korean researchers.
Macroscopic or gross haematuria is a commonly seen condition in the ED and for which there are a variety of causes. In gross haematuria, it is necessary to ensure that patients are not in urinary retention due to clot formation and in cases of clot retention, a three-way Foley catheter is used, to allow irrigation fluid to be passed through the bladder, clearing clots from the site of bleeding. Tranexamic acid has haemostatic effects and hinders fibrinolysis and clot degradation and while the drug has been used to control bleeding in conditions such as epistaxis, whether it can affect spontaneous bleeding from the lower urinary tract is less clear. However, to date, one small study in which bladder irrigation, local intra-vesical tranexamic acid and placebo were injected into the bladder via Foley catheter, found that the drug could significantly reduce the volume of required serum for bladder irrigation to clear urine.
Based on these encouraging preliminary findings, in the current study, the Korean team hypothesised that the use of tranexamic acid in those with gross haematuria, would reduce the duration of patient’s stay in the ED as well as the length of time for which Foley catheter placement was required. They conducted a ‘before’ and ‘after’ retrospective single-centre study, and examined the impact of using tranexamic acid in patients after a certain cut-off date (March 2022) and compared outcomes for patients before the specified date, i.e., those for whom tranexamic acid had not been used. The team set the primary outcomes as the length of stay in the ED and the duration of Foley catheter placement. The secondary outcomes were the admissions and the revisits for continuous bladder irrigation within 48 h after discharge.
Intra-vesical tranexamic acid and duration of ED stay
A total 159 patients with a mean age of 79.4 years (93.5% male) were included, with 86 in the ‘after’ group.
The results showed that the median length of stay in the ED was significantly shorter in the ‘after’ group (274 vs 411 minutes, p < 0.001). In addition, the median duration of the Foley catheter placement was also shorter (145 vs 308 minutes, p < 0.001).
There were also a lower proportion of ED visits among those given tranexamic acid (2.3% vs 12.3%, p = 0.031) as well as a trend towards less hospital admissions (29.1% vs 45.2%, p = 0.052).
The authors concluded that a reduction in length of stay of gross haematuria patients was observed after the implementation of intra-vesical tranexamic acid injection via a Foley catheter and called for further studies to confirm these findings.
Citation
Choi H et al. Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: A before-and-after study. Am J Emerg Med 2023
An analysis by Korean researchers of patients admitted to an emergency department (ED) with a rib fracture diagnosed on chest radiography has identified important fracture characteristics indicative of significant intra-thoracic and intra-abdominal injuries that require assessment by chest computed tomography (CT).
The ribs are frequently affected by a blunt or penetrating injury to the thorax and within an ED, it is vital for the interpreting radiologist to not only identify the presence of rib injuries but also alert the clinician about organ-specific injury. A CT chest plays a major role for the in-vivo assessment of the body composition at the tissue/organ level and is the imaging modality of choice for accurate delineation of rib fractures and associated internal injuries. However, the main limitation associated with the use of CT scan is the ionising radiation patient burden. Consequently, identification of rib fracture features that could enable more appropriate use of a chest CT for such patients are warranted.
In the current study, the Korean team retrospectively analysed adult patients diagnosed with rib fracture due to blunt chest trauma that was diagnosed based on chest radiography and who underwent a chest CT examination. The researchers set the primary outcomes as intra-thoracic and intra-abdominal injuries that could be identified on a chest CT.
Rib fracture characteristics and need for a chest CT
A total of 401 patients with a mean age of 58 years (29.5% female) were included and of whom, 279 had any intra-thoracic or intra-abdominal injuries.
Overall, there was a higher number of rib fractures in those who sustained significant internal injuries (p < 0.001) and a higher level of bilateral fractures (p = 0.001).
In regression analysis, the number of fractures (adjusted odds ratio, aOR = 1.44, 95% CI 1.16 – 1.78), lateral fractures (aOR = 2.80) and posterior rib fractures (aOR = 3.18) were all independently associated with intra-thoracic and intra-abdominal injuries. Other factors also independently associated with such internal injury were the requirement of O2 supplementation, mechanical ventilator use, requirement of transfusion, pelvic bone fracture and extremity fracture.
