Category Archives: Resus

Life-saving medicine

Acute Med, All Updates, ICU, Resus

PICCs more complicated than CVCs

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A review showed that peripherally inserted central catheters were associated with higher rates of complications that standard central venous catheters


We undertook a review of studies comparing complications of centrally or peripherally inserted central venous catheters. Twelve studies were included. Catheter tip malpositioning (9.3% vs 3.4%, p = 0.0007), thrombophlebitis (78 vs 7.5 per 10 000 indwelling days, p = 0.0001) and catheter dysfunction (78 vs 14 per 10 000 indwelling days, p = 0.04) were more common with peripherally inserted catheters than with central catheter placement, respectively. There was no difference in infection rates. We found that the risks of tip malpositioning, thrombophlebitis and catheter dysfunction favour clinical use of centrally placed catheters instead of peripherally inserted central catheters, and that the two catheter types do not differ with respect to catheter- related infection rates.

Complications associated with peripheral or central routes for central venous cannulation
Anaesthesia. 2012 Jan;67(1):65-71

All Updates, PHARM, Resus, Trauma

Make space for pre-hospital intubation

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“Control your environment – don’t let it control you” is a reliable adage for pre-hospital providers, and its adherence can assist in in-hospital resuscitation too. Commanding control of ones space is a skill demonstrated by more seasoned paramedics compared with novices and the requirement, where possible, for 360 degrees of access around a patient is included in some Standard Operating Procedures for pre-hospital rapid sequence intubation.

Brett Rosen MD controlling space in the field

Evidence for this approach is now further supported by a study demonstrating that limited surrounding space on scene was a significant risk factor for difficult pre-hospital intubation by European EMS physicians.
Other predisposing factors for difficult prehospital intubation included obesity and a short neck.


OBJECTIVES:For experienced personnel endotracheal intubation (ETI) is the gold standard to secure the airway in prehospital emergency medicine. Nevertheless, substantial procedural difficulties have been reported with a significant potential to compromise patients’ outcomes. Systematic evaluation of ETI in paramedic operated emergency medical systems (EMS) and in a mixed physician/anaesthetic nurse EMS showed divergent results. In our study we systematically assessed factors associated with difficult ETI in an EMS exclusively operating with physicians.

METHODS:Over a 1-year period we prospectively collected data on the specific conditions of all ETIs of two physician staffed EMS vehicles. Difficult ETI was defined by more than 3 attempts or a difficult visualisation of the larynx (Cormack and Lehane grade 3, or worse). For each patient ETI conditions, biophysical characteristics and factors of the surrounding scene were assessed. Additionally, physicians were asked whether they had expected difficult ETI in advance.

RESULTS:Out of 3979 treated patients 305 (7.7%) received ETI. For 276 patients complete data sets were available. The incidence of difficult ETI was 13.0%. In 4 cases (1.4%) ETI was impossible, but no patient was unable to be ventilated sufficiently. Predicting conditions for difficult intubation were limited surrounding space on scene (p<0.01), short neck (p<0.01), obesity (p<0.01), face and neck injuries (p<0.01), mouth opening<3cm (p<0.01) and known ankylosing spondylitis (p<0.01). ETI on the floor or with C-spine immobilisation in situ were of no significant influence. The incidence of unexpected difficult ETI was 5.0%.
CONCLUSIONS: In a physician staffed EMS difficult prehospital ETI occurred in 13% of cases. Predisposing factors were limited surrounding space on scene and certain biophysical conditions of the patient (short neck, obesity, face and neck injuries, and anatomical restrictions). Unexpected difficult ETI occurred in 5% of the cases.

Difficult prehospital endotracheal intubation – predisposing factors in a physician based EMS
Resuscitation. 2011 Dec;82(12):1519-24

All Updates, ICU, Resus, Trauma

Sedation for traumatic brain injury

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What are the best sedatives for patients with traumatic brain injury? A systematic review found no evidence that one sedative agent is better than another for improvement of neurologic outcome or mortality in critically ill adults with severe TBI. Thirteen randomised trials including around 380 patients were reviewed.
Why sedate brain injured patients anyway? Reasons include:

  • minimise noxious stimuli
  • improve patient comfort
  • reduce metabolic requirements of the injured brain to avoid ischemic progression of the traumatic lesion in presence of increased ICP
  • facilitate mechanical ventilation to control PaCo2
  • avoid ICP rises due to airway instrumentation such as those induced by coughing

Sedation generally improved intracranial pressure (ICP) and cerebral perfusion pressure (CPP) vs. baseline in most trials.
Interestingly boluses or short infusions of opioids resulted in (often transient) increases in ICP and decreases in MAP and CPP in three RCTs. An accompanying editorial suggests this may be due to large opioid doses (up to 3 μg/kg of fentanyl) and consequent hypotension; hypotension itself may trigger autoregulatory cerebral vasodilatation and increase ICP and decrease CPP. Although opioids have been linked with increased ICP through decreased cerebrovascular resistance, increased cerebral blood flow or Paco2, and disturbed cerebral autoregulation, they state that in studies in which hypotension after opioid administration was prevented, an ICP increasing effect was not seen. It is important to note the small sample sizes studied and the long time period of studies included, dating back some decades.
Importantly, ketamine did not result in the increase in ICP purported by older literature.


OBJECTIVES: To summarize randomized controlled trials on the effects of sedative agents on neurologic outcome, mortality, intracranial pressure, cerebral perfusion pressure, and adverse drug events in critically ill adults with severe traumatic brain injury.

DATA SOURCES: PubMed, MEDLINE, EMBASE, the Cochrane Database, Google Scholar, two clinical trials registries, personal files, and reference lists of included articles.

STUDY SELECTION: Randomized controlled trials of propofol, ketamine, etomidate, and agents from the opioid, benzodiazepine, α-2 agonist, and antipsychotic drug classes for management of adult intensive care unit patients with severe traumatic brain injury.

DATA EXTRACTION: In duplicate and independently, two investigators extracted data and evaluated methodologic quality and results.

DATA SYNTHESIS: Among 1,892 citations, 13 randomized controlled trials enrolling 380 patients met inclusion criteria. Long-term sedation (≥24 hrs) was addressed in six studies, whereas a bolus dose, short infusion, or doubling of plasma drug concentration was investigated in remaining trials. Most trials did not describe baseline traumatic brain injury prognostic factors or important cointerventions. Eight trials possibly or definitely concealed allocation and six were blinded. Insufficient data exist regarding the effects of sedative agents on neurologic outcome or mortality. Although their effects are likely transient, bolus doses of opioids may increase intracranial pressure and decrease cerebral perfusion pressure. In one study, a long-term infusion of propofol vs. morphine was associated with a reduced requirement for intracranial pressure-lowering cointerventions and a lower intracranial pressure on the third day. Trials of propofol vs. midazolam and ketamine vs. sufentanil found no difference between agents in intracranial pressure and cerebral perfusion pressure.

CONCLUSIONS: This systematic review found no convincing evidence that one sedative agent is more efficacious than another for improvement of patient-centered outcomes, intracranial pressure, or cerebral perfusion pressure in critically ill adults with severe traumatic brain injury. High bolus doses of opioids, however, have potentially deleterious effects on intracranial pressure and cerebral perfusion pressure. Adequately powered, high-quality, randomized controlled trials are urgently warranted.

Sedation for critically ill adults with severe traumatic brain injury: A systematic review of randomized controlled trials
Crit Care Med. 2011 Dec;39(12):2743-51

All Updates, Resus, Trauma

Complications after penetrating cardiac injury

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Trauma specialists from Arizona and California describe patients with penetrating cardiac wounds, a quarter of whom survive to discharge. Survival post discharge is good, with a range of complications at follow up but no operative intervention was required for the complications.


HYPOTHESIS:
A significant rate of postdischarge complications is associated with penetrating cardiac injuries.

DESIGN: Retrospective trauma registry review.

SETTING: Level I trauma center.

PATIENTS: All patients sustaining penetrating cardiac injuries between January 2000 and June 2010. Patient demographics, clinical data, operative findings, outpatient follow-up, echocardiogram results, and outcomes were extracted.

MAIN OUTCOME MEASURES: Cardiac-related complications and mortality.

