SAEM 2015

SAN DIEGO – Patients presenting to emergency departments with acute low back pain who were treated with nonsteroidal anti-inflammatory drug monotherapy did as well as those who received an NSAID combined with an opioid or muscle relaxant, though combination therapies are far more commonly prescribed in the ED.

At the annual meeting of the Society for Academic Emergency Medicine, Dr. Benjamin W. Friedman of Montefiore Medical Center in New York presented results from a trial of 323 adult patients aged 64 and younger at Montefiore’s emergency department who had acute low back pain not related to trauma, and functional impairment.

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Patients were evaluated at baseline using the Roland Morris Disability Questionnaire (RMDQ), and randomized to receive naproxen sodium 500 mg along with placebo tablets (n = 107), cyclobenzaprine 5 mg (n = 108), or oxycodone 5 mg/acetaminophen 325 mg (n = 108) for low back pain. Patients and clinicians were blinded to treatment assignment.

Subjects were advised to take naproxen sodium along with 1 or 2 tablets of the study drug, every 8 hours as needed. They were followed up by telephone 1 week later and again at 3 months, with 92% followed up at 3 months.

At 1 week after the ED visit, there were no clinically or statistically significant differences seen among the treatment groups in improvements measured by RMDQ scores, with placebo subjects showing a mean improvement of 9.6% (98% CI, 7.7-11.5); cyclobenzaprine subjects, 10.1 (98% CI, 7.9-12.3); and oxycodone/acetaminophen subjects, 10.9 (98% CI, 8.9-13.0). At 3 months, functional and pain outcomes did not differ significantly among the groups.

Adverse events were lowest in the placebo group, with 21% of patients reporting at least one after the first week, compared with 34% for cyclobenzaprine and 40% for oxycodone; the most commonly reported effects were drowsiness, dizziness, and gastric symptoms. “This works out to a number needed to harm for cyclobenzaprine of eight, and for Percocet [oxycodone/acetaminophen] of five,” compared with placebo, Dr. Friedman told the conference.

However, he noted, of the patients who adhered to the study medications – that is, who took them more than once – only 30% of those on oxycodone reported moderate or severe back pain at 1 week, compared with 48% of patients taking placebo, a statistically significant difference, though overall RMDQ improvement did not differ among the groups.

“Giving [oxycodone] to all your patients with lower back pain is a strategy that’s not going to work,” he said. “But if you limit it to patients who really need it and are likely to adhere to it, that’s a population who might see a benefit. Just remember, the number to harm needed is five. Don’t prescribe this medication lightly.”

Dr. Friedman said that low back pain complaints account for 2.4% of all ED visits in the United States, or 2.7 million visits annually, and that more than half of ED prescriptions for low back pain comprise combinations of two of the drug classes, with 16% of prescriptions combining all three.

Dr. Friedman’s study was internally funded and neither he nor his coinvestigators disclosed conflicts of interest.

SAN DIEGO – Patients presenting to emergency departments with acute low back pain who were treated with nonsteroidal anti-inflammatory drug monotherapy did as well as those who received an NSAID combined with an opioid or muscle relaxant, though combination therapies are far more commonly prescribed in the ED.

At the annual meeting of the Society for Academic Emergency Medicine, Dr. Benjamin W. Friedman of Montefiore Medical Center in New York presented results from a trial of 323 adult patients aged 64 and younger at Montefiore’s emergency department who had acute low back pain not related to trauma, and functional impairment.

Thinkstockphotos.com

Patients were evaluated at baseline using the Roland Morris Disability Questionnaire (RMDQ), and randomized to receive naproxen sodium 500 mg along with placebo tablets (n = 107), cyclobenzaprine 5 mg (n = 108), or oxycodone 5 mg/acetaminophen 325 mg (n = 108) for low back pain. Patients and clinicians were blinded to treatment assignment.

Subjects were advised to take naproxen sodium along with 1 or 2 tablets of the study drug, every 8 hours as needed. They were followed up by telephone 1 week later and again at 3 months, with 92% followed up at 3 months.

At 1 week after the ED visit, there were no clinically or statistically significant differences seen among the treatment groups in improvements measured by RMDQ scores, with placebo subjects showing a mean improvement of 9.6% (98% CI, 7.7-11.5); cyclobenzaprine subjects, 10.1 (98% CI, 7.9-12.3); and oxycodone/acetaminophen subjects, 10.9 (98% CI, 8.9-13.0). At 3 months, functional and pain outcomes did not differ significantly among the groups.

Adverse events were lowest in the placebo group, with 21% of patients reporting at least one after the first week, compared with 34% for cyclobenzaprine and 40% for oxycodone; the most commonly reported effects were drowsiness, dizziness, and gastric symptoms. “This works out to a number needed to harm for cyclobenzaprine of eight, and for Percocet [oxycodone/acetaminophen] of five,” compared with placebo, Dr. Friedman told the conference.

However, he noted, of the patients who adhered to the study medications – that is, who took them more than once – only 30% of those on oxycodone reported moderate or severe back pain at 1 week, compared with 48% of patients taking placebo, a statistically significant difference, though overall RMDQ improvement did not differ among the groups.

“Giving [oxycodone] to all your patients with lower back pain is a strategy that’s not going to work,” he said. “But if you limit it to patients who really need it and are likely to adhere to it, that’s a population who might see a benefit. Just remember, the number to harm needed is five. Don’t prescribe this medication lightly.”

Dr. Friedman said that low back pain complaints account for 2.4% of all ED visits in the United States, or 2.7 million visits annually, and that more than half of ED prescriptions for low back pain comprise combinations of two of the drug classes, with 16% of prescriptions combining all three.

Dr. Friedman’s study was internally funded and neither he nor his coinvestigators disclosed conflicts of interest.