The authors concluded that among blunt trauma-induced rib fracture patients, posterior and lateral fractures, more than three fractures, the need for O2 supplementation were the most important factors indicating the need for chest CT to identify intra-thoracic and intra-abdominal injuries in the emergency department.
Citation
Kim W et al. Characteristics of rib fracture patients who require chest computed tomography in the emergency department. BMC Emerg Med 2023
10th March 2023
Work by researchers from San Diego, La Jolla in the US, has shown that an increased exposure to particulate matter 2.5 μm or less in diameter (PM2.5), increases the risk for all-cause and infection-related visits to an emergency department among infants during their first year of life.
It has been recognised for several years that particulate matter comprising particles with a diameter of less than 2.5 micrometres, can penetrate deeply into the lungs, causing irritation and corrosion of the alveolar wall and therefore impairing lung function. PM2.5 comes from a wide range of sources including natural (i.e., dust, sea salt), anthropogenic emissions, e.g., vehicles, as well as household wood burning and from industry. The composition of PM2.5 is a complex mix of inorganic components such as heavy metals, organics (polycyclic aromatic hydrocarbons) and biologicals e.g., bacteria, viruses and fungi. Prior studies have shown that exposure to PM2.5 during pregnancy can increase adverse outcomes and stillbirth and early childhood exposure to air pollutants may play a role in the development of asthma. However, research to data on the impact of early PM2.5 exposure and the risk of hospitalisation during infancy is conflicting, indicating either an increased risk of bronchiolitis or no noticeable effect compared to older children.
In the current study, researchers examined all live births in California between 2014 and 2018 and estimated weekly exposure to particular matter based on the postal (zip) codes using a machine learning model. They set the outcomes of interest as both the first all-cause emergency department (ED) visit and the first infection-related visit based on birth status (pre or full-term).
Particulate matter and ED visits
A total of 983,700 infants, (49.4% female) were included in the analysis.
During the first year of life, the odds of an ED visit for any cause was higher for both pre-term (odds ratio, OR = 1.05, 95% CI 1.04 – 1.06) and full-term infants (OR = 1.05, 95% CI 1.04 – 1.05) for each 5-μg/m3 increase in exposure to PM2.5.
Similarly, there were elevated odds for a respiratory infection-related ED visit, pre-term (OR = 1.03) and full-term (OR = 1.05). In fact, the highest risks for an ED in both types of infant occurred between 18 to 23 weeks.
The authors concluded these elevated risks associated with exposure to particulate matter, may have implications for minimising exposure to air pollution.
Citation
Teyton A et al. Exposure to Air Pollution and Emergency Department Visits During the First Year of Life Among Preterm and Full-term Infants. JAMA Netw Open 2023
10th February 2023
A pilot study undertaken within a Chicago hospital emergency department could pave the way for the widespread development of diabetic screening programs.
It has been estimated that globally, approximately 415 million are living with diabetes yet an estimated 46% of those with the condition are undiagnosed. Although an emergency department is designed to provide critical access to healthcare, it also provides an opportunity to identify and subsequently link patients to other services. For example, screening services within an emergency department (ED) have previously been established for HIV as well as for substance use disorders. In addition, one 2016 Australian study that involved routine ED testing of HbA1c in an area with a known high prevalence of diabetes, concluded that such an initiative was a feasible way to identify those with undiagnosed disease and provided an opportunity to improve patient care. Moreover, it has become recognised, particularly in the US, that ethnic minorities and low-income adults are disproportionately affected by diabetes with a resultant increased risk of both diabetic complications and mortality. As a result, in the current study, researchers examined whether a pilot diabetic screening program performed within an ED, might enable the identification of the condition, especially among those of ethnic minorities.
The researchers made use of a best practice alert built into the electronic medical record which flagged ED patients who were at risk of diabetes, i.e., patients aged 45 years and older or 18 to 44 year olds with a recorded body mass index of 25 or greater, without a recorded history of diabetes or a HbA1c measurement within the last 3 years. The team then attempted to contact all potentially eligible patients.