RESULTS: During the 10.5-year study period, 406 of 40,706 trauma admissions (1.0%) sustained penetrating cardiac injury. One hundred nine (26.9%) survived to hospital discharge. The survivors were predominantly male (94.4%), with a mean (SD) age of 30.8 (11.7) years, and 74.3% sustained a stab wound. Signs of life were present on admission in 92.6%. Cardiac chambers involved were the right ventricle (45.9%), left ventricle (40.3%), right atrium (10.1%), left atrium (0.9%), and combined (2.8%). In-hospital follow-up was available for a mean (SD) of 11.0 (9.8) days (median, 8 days; range, 3-65 days) and outpatient follow-up was available in 46 patients (42.2%) for a mean (SD) of 1.9 (4.1) months (median, 0.9 months; range, 0.2-12 months). Abnormal echocardiograms demonstrated pericardial effusions (9), abnormal wall motion (8), decreased ejection fraction (<45%) (8), intramural thrombus (4), valve injury (4), cardiac enlargement (2), conduction abnormality (2), pseudoaneurysm (1), aneurysm (1), and septal defect (1). No operative intervention was required for the complications. The 1-year and 9-year survival rates were 97% and 88%, respectively.
CONCLUSIONS: Penetrating cardiac injuries remain highly lethal. A significant rate of cardiac complications can be expected and follow-up echocardiographic evaluation is warranted prior to discharge. The majority of these, however, can be managed without the need for surgical intervention.

Postdischarge Complications After Penetrating Cardiac Injury: a survivable injury with a high postdischarge complication rate
Arch Surg. 2011 Sep;146(9):1061-6

All Updates, ICU, Resus, Trauma

Predicting massive transfusion

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Do you have access to thromboelastometry in your Emergency Department? Further research by some of the first discoverers of acute traumatic coagulopathy involved using this tool to identify acute traumatic coagulopathy at 5 mins and predict the need for massive transfusion. Measures of coagulopathy more familiar to ED staff such as the INR took longer or (when point-of-care testing was employed) were less accurate.


OBJECTIVE: To identify an appropriate diagnostic tool for the early diagnosis of acute traumatic coagulopathy and validate this modality through prediction of transfusion requirements in trauma hemorrhage.

DESIGN: Prospective observational cohort study.

SETTING: Level 1 trauma center.

PATIENTS: Adult trauma patients who met the local criteria for full trauma team activation. Exclusion criteria included emergency department arrival >2 hrs after injury, >2000 mL of intravenous fluid before emergency department arrival, or transfer from another hospital.

INTERVENTIONS: None.

MEASUREMENTS: Blood was collected on arrival in the emergency department and analyzed with laboratory prothrombin time, point-of-care prothrombin time, and rotational thromboelastometry. Prothrombin time ratio was calculated and acute traumatic coagulopathy defined as laboratory prothrombin time ratio >1.2. Transfusion requirements were recorded for the first 12 hrs following admission.

MAIN RESULTS: Three hundred patients were included in the study. Laboratory prothrombin time results were available at a median of 78 (62-103) mins. Point-of-care prothrombin time ratio had reduced agreement with laboratory prothrombin time ratio in patients with acute traumatic coagulopathy, with 29% false-negative results. In acute traumatic coagulopathy, the rotational thromboelastometry clot amplitude at 5 mins was diminished by 42%, and this persisted throughout clot maturation. Rotational thromboelastometry clotting time was not significantly prolonged. Clot amplitude at a 5-min threshold of ≤35 mm had a detection rate of 77% for acute traumatic coagulopathy with a false-positive rate of 13%. Patients with clot amplitude at 5 mins ≤35 mm were more likely to receive red cell (46% vs. 17%, p < .001) and plasma (37% vs. 11%, p < .001) transfusions. The clot amplitude at 5 mins could identify patients who would require massive transfusion (detection rate of 71%, vs. 43% for prothrombin time ratio >1.2, p < .001).
CONCLUSIONS: In trauma hemorrhage, prothrombin time ratio is not rapidly available from the laboratory and point-of-care devices can be inaccurate. Acute traumatic coagulopathy is functionally characterized by a reduction in clot strength. With a threshold of clot amplitude at 5 mins of ≤35 mm, rotational thromboelastometry can identify acute traumatic coagulopathy at 5 mins and predict the need for massive transfusion.