SAN DIEGO – Patients presenting to emergency departments with acute low back pain who were treated with nonsteroidal anti-inflammatory drug monotherapy did as well as those who received an NSAID combined with an opioid or muscle relaxant, though combination therapies are far more commonly prescribed in the ED.

At the annual meeting of the Society for Academic Emergency Medicine, Dr. Benjamin W. Friedman of Montefiore Medical Center in New York presented results from a trial of 323 adult patients aged 64 and younger at Montefiore’s emergency department who had acute low back pain not related to trauma, and functional impairment.

Thinkstockphotos.com

Patients were evaluated at baseline using the Roland Morris Disability Questionnaire (RMDQ), and randomized to receive naproxen sodium 500 mg along with placebo tablets (n = 107), cyclobenzaprine 5 mg (n = 108), or oxycodone 5 mg/acetaminophen 325 mg (n = 108) for low back pain. Patients and clinicians were blinded to treatment assignment.

Subjects were advised to take naproxen sodium along with 1 or 2 tablets of the study drug, every 8 hours as needed. They were followed up by telephone 1 week later and again at 3 months, with 92% followed up at 3 months.

At 1 week after the ED visit, there were no clinically or statistically significant differences seen among the treatment groups in improvements measured by RMDQ scores, with placebo subjects showing a mean improvement of 9.6% (98% CI, 7.7-11.5); cyclobenzaprine subjects, 10.1 (98% CI, 7.9-12.3); and oxycodone/acetaminophen subjects, 10.9 (98% CI, 8.9-13.0). At 3 months, functional and pain outcomes did not differ significantly among the groups.

Adverse events were lowest in the placebo group, with 21% of patients reporting at least one after the first week, compared with 34% for cyclobenzaprine and 40% for oxycodone; the most commonly reported effects were drowsiness, dizziness, and gastric symptoms. “This works out to a number needed to harm for cyclobenzaprine of eight, and for Percocet [oxycodone/acetaminophen] of five,” compared with placebo, Dr. Friedman told the conference.

However, he noted, of the patients who adhered to the study medications – that is, who took them more than once – only 30% of those on oxycodone reported moderate or severe back pain at 1 week, compared with 48% of patients taking placebo, a statistically significant difference, though overall RMDQ improvement did not differ among the groups.

“Giving [oxycodone] to all your patients with lower back pain is a strategy that’s not going to work,” he said. “But if you limit it to patients who really need it and are likely to adhere to it, that’s a population who might see a benefit. Just remember, the number to harm needed is five. Don’t prescribe this medication lightly.”

Dr. Friedman said that low back pain complaints account for 2.4% of all ED visits in the United States, or 2.7 million visits annually, and that more than half of ED prescriptions for low back pain comprise combinations of two of the drug classes, with 16% of prescriptions combining all three.

Dr. Friedman’s study was internally funded and neither he nor his coinvestigators disclosed conflicts of interest.

SAN DIEGO – Ketamine sedates violent and highly agitated patients in the emergency department faster than other widely used agents and with a similar rate of adverse events, based on the results of a small observational study presented at the annual meeting of the Society for Academic Emergency Medicine.

Dr. Jeffrey Riddell and his colleagues at the University of California San Francisco, Fresno, reported results from a prospective cohort of 83 patients, 18-65 years old, who presented with acute agitation requiring sedation at a single urban ED.

Ketamine was given to 21 patients at a median dose of 70 mg IV or 250 mg IM. Another 9 patients received haloperidol (5 mg IM), 39 got lorazepam or midazolam (2 mg IV or IM), and 14 were treated with a combination of haloperidol, diphenhydramine, and lorazepam.

Ketamine proved the fastest acting, with a median time to sedation of 3 minutes. Median time to sedation was 8 minutes for haloperidol alone, 10 minutes for the benzodiazepines, and 17.5 minutes for the combination of sedative agents. Patient selection may have been at play in the longer time seen with the combination therapy, a result of clinicians selecting this option for the most agitated patients, Dr. Riddell said in an interview.

Adverse events measured in the study were dystonia, hypotension, hypoxia, and intubation. One of the 9 patients in the haloperidol group had an adverse event, as did 2 of 14 given the combination, 3 of 39 given benzodiazepines, and 3 of 21 given ketamine. “The study wasn’t powered to detect a clinically significant difference in side effects, but in this small subset [the rate of adverse events] looked similar,” Dr. Riddell said.

Ketamine’s onset of action, compared with the other agents, was all the more remarkable, he said, because physicians did not separate intramuscular and intravenous delivery forms. Intramuscular delivery is generally slower, therefore, intravenous sedation with ketamine could be even faster than 3 minutes.

Dr. Riddell said his team hoped that the observational study will form the basis for a randomized controlled trial with clinicians blinded to treatment allocation. “Only the ED pharmacist will be aware of the medication type,” he said.

The preliminary data on ketamine’s speed and safety “bore out what our experience was with it in the ED,” he said. “There’s still not a lot of good data about it for agitated patients in the ED, though there’s tons of data for procedural sedation. Extrapolating from that, we’re trying to show that it also works in the ED population that needs a medication for sedation.”

The study was funded by the National Institutes of Health through a grant from the University of California San Francisco Clinical and Translational Science Institute. The investigators declared no conflicts of interest.

SAN DIEGO – Ketamine sedates violent and highly agitated patients in the emergency department faster than other widely used agents and with a similar rate of adverse events, based on the results of a small observational study presented at the annual meeting of the Society for Academic Emergency Medicine.

Dr. Jeffrey Riddell and his colleagues at the University of California San Francisco, Fresno, reported results from a prospective cohort of 83 patients, 18-65 years old, who presented with acute agitation requiring sedation at a single urban ED.

