You Put a Catheter Where? The Groin May Not be as Dirty as Previously Reported

This is part of a recurring series examining landmark articles in Emergency Medicine, in the style of ALiEM’s 52 Articles.

Discussing:  Marik, P. Flemmer, M. Harrison, W. “The Risk of Cathether-Related Bloodstream Infections with Femoral Venous Catheters As Compared to Subclavian and Internal Jugular Venous Cathethers: A Systematic Review of the Literature and Meta-Analysis.” Critical Care Medicine, 2012, Vol 40(8). 2479-2485

Main Points:

  1. This 2012 meta-analysis demonstrated that catheter-related blood stream infection (CRBI) risk is no different between internal jugular, subclavian, and femoral catheter insertion. The authors demonstrated that previous level 1A guidelines regarding femoral catheter infectious risk were in error.
  2. The overall risk of CRBI is declining over the recent years and likely due to the combination of more precautions at the time of insertion as well as vigilant management of the catheter once placed.

Background:

There is significant morbidity and mortality associated with CRBI. In the United States alone, an estimated 30-60 thousand patient deaths occur annually secondary to this infectious process. In 2011 a clinical recommendation from respected organizations including the CDC’s Healthcare Infection Control Practices Advisory Committee as well as the Infectious Disease Society of America issued a class 1A recommendation to “avoid using the femoral vein for central access in adult patients.” This recommendation would suggest that there is strong supporting data including at least one well performed RCT. The purpose of this meta-analysis by Marik and his colleagues was to call into question the validity of such an absolute statement. Marik and his partner Flemmer performed an exhaustive literature search and were able to find 2 RCTs and 8 cohort trials to include in their meta-analysis. This literature review was more comprehensive then the citations provided by the societies issuing the level 1A recommendations. There study, however, focused solely on the question of CRBI and did not address concerns other concerns associated with central venous access such as injury to nearby structures, DVT, or bleeding.

Details:

This study reviewed more data than the 1A recommendation from the CDC and IDSA and could not find compelling evidence that the femoral vein should be avoided for concerns of CRBI. Furthermore, it appears that the universal precautions that are being used currently have likely led to an overall decrease in CRBI compared to the years past. For example, the rate of CRBI in the United States in 1998 was 5.32/1,000 catheter days and has subsequently dropped to 2.05/1,000 in recent data. The Welsh Healthcare Associated Infection Program which is the largest collection of data and noted that in over 55 thousand catheter days in 2009 and 2010 there were only 0.61/1,000 catheter day infectious risk with no difference between insertion sites. Marik and his colleagues therefore note that the site of preference should “depend on the expertise and skill of the operator and the risks associated with placement.” The authors recommend against using femoral vein catheters in renal transplant patients, patients who would benefit from early mobilization as well as the massively obese due to a subgroup analysis in the Parienti study that noted worse outcomes in these individuals.

The average CRBI density in the compilation of trials was noted to be 2.5 +/- 1.9 per 1,000 catheter days (range 0.6-7.2). In compiling the data it was noted that two of the cohort trials, Lorente and Nagashima, appeared as statistical outliers increasing the heterogeneity of the meta-analysis significantly. It is unclear why these two trials demonstrated a more than two-fold increased risk of CRBI with femoral catheter insertion. If these trials were removed from the data the authors noted that there appeared to be no heterogeneity within the study (RR 1.02, 95% CI 0.64-1.65, p = 0.92, I² = 0%). This study also performed a meta-regression that appeared to demonstrate a significant interaction between the risk of infection and the year of publication (p = 0.01).

Level of Evidence:

Based on the design of this study, including RCTs and cohort trials, with a few limitations this study was graded a level III based on the ACEP Clinical Policy Grading Scheme for meta-analyses.

Surprises:

In many aspects of medicine it is curious to see how wide practice variation can be, especially when considering geographic and healthcare system influences. This notion is highlighted by reviewing the different guidelines within this meta analysis by various public health/safety committees across the United States and United Kingdom.