Functional definition and characterization of acute traumatic coagulopathy.
Crit Care Med. 2011 Dec;39(12):2652-2658

Acute Med, All Updates, Resus, Trauma

Modified ED thoracotomy to avoid exsanguination

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Emergency physicians from Minnesota (and graduates of the amazing Hennepin Emergency Medicine Residency) describe a patient who developed cardiac tamponade after an ablation procedure for dysrhythmia. Attempts at pericardiocentesis by both emergency and cardiology staff were hindered by clotted blood, and so a left lateral thoracotomy was performed in the ED due to loss of pulse and lack of immediate availability of an operating room. A limited pericardial incision was made to allow drainage of sufficient blood to relieve tamponade while avoiding catastrophic blood loss from the underlying lesion, which turned out to be a 1.5-cm hole in the right ventricular outflow tract. The patient made a full recovery.

Cardiac dysrhythmias are a common problem in the United States. Radiofrequency ablation is being used more frequently as a treatment for these diagnoses. Although rare, serious complications such as cardiac tamponade have been reported as a result of ablation procedures. Traditionally, emergency department (ED) thoracotomy has been reserved for cases of traumatic arrest only. We report a case of a successful modified ED thoracotomy in a patient with postablation cardiac tamponade and subsequent obstructive shock who failed intravenous fluid resuscitation, pressor administration, and multiple attempts at pericardiocentesis. In this case, a modified approach was used to incise the pericardium. Although this was associated with large blood loss, we believed that using the traditional method of completely removing the pericardium would have resulted in uncontrolled hemorrhage. Instead, our method led to successful resuscitation of the patient until definitive care was available. A smaller pericardial incision than is traditionally used during ED thoracotomy deserves further consideration and research to determine whether and when it may be most useful as a temporizing treatment of cardiac tamponade when other methods have failed.

Modified Emergency Department Thoracotomy for Postablation Cardiac Tamponade
Annals of Emergency Medicine In Press – Full Text Available here from Annals site at time of blogging

All Updates, PHARM, Resus, Trauma

More on needle thoracostomy for tension pneumothorax

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Thanks to Dr. Matthew Oliver for highlighting these articles to me.
The standard teaching of placing a handy iv catheter in the 2nd intercostal space, midclavicular line for tension pneumothorax has been challenged by previous studies suggesting about a third of adults have a chest wall that is too thick for a standard 4.5 to 5 cm needle.
Some have therefore suggested that a lateral approach may be more appropriate.
Three studies this month provide more, although not entirely consistent, information.
An ultrasound study differed from previous CT studies by suggesting that most patients will have chest wall thickness (CWT) less than 4.5 cm, and found that the CW was thicker in the lateral area (4th intercostal space, midaxillary line)1.
In a cadaveric model, needle thoracostomy was successfully placed (confirmed by thoracotomy) in all attempts at the fifth intercostal space at the midaxillary line but in only just over half of insertions at the traditional second intercostal position2.
In a further study of trauma CT scans, measured CWT suggests that the lateral approach is less likely to be successful than the anterior approach, and the anterior approach may fail in many patients as well3.

The take home message for us must therefore remain that needle thoracostomy for tension pneumothorax might not be successful with a standard iv catheter, regardless of which approach is used. If tension pneumothorax is a possibility in the deteriorating patient and needle decompression has been unsuccessful, an alternative means of decompression (or ruling out pneumothorax) must be employed.

1. Ultrasound determination of chest wall thickness: implications for needle thoracostomy
Am J Emerg Med. 2011 Nov;29(9):1173-7
[EXPAND Abstract]


Objective: Computed tomography measurements of chest wall thickness (CWT) suggest that standard- length angiocatheters (4.5 cm) may fail to decompress tension pneumothoraces. We used an alternative modality, ultrasound, to measure CWT. We correlated CWT with body mass index (BMI) and used national data to estimate the percentage of patients with CWT greater than 4.5 cm.

Methods: This was an observational, cross-sectional study of a convenience sample. We recorded standing height, weight, and sex. We measured CWT with ultrasound at the second intercostal space, midclavicular line and at the fourth intercostal space, midaxillary line on supine subjects. We correlated BMI (weight [in kilograms]/height2 [in square meters]) with CWT using linear regression. 95% Confidence intervals (CIs) assessed statistical significance. National Health and Nutrition Examination Survey results for 2007-2008 were combined to estimate national BMI adult measurements.

