The 2010 American College of Emergency Physicians’ Annual Meeting was held September 28-October 1st in Las Vegas, NV. Of the 477 abstracts presented at ACEP, we selected the 10 we thought have the most potential to change practice for emergency physicians.
The Impact Rating Scale
*Interesting, practice changing for some
**Moderate impact, practice changing for many
***High impact, practice changing for most
****A must read, practice changing for all
*****Landmark project, practice changing for all
^ = independently selected by both authors as a Top Abstract
#25 *** Investigating Depression Among Emergency Medicine Residents
What They Were Looking For: Looks at prevalence of depression at 4 EM Residency Programs.
Methods: Survey study conducted online of 99 residents.
Results: Survey found 12.3% of EM residents had the possibility of major depression.
Why It Matters: This study shows that EP’s in training are particularly susceptible to major depressive episodes and underscores the importance of providing them resources during this formative period.
#334 *** Arm Circumference for a Rapid Estimate of Emergency Patient Weight
What They Were Looking For: To determine a simple method for estimating patient weight at the bedside.
Methods: Prospective study of 408 patients who had mid-arm circumferences (MAC) measured and correlated with their actual weights
Results: With regression analysis, the following formula was derived:
Pt weight (kg) = (MAC (cm) x 3.5) - 30
Why It Matters: For ED patients too sick to have weights determined on a scale, this formula gives EPs and nurses a reasonable alternative.
#466 *** End-Tidal Carbon Dioxide Levels are Associated with Mortality in Emergency Department Patients with Suspected Sepsis
What They Were Looking For: Assessed whether levels of carbon dioxide were associated with in-hospital mortality.
Methods: Prospective cohort study of 147 patients with suspected sepsis.
Results: Mean ETCO2 of patients who survived to d/c was 32.6 (95% CI = 30.8-34.4) compared to 26.5 (95% CI = 21.9-31.1) (p=0.012) in those who did not survive. These levels were inversely correlated with serum lactate levels.
Why It Matters: This gives EP’s another surrogate marker for mortality among patients with sepsis.
#5 *** Rehydration Therapy: Hyaluronidase-Facilitated Subcutaneous (HFSC) Recombinant Human Hyaluronidase Versus Intravenous In Children
What They Were Looking For: To evaluate whether in a pediatric population with mild to moderate dehydration, HFSC fluid (normal saline) administration can be given safely and effectively in clinically-appropriate volumes (similar to IV volumes)
Methods: Phase IV, multicenter, randomized, open-label, noninferiority, company sponsored trial in ED patients aged 1 month – 10 years
Results: Interim analysis; 74 patients (37 HFSC, 37 IV); Mean age 1.98 years; Initial catheter success was 97% HFSC vs 49% IV; Median placement time was 0.6 min HFSC vs 5.0 min IV; Crossover “rescue” treatment occurred in 0/37 HFSC vs 8/37 IV; Mean (SD) volume infused 374 (292) mL HFSC vs 491 (645) mL IV; Mean (SD) duration of infusion at a single site was 2.8 (3.29) hours HFSC versus 6.0 (13.75) hours IV.
Why It Matters: Although this is an interim analysis, the subcutaneous route appears to be a useful alternative to IV administration of isotonic fluids, especially in young children with difficult or potentially failed IV access.
#62 *** EMF–Ultrasonography-Guided Nerve Blockade for Pain Control In Patients With Hip Fractures In the Emergency Department^
What They Were Looking For: To determine if US-guided nerve blockade is safer and more effective than the current standard of care and to determine which nerve block is superior in the ED setting.
Methods: All cognatively intact patients with suspected hip fracture and pain score > 5/10 received initial standard dose of morphine while awaiting x-rays. Once hip fracture radiographically confirmed, patients randomized to one of three arms: (1) US-guided 3-in-1 femoral nerve block (UFNB), (2) US-guided fascia iliaca compartment block (UFIB), or (3) IV morphine sulfate (IVMS). Nerve blocks performed using 30 ml of 0.25% bupivacaine; control group received additional dose of IV morphine
Results: 61 pts enrolled: 24 in the UFNB group, 20 in the UFIB group, and 17 in the IVMS group; All 3 groups similar at baseline with regard to age (P=.673), sex (P=.893), and pain score (P=.188). Pain scores were significantly lower in the nerve block groups compared to the control group for all time points except for the 480 min time point, which is consistent with the known kinetics of bupivacaine. We found a statistically significant difference between the two nerve block groups at 120 minutes (P<.05) and a trend at the other time points indicating that the UFIB may be superior to the UFNB. There were no documented complications.
Why It Matters: Although a pilot, this study provides great evidence for improved pain control in hip fracture patients with the use of a nerve block. Of note, EMF-6 (F Beaudoin) Ultrasonography-Guided Femoral Nerve Blocks in Elderly Patients with Hip Fractures: A Randomized Controlled Trial was also presented this year. With a goal to enroll 100 patients randomized to femoral nerve block vs sham injection, this study will also compare the use of parenteral narcotics in both patient groups.