Relevant articles:

Lorente, L. Henry, C. Martin, MM. et al. “Central Venous Catheter-Related Infection in a Prospective and Observational Study of 2, 595 Catheters.” Crit Care, 2005 9. R631-5

Nagashima, G. Kikuchi, T. Tsuyuzaki, H. et al. “To Reduce Catheter-Related Bloodstream Infections: Is the Subclavian Route Better than the Jugular Route for Central Venous Catheterization?” J Infec Chemother, 2006 12. 363-65

Parienti, JJ. Thirion, M. Megarbane, B. et al. “Members of the Cathedia Study Group: Femoral v. Jugular Venous Catheterization and Risk of Nosocomial Events in Adults Requiring Acute Renal Replacement Therapy: A Randomized Controlled Trial.” JAMA, 2008 299. 2413-22

Source Articles:

Marik, P. Flemmer, M. Harrison, W. “The Risk of Cathether-Related Bloodstream Infections with Femoral Venous Catheters As Compared to Subclavian and Internal Jugular Venous Cathethers: A Systematic Review of the Literature and Meta-Analysis.” Critical Care Medicine, 2012 Vol 40(8). 2479-2485

By

Anatoly Kazakin MD

Perusing the Literature (PTL): Haloperidol for Migraines

Introducing the newest blog section – Perusing the Literature (PTL). This section includes summaries of recent articles that residents and attendings have stumbled across that have raised an eyebrow. These monthly posts are meant to spark a discussion and do not represent a change in the standard of care (unless otherwise noted).

Let’s get the ball rolling!

______________________________________________________________________________

November 2015: Haloperidol for Migraines

The Article: Gaffigan ME, et al. A Randomized Control Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015 Sep;49(3):326-34.

The One-Liner: Intravenous haloperidol appears to be as safe and effective as metoclopramide for the ED treatment of migraine headaches.

Background: Headache accounts for 2–5% of ED visits and is the 5th most common ED complaint. Current first-line ED therapies include dopamine receptor antagonists such as prochlorperazine and metoclopramide, often with diphenhydramine. Studies have shown these medications to be safe and more effective than opiates, NSAIDs, and sumatriptan. Haloperidol is another dopamine antagonist and has been reported to be effective in the treatment of migraine headaches.

Methods: This was a prospective, double-blinded, randomized, controlled trial at a single emergency department of patients presenting with migraine headache. Each subject was given a 1L normal saline bolus and a baseline ECG completed. Diphenhydramine 25mg IV was administered, followed by the study medication – metoclopramide 10mg IV or haloperidol 5mg IV. Pain, nausea, restlessness, and sedation were assessed at 0, 20, 40, 60, and 80 min. After 80 min, the subject was either discharged home or offered rescue therapies at the discretion of the treating physician. Prior to discharge, a second ECG was obtained. Subjects were to be contacted at 48-hours after discharge and were asked if they were happy with the medication received, and if they had any recurrent or persistent symptoms specifically, headache, sleepiness, restlessness, agitation, nausea, vomiting, or chest pain.

Results:

  • A total of 64 patients were enrolled – 31 randomized to haloperidol and 33 metoclopramide.
  • Mean reduction in pain from baseline was statistically and clinically significant for both haloperidol and metoclopramide groups.
  • Pain scores between the groups did not differ at baseline, at the last measurement, in the magnitude of the pre-post treatment change, or in the time to pain relief.
  • More patients in the metoclopramide group required a rescue medication for pain relief (p < 0.02).
  • Sleepiness was statistically more common in the group that was to receive haloperidol (p < 0.02). There were no other differences between the groups in any of the other side-effect questions asked (nausea, restlessness, chest pain).
  • Mean QTcs were equal and normal in the two groups and did not change after treatment for either group.
  • 43/64 patients were reached for 48-hour follow up. Restlessness reported more by the haloperidol group (43% vs 10%, p < 0.015).

Limitations:

  • The study was single centered and admittedly small.
  • The study used a convenience sample, subjects were relatively young and mostly female (81%).
  • Post-treatment ECGs were obtained in only 45% of subjects.
  • Telephone follow up was obtained in only 67% of subjects.

 

Posted by Adam Janicki, MD, PGY4

Reviewed by Gita Pensa, MD, Clinical Assistant Professor, Department of Emergency Medicine

Tricks of the Trade: A-Line Kits for Vascular Access

Ever struggle with vascular access?

Ever tried a 20G A-Line kit?