Results: Of 51 subjects, 33 (65%) were male and 18 (35%) were female. Mean anterior CWT (male, 2.1 cm; CI, 1.9-2.3; female, 2.3 cm; CI, 1.7-2.7), lateral CWT (male, 2.4 cm; CI, 2.1-2.6; female, 2.5 cm; CI 2.0-2.9), and BMI (male, 27.7; CI, 26.1-29.3; female, 30.0; CI, 25.8-34.2) did not differ by sex. Lateral CWT was greater than anterior CWT (0.2 cm; CI, 0.1-0.4; P < .01). Only one subject with a BMI of 48.2 had a CWT that exceeded 4.5 cm. Using national BMI estimates, less than 1% of the US population would be expected to have CWT greater than 4.5 cm.
Conclusions: Ultrasound measurements suggest that most patients will have CWT less than 4.5 cm and that CWT may not be the source of the high failure rate of needle decompression in tension pneumothorax.

[/EXPAND]
2. Anterior versus lateral needle decompression of tension pneumothorax: comparison by computed tomography chest wall measurement.
Acad Emerg Med. 2011 Oct;18(10):1022-6
[EXPAND Abstract]


Objectives:  Recent research describes failed needle decompression in the anterior position. It has been hypothesized that a lateral approach may be more successful. The aim of this study was to identify the optimal site for needle decompression.

Methods:  A retrospective study was conducted of emergency department (ED) patients who underwent computed tomography (CT) of the chest as part of their evaluation for blunt trauma. A convenience sample of 159 patients was formed by reviewing consecutive scans of eligible patients. Six measurements from the skin surface to the pleural surface were made for each patient: anterior second intercostal space, lateral fourth intercostal space, and lateral fifth intercostal space on the left and right sides.

Results:  The distance from skin to pleura at the anterior second intercostal space averaged 46.3 mm on the right and 45.2 mm on the left. The distance at the midaxillary line in the fourth intercostal space was 63.7 mm on the right and 62.1 mm on the left. In the fifth intercostal space the distance was 53.8 mm on the right and 52.9 mm on the left. The distance of the anterior approach was statistically less when compared to both intercostal spaces (p <  0.01).
Conclusions:  With commonly available angiocatheters, the lateral approach is less likely to be successful than the anterior approach. The anterior approach may fail in many patients as well. Longer angiocatheters may increase the chances of decompression, but would also carry a higher risk of damage to surrounding vital structures.

[/EXPAND]
3. Optimal Positioning for Emergent Needle Thoracostomy: A Cadaver-Based Study
J Trauma. 2011 Nov;71(5):1099-1103/a>
[EXPAND Abstract]


Background:  Needle thoracostomy is an emergent procedure designed to relieve tension pneumothorax. High failure rates because of the needle not penetrating into the thoracic cavity have been reported. Advanced Trauma Life Support guidelines recommend placement in the second intercostal space, midclavicular line using a 5-cm needle. The purpose of this study was to evaluate placement in the fifth intercostal space, midaxillary line, where tube thoracostomy is routinely performed. We hypothesized that this would result in a higher successful placement rate.

Methods:  Twenty randomly selected unpreserved adult cadavers were evaluated. A standard 14-gauge 5-cm needle was placed in both the fifth intercostal space at the midaxillary line and the traditional second intercostal space at the midclavicular line in both the right and left chest walls. The needles were secured and thoracotomy was then performed to assess penetration into the pleural cavity. The right and left sides were analyzed separately acting as their own controls for a total of 80 needles inserted into 20 cadavers. The thickness of the chest wall at the site of penetration was then measured for each entry position.

Results:  A total of 14 male and 6 female cadavers were studied. Overall, 100% (40 of 40) of needles placed in the fifth intercostal space and 57.5% (23 of 40) of the needles placed in the second intercostal space entered the chest cavity (p < 0.001); right chest: 100% versus 60.0% (p = 0.003) and left chest: 100% versus 55.0% (p = 0.001). Overall, the thickness of the chest wall was 3.5 cm ± 0.9 cm at the fifth intercostal space and 4.5 cm ± 1.1 cm at the second intercostal space (p < 0.001). Both right and left chest wall thicknesses were similar (right, 3.6 cm ± 1.0 cm vs. 4.5 cm ± 1.1 cm, p = 0.007; left, 3.5 ± 0.9 cm vs. 4.4 cm ± 1.1 cm, p = 0.008).
Conclusions:In a cadaveric model, needle thoracostomy was successfully placed in 100% of attempts at the fifth intercostal space but in only 58% at the traditional second intercostal position. On average, the chest wall was 1 cm thinner at this position and may improve successful needle placement. Live patient validation of these results is warranted.