Ketamine was given to 21 patients at a median dose of 70 mg IV or 250 mg IM. Another 9 patients received haloperidol (5 mg IM), 39 got lorazepam or midazolam (2 mg IV or IM), and 14 were treated with a combination of haloperidol, diphenhydramine, and lorazepam.

Ketamine proved the fastest acting, with a median time to sedation of 3 minutes. Median time to sedation was 8 minutes for haloperidol alone, 10 minutes for the benzodiazepines, and 17.5 minutes for the combination of sedative agents. Patient selection may have been at play in the longer time seen with the combination therapy, a result of clinicians selecting this option for the most agitated patients, Dr. Riddell said in an interview.

Adverse events measured in the study were dystonia, hypotension, hypoxia, and intubation. One of the 9 patients in the haloperidol group had an adverse event, as did 2 of 14 given the combination, 3 of 39 given benzodiazepines, and 3 of 21 given ketamine. “The study wasn’t powered to detect a clinically significant difference in side effects, but in this small subset [the rate of adverse events] looked similar,” Dr. Riddell said.

Ketamine’s onset of action, compared with the other agents, was all the more remarkable, he said, because physicians did not separate intramuscular and intravenous delivery forms. Intramuscular delivery is generally slower, therefore, intravenous sedation with ketamine could be even faster than 3 minutes.

Dr. Riddell said his team hoped that the observational study will form the basis for a randomized controlled trial with clinicians blinded to treatment allocation. “Only the ED pharmacist will be aware of the medication type,” he said.

The preliminary data on ketamine’s speed and safety “bore out what our experience was with it in the ED,” he said. “There’s still not a lot of good data about it for agitated patients in the ED, though there’s tons of data for procedural sedation. Extrapolating from that, we’re trying to show that it also works in the ED population that needs a medication for sedation.”

The study was funded by the National Institutes of Health through a grant from the University of California San Francisco Clinical and Translational Science Institute. The investigators declared no conflicts of interest.

SAN DIEGO – Ketamine sedates violent and highly agitated patients in the emergency department faster than other widely used agents and with a similar rate of adverse events, based on the results of a small observational study presented at the annual meeting of the Society for Academic Emergency Medicine.

Dr. Jeffrey Riddell and his colleagues at the University of California San Francisco, Fresno, reported results from a prospective cohort of 83 patients, 18-65 years old, who presented with acute agitation requiring sedation at a single urban ED.

Ketamine was given to 21 patients at a median dose of 70 mg IV or 250 mg IM. Another 9 patients received haloperidol (5 mg IM), 39 got lorazepam or midazolam (2 mg IV or IM), and 14 were treated with a combination of haloperidol, diphenhydramine, and lorazepam.

Ketamine proved the fastest acting, with a median time to sedation of 3 minutes. Median time to sedation was 8 minutes for haloperidol alone, 10 minutes for the benzodiazepines, and 17.5 minutes for the combination of sedative agents. Patient selection may have been at play in the longer time seen with the combination therapy, a result of clinicians selecting this option for the most agitated patients, Dr. Riddell said in an interview.

Adverse events measured in the study were dystonia, hypotension, hypoxia, and intubation. One of the 9 patients in the haloperidol group had an adverse event, as did 2 of 14 given the combination, 3 of 39 given benzodiazepines, and 3 of 21 given ketamine. “The study wasn’t powered to detect a clinically significant difference in side effects, but in this small subset [the rate of adverse events] looked similar,” Dr. Riddell said.

Ketamine’s onset of action, compared with the other agents, was all the more remarkable, he said, because physicians did not separate intramuscular and intravenous delivery forms. Intramuscular delivery is generally slower, therefore, intravenous sedation with ketamine could be even faster than 3 minutes.

Dr. Riddell said his team hoped that the observational study will form the basis for a randomized controlled trial with clinicians blinded to treatment allocation. “Only the ED pharmacist will be aware of the medication type,” he said.

The preliminary data on ketamine’s speed and safety “bore out what our experience was with it in the ED,” he said. “There’s still not a lot of good data about it for agitated patients in the ED, though there’s tons of data for procedural sedation. Extrapolating from that, we’re trying to show that it also works in the ED population that needs a medication for sedation.”

The study was funded by the National Institutes of Health through a grant from the University of California San Francisco Clinical and Translational Science Institute. The investigators declared no conflicts of interest.

SAN DIEGO – Children who have suffered blunt trauma are routinely screened in emergency departments for intra-abdominal injury via computed tomography of the abdomen and pelvis.

But concerns about excess exposure to CT radiation, particularly to the gonads, led one group of researchers to question whether it’s necessary to scan the entire abdominopelvic region in all of these patients to identify intra-abdominal injury (IAI).

Dr. Stacy Reynolds and her colleagues at the Carolinas Medical Center in Charlotte, N.C., hypothesized that CT limited to the radiographic abdomen – the region between the dome of the diaphragm to the top of the iliac crest – can capture the vast majority of IAIs in this population.

At the Society for Academic Emergency Medicine annual meeting, Dr. Reynolds presented results from a retrospective cohort study enrolling 313 hemodynamically stable pediatric patients (median age 14 years, 64% male) presenting to 12 EDs after blunt trauma. Patients with known pelvic fractures or hip dislocation were excluded, as they would have had a clear indication for a full abdominopelvic CT.

All subjects underwent axial abdominopelvic CT imaging. Researchers created matched pairs of images comprising the original scans and those that had been altered with software that truncated the pelvic portion of the study to create CT abdomen-only studies. Study radiologists were blinded to the results of the original scans.