Even if you have,  once a flash is obtained it is common to not be able to thread the wire. If you pull the needle out of the catheter, it is rigid and difficult to replace in the catheter and rarely results in salvaging the attempt. In this video, I show you that by cutting the white cap off the back of the a-line kit, it will liberate the guide wire allowing the proceduralist to use it as a backup if the first attempt at placing the catheter fails. I have found,  many times when a flash is obtained but the wire doesn’t pass, the attempt can be salvaged with this technique. Enjoy…

 

CITW 8: A Painful Eye

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 47 year old male with a history of DM and HTN presents to the ED with a painful and red left eye, worsening over the past 24-36 hours.  It is associated with blurred vision, photophobia, headache, a foreign body sensation, and drainage. He tried saline drops without relief. He’s never had this before. He denies any trauma to the eye, although states he did leave his contacts in two nights ago. He denies fevers, chills, or any other associated symptoms.

Vitals: BP 156/87, HR 87, T 98.9 °F, RR 14, SpO2 100 % on RA

Notable PE: Visual acuity (R 20/30 L 20/50). EOMI intact, but painful. Pupils 3 mm and reactive. Lids everted and swept revealing no foreign bodies. Visual fields intact. Normal accommodation. Left eye findings below:

Eye
What’s the diagnosis?
Continue reading

US articles: PTX in trauma, FAST for Thoracotomy, Pedi Hip Effusions

brownsound 2

Brown Ultrasound Tape Review:  10/15/15

Article 1: FAST Exam to Predict Survivors of ED Thoracotomy

Inabi, et al. FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy. Annals of Surgery 262(3):512-518, 2015.

Fresh off the trauma surgical press last month, this study examined the utility of FAST exam (specifically parasternal and subxiphoid cardiac views) to predict positive outcomes (survival to discharge or organ donation) of ED resuscitative thoracotomy (RT).

This was a prospective cohort study at LA County/USC Medical Center. In 3.5 years, 187 patients arrived in traumatic arrest and underwent FAST and RT (that’s 4-5 thoracotomies a month – WOW!). They documented +/- pericardial fluid and +/-  cardiac motion. PGY2-4 EM residents performed the FAST exams after some formal training, and they were supervised by “faculty” – not clear if those were surgeons or EM attendings.

About ½ patients lost vitals at the scene and another ¼ both en route and in the ED. Overall survival – 6 patients (3.2%). Overall organ donation – 3 patients (1.6%). Cardiac motion on FAST was 100% sensitive for the identification of survivors and organ donors (and 73.7% specific).  While the tables and discussion include a lot on the presence or absence of pericardial fluid, this did not impact the sensitivity or specificity of FAST. If cardiac motion was absent, the likelihood of survival was 0.

Bottom line: Given that RT is such a high risk, low survival procedure, cardiac FAST can be used (with excellent sensitivity) to identify traumatic arrest patients with better odds of survival or organ donation from ED thoracotomy. No cardiac motion means pretty much no chance of survival or organ donation.


 

Article 2: Handheld E-FAST for Pneumothorax

Kirkpatrick, et al. Hand-Held Thoracic Sonography for Detecting Post-Traumatic Pneumothoraces: The Extended Focused Assessment With Sonography for Trauma (EFAST). Journal of Trauma 57:288-295, 2004.

This was another trauma surgery study out of Vancouver Hospital and Health Sciences Centre interested in the test characteristics of hand-held US to look for PTX in trauma patients. They compared EFAST examinations for PTX to:

(1) CXR results

(2) a “composite standard” of clinical information, which included some combination of CXR, CT if it happened, clinical course, and need for chest tubes/needle decompression

(3) CT alone (the gold standard for patients who had a CT).

This was a retrospective chart review on trauma patients (note – those who were in “physiologic extremis” with suspected PTX were excluded). All EFASTs were done by the attending trauma surgeon using a linear transducer. They looked for lung sliding or comet tail artifacts or color power Doppler evidence of pleural sliding in at least 3 rib spaces. PTX was diagnosed if neither sliding nor comet tail artifacts were seen.

Continue reading

When life gives you LEMONs- Predicting difficult intubations in the ED

Article:

Reed MJ, Dunn MJ, & McKeown DW. Can an Airway Assessment Score Predict Difficulty at Intubation in the Emergency Department? Emerg Med J 2005; 22(2): 99 – 102.