[/EXPAND]
Update October 2012: See this post about a further CT-scan based study favouring the 5th ICS compared with the 2nd

All Updates, PHARM, Resus, Trauma, Ultrasound

Tension pneumo treatment and chest wall thickness

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An interesting ultrasound-based study challenges the assertion that a significant proportion of adults have a chest wall that is too thick for a standard iv cannula to reach the pleural space when attempting to decompress a tension pneumothorax. Perhaps there are other factors that make this technique so frequently ineffective.
The authors postulate that ultrasound measurements of chest wall thickness might be less than those obtained by CT scan due to the downward pressure on the tissues caused when the ultrasound transducer is placed on the chest, something that may also occur when a cannula is being pushed in, but would not be maintained after insertion of a cannula, perhaps leading to subsequent misplacement as the tissues recoil.
My view is that needle decompression might buy you time as a holding measure, but the patient with a tension pneumothorax will need a thoracostomy sooner rather than later.


Objective: Computed tomography measurements of chest wall thickness (CWT) suggest that standard- length angiocatheters (4.5 cm) may fail to decompress tension pneumothoraces. We used an alternative modality, ultrasound, to measure CWT. We correlated CWT with body mass index (BMI) and used national data to estimate the percentage of patients with CWT greater than 4.5 cm.

Methods: This was an observational, cross-sectional study of a convenience sample. We recorded standing height, weight, and sex. We measured CWT with ultrasound at the second intercostal space, midclavicular line and at the fourth intercostal space, midaxillary line on supine subjects. We correlated BMI (weight [in kilograms]/height2 [in square meters]) with CWT using linear regression. 95% Confidence intervals (CIs) assessed statistical significance. National Health and Nutrition Examination Survey results for 2007-2008 were combined to estimate national BMI adult measurements.

Results: Of 51 subjects, 33 (65%) were male and 18 (35%) were female. Mean anterior CWT (male, 2.1 cm; CI, 1.9-2.3; female, 2.3 cm; CI, 1.7-2.7), lateral CWT (male, 2.4 cm; CI, 2.1-2.6; female, 2.5 cm; CI 2.0-2.9), and BMI (male, 27.7; CI, 26.1-29.3; female, 30.0; CI, 25.8-34.2) did not differ by sex. Lateral CWT was greater than anterior CWT (0.2 cm; CI, 0.1-0.4; P <.01). Only one subject with a BMI of 48.2 had a CWT that exceeded 4.5 cm. Using national BMI estimates, less than 1% of the US population would be expected to have CWT greater than 4.5 cm.
Conclusions: Ultrasound measurements suggest that most patients will have CWT less than 4.5 cm and that CWT may not be the source of the high failure rate of needle decompression in tension pneumothorax.

Ultrasound determination of chest wall thickness: implications for needle thoracostomy

Am J Emerg Med. 2011 Nov;29(9):1173-7

Acute Med, All Updates, Resus

Needle versus mini-chest tube for pneumothorax

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A mini-chest tube with Heimlich valve was an alternative to needle aspiration in patients with spontaneous pneumothorax, with some apparently favourable outcomes in this small study. The authors do not specify what type of chest tube they used but report it was 12 Fr diameter. They highlight an interesting difference in guidelines for the treatment of spontaneous primary pneumothorax:
“Traditional preference has been for chest tube insertion and admission to the ward. British Thoracic Society recommends needle aspiration (NA) as the initial treatment of choice, but American College of Chest Physicians Consensus prefers insertion of small-bore catheters (≤14F) or chest tubes (16-22F).”


OBJECTIVES: The aim of this study was to compare outcomes and complications associated with needle aspiration (NA) and minichest tube (MCT) insertion with Heimlich valve attachment in the treatment of primary spontaneous pneumothorax at an emergency department (ED).