Twenty-six IAI’s were diagnosed in 24 patients: 8 hepatic injuries, 12 splenic injuries, 5 renal injuries, and 1 retroperitoneal hemorrhage. Abdominal CT alone was 85% sensitive (95% confidence interval, 65%-96%) and 99% specific (95% CI, 97%-100%) in identifying IAIs. The four missed injuries were solid organ injuries within the radiographic abdomen. False positives occurred in two of the complete scans, both involving free fluid prompting suspicion of small bowel injury later ruled out by clinical observation.

Dr. Reynolds said in an interview said that the findings, while promising, were limited by the study’s small numbers, and its use of axial images alone, when sagittal images also would be required for the most accurate diagnoses. Also, physician suspicion of IAI prior to imaging was not captured because of the study’s retrospective design, she said. “The real key to whether or not this hypothesis is valuable is if physicians are able to target the right population of patients for application.”

Dr. Reynolds cautioned that the findings would need to be validated in a larger trial before any changes could be made to clinical practice. “Some of the outcomes that we need to make sure whether we’re missing are still rare,” she said. “You couldn’t feel confident that this is the right way to go with a study this small, but it establishes that we can safely and ethically pursue a multicenter trial that would examine the issue with bigger numbers.”

Other groups of investigators, including members of the Pediatric Emergency Care Applied Research Network (PECARN), also have taken up the question of identifying children at low risk of IAI who may not need CT screening after blunt trauma. In 2013, PECARN published a prediction rule using only patient history and physical examination findings intended to obviate use of CT in the lowest-risk patients (Ann. Emerg. Med. 2013;62:107-16.e2).

Dr. Reynolds said that while overuse of CT was a worrisome trend that could have long-term implications for patients, and that it was important to identify ways it might be limited, there is a reason it remains the go-to technology in the ED for detecting IAI. “It’s got very high sensitivity and specificity. If you’re a busy trauma surgeon who’s admitting 20 injured patients in a night, there’s no faster or more efficient way to determine whether the patient in front of you is injured.”

The study was funded by the Carolinas Trauma Network Research Center of Excellence. None of the investigators disclosed conflicts of interest.

SAN DIEGO – Children who have suffered blunt trauma are routinely screened in emergency departments for intra-abdominal injury via computed tomography of the abdomen and pelvis.

But concerns about excess exposure to CT radiation, particularly to the gonads, led one group of researchers to question whether it’s necessary to scan the entire abdominopelvic region in all of these patients to identify intra-abdominal injury (IAI).

Dr. Stacy Reynolds and her colleagues at the Carolinas Medical Center in Charlotte, N.C., hypothesized that CT limited to the radiographic abdomen – the region between the dome of the diaphragm to the top of the iliac crest – can capture the vast majority of IAIs in this population.

At the Society for Academic Emergency Medicine annual meeting, Dr. Reynolds presented results from a retrospective cohort study enrolling 313 hemodynamically stable pediatric patients (median age 14 years, 64% male) presenting to 12 EDs after blunt trauma. Patients with known pelvic fractures or hip dislocation were excluded, as they would have had a clear indication for a full abdominopelvic CT.

All subjects underwent axial abdominopelvic CT imaging. Researchers created matched pairs of images comprising the original scans and those that had been altered with software that truncated the pelvic portion of the study to create CT abdomen-only studies. Study radiologists were blinded to the results of the original scans.

Twenty-six IAI’s were diagnosed in 24 patients: 8 hepatic injuries, 12 splenic injuries, 5 renal injuries, and 1 retroperitoneal hemorrhage. Abdominal CT alone was 85% sensitive (95% confidence interval, 65%-96%) and 99% specific (95% CI, 97%-100%) in identifying IAIs. The four missed injuries were solid organ injuries within the radiographic abdomen. False positives occurred in two of the complete scans, both involving free fluid prompting suspicion of small bowel injury later ruled out by clinical observation.

Dr. Reynolds said in an interview said that the findings, while promising, were limited by the study’s small numbers, and its use of axial images alone, when sagittal images also would be required for the most accurate diagnoses. Also, physician suspicion of IAI prior to imaging was not captured because of the study’s retrospective design, she said. “The real key to whether or not this hypothesis is valuable is if physicians are able to target the right population of patients for application.”

Dr. Reynolds cautioned that the findings would need to be validated in a larger trial before any changes could be made to clinical practice. “Some of the outcomes that we need to make sure whether we’re missing are still rare,” she said. “You couldn’t feel confident that this is the right way to go with a study this small, but it establishes that we can safely and ethically pursue a multicenter trial that would examine the issue with bigger numbers.”

Other groups of investigators, including members of the Pediatric Emergency Care Applied Research Network (PECARN), also have taken up the question of identifying children at low risk of IAI who may not need CT screening after blunt trauma. In 2013, PECARN published a prediction rule using only patient history and physical examination findings intended to obviate use of CT in the lowest-risk patients (Ann. Emerg. Med. 2013;62:107-16.e2).

Dr. Reynolds said that while overuse of CT was a worrisome trend that could have long-term implications for patients, and that it was important to identify ways it might be limited, there is a reason it remains the go-to technology in the ED for detecting IAI. “It’s got very high sensitivity and specificity. If you’re a busy trauma surgeon who’s admitting 20 injured patients in a night, there’s no faster or more efficient way to determine whether the patient in front of you is injured.”

The study was funded by the Carolinas Trauma Network Research Center of Excellence. None of the investigators disclosed conflicts of interest.

SAN DIEGO – Children who have suffered blunt trauma are routinely screened in emergency departments for intra-abdominal injury via computed tomography of the abdomen and pelvis.

But concerns about excess exposure to CT radiation, particularly to the gonads, led one group of researchers to question whether it’s necessary to scan the entire abdominopelvic region in all of these patients to identify intra-abdominal injury (IAI).