#19 **** Prospective Study of the Incidence of Contrast-Induced Nephropathy Among Patients Evaluated for Pulmonary Embolism by Contrast-Enhance Computed Tomography
What They Were Looking For: Following CTA, authors looked at rates of contrast-induced nephropathy (increase in Cr >0.5 mg/dL or >25%, Cr>3, need for dialysis or VTE/DVT.
Methods: Prospective, consecutive cohort study. 175 subjects enrolled.
Results: Incidence of CIN following CTPA was 15% (95% CI 10-21%). Relative risk of 6 for severe renal failure or death from renal failure within 45 days.
Why It Matters: Another study emphasizing the risk of contrast radiographic studies is significant. Arming ourselves and our patients with information regarding these risks is responsible, patient-centered and important. Future studies noting sub-groups that may be particularly affected would be helpful to the practicing EP.
#7 **** Efficacy of Topical Lidocaine Preparations (TLP) In Spontaneous Rupture of Uncomplicated Skin Abscesses
What They Were Looking For: To determine incidence of spontaneous drainage of superficial skin abscesses after application of (TLP), and whether management with manual expression of pus only is associated with worse outcomes than formal I&D
Methods: Prospective cohort study; Ages 6 months – 18 years; Part of randomized controlled trial comparing efficacy of 7 days cephalexin vs clindamycin; TLP (LMX-4 4% lidocaine cream) was applied for 30 minutes over the abscess with a bio-occlusive dressing followed by a procedure at discretion of the treating clinician
Results: 156 pts received TLP; 81/156 (52%) of those who received a TLP and 5/44 (11%) of those who did not receive TLP had history of spontaneous drainage prior to presentation; Among those with a history of spontaneous drainage and who received TLP, 40/81 (49%) had re-opening of their infections with manual expression of pus as their only subsequent procedure; 39/81 (48%) had a formal I&D procedure, while 2/81 (2%) had no procedure; 75/156 had no history of spontaneous drainage prior to presentation; 17/75 (23%) had spontaneous rupture of their abscess after application of TLP with manual expression of pus only; 56/75 (75%) had a formal I&D, while 2/75 (3%) had no procedure
Why It Matters: A TLP with a bio-occlusive dressing appears to promote spontaneous drainage or reopening of abscesses that had a history of drainage prior to presentation. This study found no significant differences in outcomes among patients that had manual expression of pus versus formal I&D at 48-72 hours and 7 days.
#88 **** Pelvic Radiographs Are Not Needed In Children With Major Abdominopelvic Trauma Who Are Evaluated With an Abdominopelvic Computed Tomography Scan (APCTS)
What They Were Looking For: To determine the yield of pelvic radiographs in patients undergoing APCTS. The study hypothesis was that pelvic radiographs would not be useful if the child was having APCTS.
Methods: Prospective study; Pediatric ED; All consecutive children 18 years of age or less who met criteria for activation of the trauma team were enrolled. No children were excluded. All children had same radiographic studies performed which included a pelvic radiograph and an APCTS.
Results: 600 children enrolled; Mean age was 11.8 + 4.7 years-old (range of 2 to 18 years-old); Mechanism of injury included: MVA 456 (26%), hit by a car 72 (12%), fall 36 (6%), bicycle accident 24 (4%), and GSW 12 (2%); 162 (27%) had pelvic fractures; plain pelvic xray identified 48 (29.6%) fractures while the CT scan identified all 162 (100%)
Why It Matters: Although it might be intuitive, this abstract supports the fact that pelvic radiographs are unnecessary in children with major trauma who will undergo APCTS. This not only saves money, but significant radiation exposure as well.
#21 – Computerized Prescriber Order Entry Does Not Decrease Medication Errors Upon Implementation in a Community Hospital Emergency Department
#253 – Computerized Prescriber Order Entry Decreases Patient Satisfaction and Emergency Physician Productivity
What They Were Looking For: To determine whether CPOE improves medication ordering safety, improves adherence to JCMM standards and to measure its affect on patient satisfaction and EP productivity.
Methods: Retrospective, observational trial of 400 patients. Before-and-after study of 20K+ subjects.
Results: #’s of drug errors which were low in both arms were not significantly affected. Adherence to JCCM standards improved. Room to doc times increased from 29 min to 39 min, LOS increased approximately 7 min and % of time spent on ambulance diversion increased from 2.2% to 5.2 %. Press Ganey survey scores of the ED fell from 75% to 58% and EP ranking declined from 91% to 62%.
Why It Matters: Two troubling studies showing that post-CPOE implementation, crucial metrics involving patient satisfaction and throughput were negatively affected. The upside of such a program at this institution also appeared to be minimal. As many EDs are considering CPOE, a frank discussion regarding expectations post-CPOE for the ED and EPs should include these important studies.
Dr. Breyer is an Associate Program Director at Christiana Care Health System in Newark, Delaware. His research interests include Medical Education and Ultrasound.
Dr. Valente is an Assistant Professor at the Alpert Medical School of Brown University in Providence, RI. He is boarded in Emergency Medicine and Pediatric Emergency Medicine. His interests include trauma, pediatrics, advanced airway education, wound care, and ultrasound.