Main Points:

  1. Rapid assessment tools can be helpful in predicting difficult intubations in the emergency department
  1. Use of SOME elements of the LEMON (look, evaluate, mallampati, obstruction, neck mobility) approach to airway assessment MAY be helpful in predicting likely laryngoscopic view (Cormack- Lehane grade) as a proxy for difficulty of intubation. The following are more likely found in patients with high grade views (2-4).
  • large incisors
  • reduced inter-incisor distance
  • reduced thyroid to floor of mouth distance

Background:

Predicting difficult intubations is not always straightforward. At the time of publication (2005), little validation of rapid assessment of possible difficult intubations in the ED. The authors test the use of the LEMON approach as a predictor of difficult intubations, and suggest key parts of the assessment that are most helpful.

 

Details:

The study was a prospective, observational trial conducted in the UK at a teaching Emergency Department between June 2002 and September 2003.   156/177 patients intubated over that time were included in the study. Those excluded were done so because no LEMON assessment was completed. Of the remaining included, a modified LEMON assessment was completed including: LOOK- facial trauma, large incisors, large tongue, facial hair; EVALUATE- inter-incisor distance (<3 fingers), hyoid-mental distance (<3 fingers), thyroid to floor of mouth distance (<2 fingers); MALLAMPATI 1/2 versus 3/4 ; OBSTRUCTION; and NECK MOBILITY- cervical collar versus no collar. One point was assigned for each criterion that was found. If a criterion was though unassessable, a score of zero was given. Outcome was determined by laryngoscopic view as outlined by the Cormack-Lehane grading scale; grade 1 was considered an easy intubation, grades 2-4 were considered difficult. ALL intubations were successful, and if multiple attempts were used, the grade of view on the successful attempt was used. Authors used Fischer’s exact test to compare the categorical variables, Student’s t test to compare continuous data. Spearman rank sum test was used to assess correlation between categorical variables.

Continue reading

Peds EM Follow Up 2015: Pediatric Osteomyelitis

2 Articles of Interest & An Excruciating, Detailed and Lengthy Guide to Diagnosis and Management

 

Dartnell J, Ramachandran M, Katchburian M. Haematogenous Acute and Subacute Paediatric Osteomyelitis: A Systematic Review of the Literature. J Bone Joint Surg Br. 2012 May;94(5):584-95.

  • A meta-analysis of 1854 papers, 132 of which were examined in detail
  • 40% of patients were afebrile
  • Tibia and femur were most common sites
  • Exam, labs, and imaging must be used in combination
  • S. aureus > Kingella > other
  • Typical treatment: start empiric IV abx, switch to PO when possible

Harris JC, et al. How Useful are Laboratory Investigations in the Emergency Department Evaluation of Possible Osteomyelitis? Emerg Med Australias. 2011 Jun;23(3):317-30. Epub 2011 Apr 4

  • A meta-analysis of 36 studies of adults and children
  • Recommended algorithm:
    • Adults and kids w/ low pretest probability: nL ESR and CRP<5 → done
    • Med/high pretest probability and puncture wounds: nL ESR and CRP<5 → LOW NPV
    • ESR >30 and/or CRP>10-30 → further investigation (imaging) required
    • WBC count is not especially helpful!

Osteo locations

 

PEDIATRIC OSTEOMYELITIS:

  • Definition: bacteria infecting bone
  • Usually hematogenous spread, but can be direct inoculation (surgery, open trauma, puncture, etc) or contiguous spread (skin, sinus, dental infections)

CLINICAL PRESENTATION

  • Constitutional symptoms, irritability, decreased PO
  • +/- fever
  • Localized pain, bony tenderness
  • Functional limitations, i.e. unwilling to crawl or walk
  • Time course: usually several days to >1 week
  • Risk factors: bacteremia, sepsis, immunocompromised, indwelling catheters/hardware, prematurity, skin infection, complicated delivery, GU abnormalities

Continue reading

Orthopedic Review: Distal Radius Fracture Reduction

Case: 64 yo F presents to the Emergency Department after tripping over a curb and suffering a FOOSH (fall on outstretched hand) injury. There is obvious deformity about the wrist with associated swelling and tenderness. X-ray imaging reveals the following:

Her exam and imaging are consistent with a distal radius fracture. How do you treat this?