Diabetic screening program and diabetes detection
A total of 352 eligible individuals with a mean age of 52.2 years (54.5% female) were identified. Among the cohort, 264 were diagnosed with prediabetes (a HbA1c level of 5.7 to 6.4%) and 88 diabetes (HbA1c > 6.5%). Among those with diabetes, 62 had severe disease (HbA1c > 10%) and nearly two-thirds of patients (64.8%) were non-Hispanic Black or of unknown ethnicity and 19.6% were Hispanic. Interestingly, among the entire cohort, 74.7% had no prior diagnosis of either prediabetes or diabetes.
While the researchers were able to successfully identify patients with undiagnosed diabetes, particularly among ethnic minorities, questions remained as to the value of undertaking diabetic screening within an ED in other areas and whether such an initiative would prove to be cost-effective.
Citation
Danielson KK et al. Prevalence of Undiagnosed Diabetes Identified by a Novel Electronic Medical Record Diabetes Screening Program in an Urban Emergency Department in the US. JAMA Netw Open 2023.
13th January 2023
Three screening-based predictive tools for COVID-19 used within an emergency department (ED) have been shown to be inferior to a polymerase chain reaction (PCR) test according to the results of a study by US researchers.
During the early phase of the COVID-19 pandemic, diagnostic testing was not always readily available. Consequently, there was a need for clinical decision-making methods to identify patients most likely to be infected with the virus. Some such methods were developed and one study using a risk score for COVID-19 diagnosis, achieved an area under the receiver operating characteristic curve of 0.85 in a validation dataset, prompting the authors to suggest that it could be used as a supplemental tool to assist in the clinical decision to quarantine patients admitted to hospital from the emergency room. Nevertheless, while there are several available methods, no studies have compared the performance of different methods to predict the likelihood that a patient presenting to an ED has COVID-19.
In the current study, the US team retrospectively assessed three screening-based methods to determine which was better at detecting those who ultimately tested positive for COVID-19. The three methods were a nursing triage screen (NTS), an ED review of systems (ROS) performed by physicians and physician assistants and a standardised COVID-19 probability assessment (PA) by an ED attending (i.e., consultant) physician. The study included all patients aged 18 years or older who were admitted to hospital from the ED and who had a PCR confirmed positive COVID-19 infection. The NTS for example, involved asking about the presence of symptoms including fever, chills, weakness, severe headache, anosmia, dysgeusia, conjunctival injection, sore throat, cough, shortness of breath (SOB), abdominal pain, vomiting, diarrhoea, bruising or bleeding, myalgia, arthralgia and rash. Similarly, the ED review of ROS asked about symptoms, whereas after the initial ROS (but before the COVID-19 test result was available), the attending physician would classify the patient as high, moderate, low or no probability of having COVID-19. The sensitivity, specificity and positive predictive value (PPV) and negative predictive value (NPV) were calculated for each method. and regression analysis used to assessed each tool’s performance.
Screening-based prediction and COVID-19 positivity
A total of 748 patients with mean age of 57.5 years (56.8% male) were included in the analysis. Overall, 21.3% of patients tested positive for COVID-19 following a PCR test.
The attending physician had the highest sensitivity (0.62, 95% CI 0.53 – 0.71), followed by the ED ROS (0.53, 95% CI 0.43 – 0.62) and the least sensitive was the NTS (0.46, 95% CI 0.37 – 0.56). Specificity values were also highest for the attending physician (0.76) though this was similar to the NTS (0.71) and lowest for the ED ROS (0.62). Nevertheless, all three methods had a low positive predictive value, ranging from 26% (ED ROS) to 40% (attending physician).
The authors concluded that none of the three screening-based tools was accurate enough to replace a COVID-19 PCR test, adding that hospitals should not rely symptom screening to identify infected patients and recommended universal COVID-19 testing prior to all admissions.
Citation
Dilorenzo MA et al. Performance of three screening tools to predict COVID-19 positivity in emergency department patients. Emerg Med J 2023
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