Dr. Stacy Reynolds and her colleagues at the Carolinas Medical Center in Charlotte, N.C., hypothesized that CT limited to the radiographic abdomen – the region between the dome of the diaphragm to the top of the iliac crest – can capture the vast majority of IAIs in this population.

At the Society for Academic Emergency Medicine annual meeting, Dr. Reynolds presented results from a retrospective cohort study enrolling 313 hemodynamically stable pediatric patients (median age 14 years, 64% male) presenting to 12 EDs after blunt trauma. Patients with known pelvic fractures or hip dislocation were excluded, as they would have had a clear indication for a full abdominopelvic CT.

All subjects underwent axial abdominopelvic CT imaging. Researchers created matched pairs of images comprising the original scans and those that had been altered with software that truncated the pelvic portion of the study to create CT abdomen-only studies. Study radiologists were blinded to the results of the original scans.

Twenty-six IAI’s were diagnosed in 24 patients: 8 hepatic injuries, 12 splenic injuries, 5 renal injuries, and 1 retroperitoneal hemorrhage. Abdominal CT alone was 85% sensitive (95% confidence interval, 65%-96%) and 99% specific (95% CI, 97%-100%) in identifying IAIs. The four missed injuries were solid organ injuries within the radiographic abdomen. False positives occurred in two of the complete scans, both involving free fluid prompting suspicion of small bowel injury later ruled out by clinical observation.

Dr. Reynolds said in an interview said that the findings, while promising, were limited by the study’s small numbers, and its use of axial images alone, when sagittal images also would be required for the most accurate diagnoses. Also, physician suspicion of IAI prior to imaging was not captured because of the study’s retrospective design, she said. “The real key to whether or not this hypothesis is valuable is if physicians are able to target the right population of patients for application.”

Dr. Reynolds cautioned that the findings would need to be validated in a larger trial before any changes could be made to clinical practice. “Some of the outcomes that we need to make sure whether we’re missing are still rare,” she said. “You couldn’t feel confident that this is the right way to go with a study this small, but it establishes that we can safely and ethically pursue a multicenter trial that would examine the issue with bigger numbers.”

Other groups of investigators, including members of the Pediatric Emergency Care Applied Research Network (PECARN), also have taken up the question of identifying children at low risk of IAI who may not need CT screening after blunt trauma. In 2013, PECARN published a prediction rule using only patient history and physical examination findings intended to obviate use of CT in the lowest-risk patients (Ann. Emerg. Med. 2013;62:107-16.e2).

Dr. Reynolds said that while overuse of CT was a worrisome trend that could have long-term implications for patients, and that it was important to identify ways it might be limited, there is a reason it remains the go-to technology in the ED for detecting IAI. “It’s got very high sensitivity and specificity. If you’re a busy trauma surgeon who’s admitting 20 injured patients in a night, there’s no faster or more efficient way to determine whether the patient in front of you is injured.”

The study was funded by the Carolinas Trauma Network Research Center of Excellence. None of the investigators disclosed conflicts of interest.

SAN DIEGO – A simple three-variable prediction rule can accurately predict which febrile infants younger than 2 months with fever who present to the emergency department have serious bacterial infections.

Bacterial meningitis, urinary tract infections, and bacteremia are considered serious bacterial infections; many young infants with these infections are difficult to identify, and current laboratory protocols for identifying them include urinalysis, white blood cell counts, band counts, and sometimes cerebrospinal fluid.

If validated in larger studies, the new prediction rule – which does not require cerebrospinal fluid – could limit lumbar punctures, antibiotic use, and unnecessary hospitalizations among infants at negligible risk of serious bacterial infections (SBI).

In a presentation at the annual meeting of the Society for Academic Emergency Medicine, Dr. Nathan Kuppermann of the University of California, Davis, demonstrated results from a large prospective cohort study of 1,821 febrile infants 60 days old and younger conducted at 21 emergency departments. Infants with underlying congenital anomalies or critical illness were excluded from the study.

The investigators evaluated eight variables as potential predictors: age, temperature, Yale Observation Scale score, and clinician suspicion of SBI, along with four laboratory variables (urinalysis, white blood cell count, absolute neutrophil count [ANC], and procalcitonin). Band counts were available at some, but not all of the study centers, and therefore were not evaluated.

Dr. Kuppermann and his colleagues found that positive urinalysis, ANC of 4.09 x 1,000/mm³ or higher, and serum procalcitonin of 1.71 ng/mL or higher were, taken together, 98%-99% sensitive and about 60% specific, in predicting SBI in the cohort. Negative predictive values approached 100%. The rate of SBI was 9.3% of the cohort, in keeping with expected rates.

“The SBI positive group was more likely to have higher clinician suspicion of SBI, and all of the lab markers were more elevated in the SBI positive group than the SBI negative group,” Dr. Kuppermann said at the meeting. However, after the researchers considered all of the predictors as a group, only the urinalysis, the ANC, and the procalcitonin remained important. Only 3 of 170 (1.76%)* infants with SBIs were missed when the three-variable prediction tool was used.

To make the prediction rule easier to remember and use, the investigators evaluated lower, more standard, and easier to remember thresholds for the three variables. They reanalyzed their data using a lower cutoff point for ANC of 4.00 x 1,000/mm³, and a lowered procalcitonin cutoff of 0.5 ng/mL. The rule performed almost identically as the original rule, and did not miss any more patients with SBIs beyond the original three.

Dr. Kuppermann described the three-variable rule as “simple, objective, and highly accurate” in predicting or ruling out SBI. Nonetheless, it requires external validation in a large cohort, he acknowledged. He said he would continue to routinely perform lumbar punctures in infants younger than 30 days with fever until the findings could be further validated.