Page ortho?

Providing adequate analgesia, reduction of fracture, and proper splinting is well within the scope of EM practice, especially in the community setting. This post will review the technique of hematoma block for analgesia as well as the different techniques for reduction of distal radius fractures and application of splint.

Hematoma Block

  • Can be used alone or in combination with other analgesic modalities such as IV narcotics or benzodiazepines
  • Simple technique
  • Very few complications

 

But is hematoma block effective?

  • In 2011, prospective randomized controlled trial comparing hematoma block to conscious sedation with IV Propofol
  • 96 patients underwent randomization and researchers compared patients’ pain using VAS (visual analog scale) during the procedure and after the procedure
  • Patients who received Propofol had pain scores of 0 during the procedure compared to 0.97+/-0.7 in patients who received hematoma block
  • After the procedure, patients who received Propofol had pain scores of 2.72+/-0.7 compared to 2.25+/-0.2 in patients who received hematoma block
  • Patients who received hematoma block had significantly shorter ED stay times (0.9hrs vs 2.6 hrs)

Hematoma blocks result in similar analgesia as conscious sedation with IV Propofol AND leads to shorter ED stay times

Setting up for the procedure:

  • 10cc 1% Lidocaine
  • 10cc syringe with 2 large needles (one for drawing up Lidocaine, one for injecting)
  • Skin cleanser (betadine, Chloraprep, or alcohol wipe)

Procedure Technique:

  1. Identify the fracture site by palpating along the dorsal aspect of the forearm to feel for bony step-off. Cleanse this entire area thoroughly with skin cleanser.
  2. Insert needle attached to syringe filled with 10cc 1% Lidocaine at that site and advance needle along periosteum until needle falls into fracture site.
  3. Draw back on plunger to aspirate blood confirming the needle is in the fracture site.
  4. Inject 10cc Lidocaine into fracture site and remove needle.
  5. Allow 10-15min to pass to ensure full analgesic effect.

Continue reading

CITW 7: A Swollen Elbow

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 6 year old male presents to the ED after falling about 4 feet off the monkey bars at his school playground, landing on his right arm. He’s had worsening pain and swelling of the right elbow since the fall, resulting in limited range of motion.  He denies numbness, tingling, or weakness. He sustained no other injuries.

Vitals: BP 107/72, HR 105, T 98.7 °F, RR 22, SpO2 100 % on RA

Notable PE: There is mild swelling of the right elbow, with limited active range of motion, but intact passive range of motion.  No obvious deformity. He is tender in the lateral supracondylar region. His right upper extremity is neurovascularly intact.

Plain films were obtained:

Rad Head 1

Rad Head 2

What’s the diagnosis?

Continue reading

LBBB doesn’t have to block an MI diagnosis

What we are taking about:

Sgarbossa EM, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. N Engl J Med. 1996 Feb 22;334(8):481-7.


Main Points:

In the presence of a left bundle branch block, suspect acute infarction when:

  1. ST-segment elevation ≥1 mm and concordant with QRS complex
  2. ST-segment depression ≥1 mm in lead V1, V2, or V3
  3. ST-segment elevation ≥5 mm and discordant with QRS complex

Background:

The presence of left bundle branch block on the electrocardiogram may conceal the changes of acute myocardial infarction, which can delay both its recognition and treatment. This study aimed to identify electrocardiographic criteria for the diagnosis of acute infarction in the presence of left bundle-branch block.


Methods:

This was a retrospective cohort study looking at electrocardiograms of North American patients enrolled in the GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) trial who presented with chest pain, had left bundle-branch block on baseline EKG, and acute myocardial infarction confirmed by enzyme studies (total of 131 patients). These EKGs were blindly compared with the electrocardiograms of control patients from the Duke Databank for Cardiovascular Disease who had chronic coronary artery disease and left bundle-branch block. The patients in the control group did not have acute chest pain at the time of the electrocardiographic recording.

Multivariate Analysis was used to determine independent predictors of acute myocardial infarction. These criteria were used to develop a scoring system to identify patients with acute myocardial infarction. Continue reading