METHODS: Patients presenting with primary spontaneous pneumothorax were randomized to NA or MCT. They had repeat chest x-rays immediately after the procedure and 6 hours later. Patients who underwent NA were discharged if repeat x-rays showed less than 10% pneumothorax. Those who had MCT were discharged if repeat x-rays did not show worsening of pneumothorax. They were reviewed at the outpatient clinic within 3 days. The primary outcomes of interest were failure rate and admission rate. The secondary outcomes were complication rate, pain and satisfaction scores, length of hospital stay, and rate of full recovery during outpatient follow-up.

RESULTS: There were 48 patients whose mean age was 25 years. We found no difference in failure rate between the groups, except that there were more MCT (24%) than NA patients (4%) with complete expansion at first review (difference, -0.20; 95% confidence interval, -0.38 to -0.01). Thirty-five percent of NA group and 20% of MCT group needed another procedure at the ED. Fifty-two percent of NA patients and 28% of MCT patients were admitted from the ED to the inpatient ward. Nine percent and 12%, respectively, of patients who had NA and MCT were admitted from the review clinic. Both groups of patients had equivalent pain scores, satisfaction scores, and complication rates.

CONCLUSION: Both MCT and NA allowed safe management of primary spontaneous pneumothorax in the outpatient setting.

A randomized controlled trial comparing minichest tube and needle aspiration in outpatient management of primary spontaneous pneumothorax
Am J Emerg Med. 2011 Nov;29(9):1152-7

Acute Med, All Updates, ICU, Resus

AF in sepsis and risk of stroke

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Atrial fibrillation can occur in the setting of severe sepsis, and often presents a therapeutic conundrum for critical care physicians, in that it can be relatively resistant to treatment until the sepsis has resolved, and its prognostic significance is unclear. A new study on a massive dataset shows atrial fibrillation in the setting of severe sepsis is associated with an increased risk of stroke and increased hospital mortality. Patients with severe sepsis who developed new-onset AF had a greater risk of in-hospital stroke than patients with preexisting AF and individuals without a history of AF.


Context New-onset atrial fibrillation (AF) has been reported in 6% to 20% of patients with severe sepsis. Chronic AF is a known risk factor for stroke and death, but the clinical significance of new-onset AF in the setting of severe sepsis is uncertain.

Objective To determine the in-hospital stroke and in-hospital mortality risks associated with new-onset AF in patients with severe sepsis.

Design and Setting Retrospective population-based cohort of California State Inpatient Database administrative claims data from nonfederal acute care hospitals for January 1 through December 31, 2007.

Patients Data were available for 3 144 787 hospitalized adults. Severe sepsis (n = 49 082 [1.56%]) was defined by validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 995.92. New-onset AF was defined as AF that occurred during the hospital stay, after excluding AF cases present at admission.

Main Outcome Measures A priori outcome measures were in-hospital ischemic stroke (ICD-9-CM codes 433, 434, or 436) and mortality.

Results Patients with severe sepsis were a mean age of 69 (SD, 16) years and 48% were women. New-onset AF occurred in 5.9% of patients with severe sepsis vs 0.65% of patients without severe sepsis (multivariable-adjusted odds ratio [OR], 6.82; 95% CI, 6.54-7.11; P < .001). Severe sepsis was present in 14% of all new-onset AF in hospitalized adults. Compared with severe sepsis patients without new-onset AF, patients with new-onset AF during severe sepsis had greater risks of in-hospital stroke (75/2896 [2.6%] vs 306/46 186 [0.6%] strokes; adjusted OR, 2.70; 95% CI, 2.05-3.57; P < .001) and in-hospital mortality (1629 [56%] vs 18 027 [39%] deaths; adjusted relative risk, 1.07; 95% CI, 1.04-1.11; P < .001). Findings were robust across 2 definitions of severe sepsis, multiple methods of addressing confounding, and multiple sensitivity analyses.
Conclusion Among patients with severe sepsis, patients with new-onset AF were at increased risk of in-hospital stroke and death compared with patients with no AF and patients with preexisting AF.

Incident Stroke and Mortality Associated With New-Onset Atrial Fibrillation in Patients Hospitalized With Severe Sepsis
JAMA. 2011 Nov 13. [Epub ahead of print]