“But personally, in that second month of life, I would use these data to decide who actually needs a lumbar puncture and hospitalization,” he said.

Dr. Kuppermann also noted as a limitation of the study that the cohort included few infants with bacterial meningitis.

The study was conducted in the Pediatric Emergency Care Applied Research Network (PECARN) and supported by grants from the Health Resources and Services Administration, the Maternal and Child Health Bureau, the Emergency Medical Services for Children program, and the National Institutes of Health. Dr. Kuppermann disclosed no relevant conflicts of interest.

*A correction was made to this article 6/24/15 

SAN DIEGO – A simple three-variable prediction rule can accurately predict which febrile infants younger than 2 months with fever who present to the emergency department have serious bacterial infections.

Bacterial meningitis, urinary tract infections, and bacteremia are considered serious bacterial infections; many young infants with these infections are difficult to identify, and current laboratory protocols for identifying them include urinalysis, white blood cell counts, band counts, and sometimes cerebrospinal fluid.

If validated in larger studies, the new prediction rule – which does not require cerebrospinal fluid – could limit lumbar punctures, antibiotic use, and unnecessary hospitalizations among infants at negligible risk of serious bacterial infections (SBI).

In a presentation at the annual meeting of the Society for Academic Emergency Medicine, Dr. Nathan Kuppermann of the University of California, Davis, demonstrated results from a large prospective cohort study of 1,821 febrile infants 60 days old and younger conducted at 21 emergency departments. Infants with underlying congenital anomalies or critical illness were excluded from the study.

The investigators evaluated eight variables as potential predictors: age, temperature, Yale Observation Scale score, and clinician suspicion of SBI, along with four laboratory variables (urinalysis, white blood cell count, absolute neutrophil count [ANC], and procalcitonin). Band counts were available at some, but not all of the study centers, and therefore were not evaluated.

Dr. Kuppermann and his colleagues found that positive urinalysis, ANC of 4.09 x 1,000/mm³ or higher, and serum procalcitonin of 1.71 ng/mL or higher were, taken together, 98%-99% sensitive and about 60% specific, in predicting SBI in the cohort. Negative predictive values approached 100%. The rate of SBI was 9.3% of the cohort, in keeping with expected rates.

“The SBI positive group was more likely to have higher clinician suspicion of SBI, and all of the lab markers were more elevated in the SBI positive group than the SBI negative group,” Dr. Kuppermann said at the meeting. However, after the researchers considered all of the predictors as a group, only the urinalysis, the ANC, and the procalcitonin remained important. Only 3 of 170 (1.76%)* infants with SBIs were missed when the three-variable prediction tool was used.

To make the prediction rule easier to remember and use, the investigators evaluated lower, more standard, and easier to remember thresholds for the three variables. They reanalyzed their data using a lower cutoff point for ANC of 4.00 x 1,000/mm³, and a lowered procalcitonin cutoff of 0.5 ng/mL. The rule performed almost identically as the original rule, and did not miss any more patients with SBIs beyond the original three.

Dr. Kuppermann described the three-variable rule as “simple, objective, and highly accurate” in predicting or ruling out SBI. Nonetheless, it requires external validation in a large cohort, he acknowledged. He said he would continue to routinely perform lumbar punctures in infants younger than 30 days with fever until the findings could be further validated.

“But personally, in that second month of life, I would use these data to decide who actually needs a lumbar puncture and hospitalization,” he said.

Dr. Kuppermann also noted as a limitation of the study that the cohort included few infants with bacterial meningitis.

The study was conducted in the Pediatric Emergency Care Applied Research Network (PECARN) and supported by grants from the Health Resources and Services Administration, the Maternal and Child Health Bureau, the Emergency Medical Services for Children program, and the National Institutes of Health. Dr. Kuppermann disclosed no relevant conflicts of interest.

*A correction was made to this article 6/24/15 

SAN DIEGO – A simple three-variable prediction rule can accurately predict which febrile infants younger than 2 months with fever who present to the emergency department have serious bacterial infections.

Bacterial meningitis, urinary tract infections, and bacteremia are considered serious bacterial infections; many young infants with these infections are difficult to identify, and current laboratory protocols for identifying them include urinalysis, white blood cell counts, band counts, and sometimes cerebrospinal fluid.

If validated in larger studies, the new prediction rule – which does not require cerebrospinal fluid – could limit lumbar punctures, antibiotic use, and unnecessary hospitalizations among infants at negligible risk of serious bacterial infections (SBI).

In a presentation at the annual meeting of the Society for Academic Emergency Medicine, Dr. Nathan Kuppermann of the University of California, Davis, demonstrated results from a large prospective cohort study of 1,821 febrile infants 60 days old and younger conducted at 21 emergency departments. Infants with underlying congenital anomalies or critical illness were excluded from the study.

The investigators evaluated eight variables as potential predictors: age, temperature, Yale Observation Scale score, and clinician suspicion of SBI, along with four laboratory variables (urinalysis, white blood cell count, absolute neutrophil count [ANC], and procalcitonin). Band counts were available at some, but not all of the study centers, and therefore were not evaluated.

Dr. Kuppermann and his colleagues found that positive urinalysis, ANC of 4.09 x 1,000/mm³ or higher, and serum procalcitonin of 1.71 ng/mL or higher were, taken together, 98%-99% sensitive and about 60% specific, in predicting SBI in the cohort. Negative predictive values approached 100%. The rate of SBI was 9.3% of the cohort, in keeping with expected rates.

“The SBI positive group was more likely to have higher clinician suspicion of SBI, and all of the lab markers were more elevated in the SBI positive group than the SBI negative group,” Dr. Kuppermann said at the meeting. However, after the researchers considered all of the predictors as a group, only the urinalysis, the ANC, and the procalcitonin remained important. Only 3 of 170 (1.76%)* infants with SBIs were missed when the three-variable prediction tool was used.

To make the prediction rule easier to remember and use, the investigators evaluated lower, more standard, and easier to remember thresholds for the three variables. They reanalyzed their data using a lower cutoff point for ANC of 4.00 x 1,000/mm³, and a lowered procalcitonin cutoff of 0.5 ng/mL. The rule performed almost identically as the original rule, and did not miss any more patients with SBIs beyond the original three.

Dr. Kuppermann described the three-variable rule as “simple, objective, and highly accurate” in predicting or ruling out SBI. Nonetheless, it requires external validation in a large cohort, he acknowledged. He said he would continue to routinely perform lumbar punctures in infants younger than 30 days with fever until the findings could be further validated.

“But personally, in that second month of life, I would use these data to decide who actually needs a lumbar puncture and hospitalization,” he said.

Dr. Kuppermann also noted as a limitation of the study that the cohort included few infants with bacterial meningitis.

The study was conducted in the Pediatric Emergency Care Applied Research Network (PECARN) and supported by grants from the Health Resources and Services Administration, the Maternal and Child Health Bureau, the Emergency Medical Services for Children program, and the National Institutes of Health. Dr. Kuppermann disclosed no relevant conflicts of interest.

*A correction was made to this article 6/24/15 

SAN DIEGO – More than 10% of geriatric patients presenting to emergency departments have signs of delirium, but not all delirium in the ED is equal, based on two presentations at the annual meeting of the Society for Academic Emergency Medicine.

For elderly patients in the emergency department, delirium is not merely present or absent. It is a heterogeneous syndrome, and certain subtypes likely indicate higher risk.

Dr. Jin Han, a researcher at Vanderbilt University in Nashville, Tenn., presented findings from a prospective, single-center observational study of 1,084 ED patients over age 65. Subjects were screened for delirium and their level of alertness. Of the 14% of patients with delirium, the researchers found the state of a patient’s arousal – decreased, normal, or increased – affected 6-month mortality.

In a separate study, Dr. Maura Kennedy of Harvard Medical School in Boston presented data suggesting that certain subtypes of delirium – particularly delirium with hypoactivity – are getting missed in the ED.

In Dr. Han’s study of 155 patients with delirium, a 4-point measurement called the Confusion Assessment Method for the Intensive Care Unit, (CAM-ICU) and the Richmond Agitation Sedation Scale (RASS) were used to measure delirium. Those with normal arousal as measured by RASS (n=15) had the highest 6-month mortality, at 40% (95% confidence interval, 20%-64%). In those with decreased arousal, the mortality rate was 27% (95% CI, 20%-35%); in those with increased arousal, mortality was 25%. The 6-month mortality rate in elderly ED patients without delirium was 11%.

Dr. Han acknowledged his study’s wide confidence intervals and the limitations of its single-site design and its screening tool, CAM-ICU, which has 70% sensitivity. Nonetheless, the findings imply that delirium needs to be looked at much more carefully in the ED. “Now if I see a patient with delirium and normal arousal, I want to make sure I rule out a potentially life-threatening illness,” he said in an interview.

Dr. Han’s research team is now collecting additional data, including etiology data and serum biomarkers, from ED patients with delirium in the hope of learning “why delirious patients with normal arousal do so poorly in terms of mortality.”

Dr. Kennedy presented a study from a cohort of 622 ED patients age 65 and older, who were screened using a tool called the Memorial Delirium Assessment Scale. The researchers compared their screening results to what doctors and nurses observed in the ED. Dr. Kennedy and her colleagues found that physicians were more likely to document delirium in a nonhypoactive patient, compared with a patient with hypoactive delirium (78% vs. 45%; P = .02).

“After all, an 88-year-old person screaming or hallucinating will get your attention, while in a busy ED, someone sleeping quietly in a bed at 2 pm might not,” Dr. Kennedy said in an interview.

Hypoactive delirium is easy to miss and is associated with poor outcomes. It needs to be screened for in the ED, as it could be dangerous to discharge some patients with delirium. Even if the patient is admitted, she added, delirium “is not necessarily going to be picked up upstairs” in the hospital.

More research needs to focus on “trying to identify the underlying cause [of delirium] in patients presenting to the ED,” Dr. Kennedy said. “And we need to start really looking at delirium as indicative of something else being wrong.”

Dr. Han’s study was funded by the National Institute on Aging and by the Emergency Medicine Foundation Center; he disclosed a consulting relationship with Bio-Signal Group. Dr. Kennedy’s studies were funded by the National Institute on Aging, and the Dennis W. Jahnigen Career Development Award. She disclosed no conflicts of interest.

SAN DIEGO – More than 10% of geriatric patients presenting to emergency departments have signs of delirium, but not all delirium in the ED is equal, based on two presentations at the annual meeting of the Society for Academic Emergency Medicine.

For elderly patients in the emergency department, delirium is not merely present or absent. It is a heterogeneous syndrome, and certain subtypes likely indicate higher risk.

Dr. Jin Han, a researcher at Vanderbilt University in Nashville, Tenn., presented findings from a prospective, single-center observational study of 1,084 ED patients over age 65. Subjects were screened for delirium and their level of alertness. Of the 14% of patients with delirium, the researchers found the state of a patient’s arousal – decreased, normal, or increased – affected 6-month mortality.

In a separate study, Dr. Maura Kennedy of Harvard Medical School in Boston presented data suggesting that certain subtypes of delirium – particularly delirium with hypoactivity – are getting missed in the ED.

In Dr. Han’s study of 155 patients with delirium, a 4-point measurement called the Confusion Assessment Method for the Intensive Care Unit, (CAM-ICU) and the Richmond Agitation Sedation Scale (RASS) were used to measure delirium. Those with normal arousal as measured by RASS (n=15) had the highest 6-month mortality, at 40% (95% confidence interval, 20%-64%). In those with decreased arousal, the mortality rate was 27% (95% CI, 20%-35%); in those with increased arousal, mortality was 25%. The 6-month mortality rate in elderly ED patients without delirium was 11%.

Dr. Han acknowledged his study’s wide confidence intervals and the limitations of its single-site design and its screening tool, CAM-ICU, which has 70% sensitivity. Nonetheless, the findings imply that delirium needs to be looked at much more carefully in the ED. “Now if I see a patient with delirium and normal arousal, I want to make sure I rule out a potentially life-threatening illness,” he said in an interview.

Dr. Han’s research team is now collecting additional data, including etiology data and serum biomarkers, from ED patients with delirium in the hope of learning “why delirious patients with normal arousal do so poorly in terms of mortality.”

Dr. Kennedy presented a study from a cohort of 622 ED patients age 65 and older, who were screened using a tool called the Memorial Delirium Assessment Scale. The researchers compared their screening results to what doctors and nurses observed in the ED. Dr. Kennedy and her colleagues found that physicians were more likely to document delirium in a nonhypoactive patient, compared with a patient with hypoactive delirium (78% vs. 45%; P = .02).

“After all, an 88-year-old person screaming or hallucinating will get your attention, while in a busy ED, someone sleeping quietly in a bed at 2 pm might not,” Dr. Kennedy said in an interview.

Hypoactive delirium is easy to miss and is associated with poor outcomes. It needs to be screened for in the ED, as it could be dangerous to discharge some patients with delirium. Even if the patient is admitted, she added, delirium “is not necessarily going to be picked up upstairs” in the hospital.

More research needs to focus on “trying to identify the underlying cause [of delirium] in patients presenting to the ED,” Dr. Kennedy said. “And we need to start really looking at delirium as indicative of something else being wrong.”

Dr. Han’s study was funded by the National Institute on Aging and by the Emergency Medicine Foundation Center; he disclosed a consulting relationship with Bio-Signal Group. Dr. Kennedy’s studies were funded by the National Institute on Aging, and the Dennis W. Jahnigen Career Development Award. She disclosed no conflicts of interest.

SAN DIEGO – More than 10% of geriatric patients presenting to emergency departments have signs of delirium, but not all delirium in the ED is equal, based on two presentations at the annual meeting of the Society for Academic Emergency Medicine.

For elderly patients in the emergency department, delirium is not merely present or absent. It is a heterogeneous syndrome, and certain subtypes likely indicate higher risk.

Dr. Jin Han, a researcher at Vanderbilt University in Nashville, Tenn., presented findings from a prospective, single-center observational study of 1,084 ED patients over age 65. Subjects were screened for delirium and their level of alertness. Of the 14% of patients with delirium, the researchers found the state of a patient’s arousal – decreased, normal, or increased – affected 6-month mortality.

In a separate study, Dr. Maura Kennedy of Harvard Medical School in Boston presented data suggesting that certain subtypes of delirium – particularly delirium with hypoactivity – are getting missed in the ED.

In Dr. Han’s study of 155 patients with delirium, a 4-point measurement called the Confusion Assessment Method for the Intensive Care Unit, (CAM-ICU) and the Richmond Agitation Sedation Scale (RASS) were used to measure delirium. Those with normal arousal as measured by RASS (n=15) had the highest 6-month mortality, at 40% (95% confidence interval, 20%-64%). In those with decreased arousal, the mortality rate was 27% (95% CI, 20%-35%); in those with increased arousal, mortality was 25%. The 6-month mortality rate in elderly ED patients without delirium was 11%.

Dr. Han acknowledged his study’s wide confidence intervals and the limitations of its single-site design and its screening tool, CAM-ICU, which has 70% sensitivity. Nonetheless, the findings imply that delirium needs to be looked at much more carefully in the ED. “Now if I see a patient with delirium and normal arousal, I want to make sure I rule out a potentially life-threatening illness,” he said in an interview.

Dr. Han’s research team is now collecting additional data, including etiology data and serum biomarkers, from ED patients with delirium in the hope of learning “why delirious patients with normal arousal do so poorly in terms of mortality.”

Dr. Kennedy presented a study from a cohort of 622 ED patients age 65 and older, who were screened using a tool called the Memorial Delirium Assessment Scale. The researchers compared their screening results to what doctors and nurses observed in the ED. Dr. Kennedy and her colleagues found that physicians were more likely to document delirium in a nonhypoactive patient, compared with a patient with hypoactive delirium (78% vs. 45%; P = .02).

“After all, an 88-year-old person screaming or hallucinating will get your attention, while in a busy ED, someone sleeping quietly in a bed at 2 pm might not,” Dr. Kennedy said in an interview.

Hypoactive delirium is easy to miss and is associated with poor outcomes. It needs to be screened for in the ED, as it could be dangerous to discharge some patients with delirium. Even if the patient is admitted, she added, delirium “is not necessarily going to be picked up upstairs” in the hospital.

More research needs to focus on “trying to identify the underlying cause [of delirium] in patients presenting to the ED,” Dr. Kennedy said. “And we need to start really looking at delirium as indicative of something else being wrong.”

Dr. Han’s study was funded by the National Institute on Aging and by the Emergency Medicine Foundation Center; he disclosed a consulting relationship with Bio-Signal Group. Dr. Kennedy’s studies were funded by the National Institute on Aging, and the Dennis W. Jahnigen Career Development Award. She disclosed no conflicts of interest.