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Department of Emergency Medicine

Department of Emergency Medicine

2014 - January R3 Journal Review

Tichter AM. Are Routine Antibiotics Beneficial for Exacerbations of Chronic Obstructive Pulmonary Disease? Ann Emerg Med 2013 Dec;62(6): 592-593.
This is a meta-analysis study that looked at the routine use of antibiotics for patients with COPD exacerbations versus placebo or patients who did not get antibiotics. A total of 1,636 patients in 12 trials (7 outpatient, 4 inpatient, 1 ICU) were analyzed. The study selection included randomized controlled trials and excluded any patients with asthma, acute bronchitis, pneumonia, or bronchiectasis. Two authors independently screened and abstracted data. Primary outcome of treatment failure was defined as deterioration of symptoms, additional antibiotics, or death. The results of the primary outcome concluded that there was a benefit to using antibiotics in treating patients with COPD exacerbations. The lowest quality of evidence was shown in the outpatient setting with a NNTB of 13, and the highest quality of evidence was shown in the ICU with a NNTB of 2. Mortality and length of stay were limited to ICU patients alone. This study showed that antibiotics are beneficial in COPD exacerbations especially in patients with higher severity of COPD exacerbation.

- Nguyen

Becattini C et al. Acute Pulmonary Embolism - External Validation of an Integrated Risk Stratification Model. Chest 2013 Nov;144(5):1539-45.
Pulmonary embolisms can provide both diagnostic and treatment challenges for the emergency medicine physician. What do you do with a hemodynamically stable patient with the diagnosis of PE? There is no consensus to this question. 

This study looked to validate a previously proposed idea that patients without right-sided ventricular dysfunction (no RV dysfunction on formal echo) and without right-sided injury (no troponin elevation) are at low risk for bad outcomes, defined as death or hemodynamic deterioration while hospitalized. Thus, it may be reasonable to treat patients with very low risk in less acute settings, possibly as out-patients. 

This study took patients from an Italian registry of PE patients from both academic and community Italian hospitals. The registry included 1716 patients over 48 months. Of the 1716 patients, 869 were hemodynamically stable patients with both echocardiography (done within 48 hours) and had troponin levels recorded (within 12 hours of admission). Of these 869 patients, 363 (42%) had both RVD on echo and elevated troponin and they had an all-cause mortality rate of 5.8%. 317 patients (36%) had either RVD or an elevated troponin and had an all-cause mortality of 2.8%. 189 (22%) had no evidence of RVD and a normal troponin. Of these 22% of hemodynamically stable PE patients with normal troponin and without RVD, the in-hospital mortality was zero, and the subsequent hemodynamic deterioration was 0.5%. Thus, patients with normal troponin and without RVD on echo at admission are at very low risk for deterioration and death. 

The limitations of this study are that the treatment of these patients was not standardized or reported, so it’s unclear if they simply responded more favorably to hospital treatments. This may not be applicable to emergency medicine physicians if echo is not rapidly available. However, other studies show that the same CT used to detect PE can also detect RVD (possibly replacing the need for an echo), which may be of future benefit in the Emergency Department.  A randomized study of treatment alternatives of these low-risk patients is necessary before new treatment algorithms can be made. In the meantime, you can reassure these low-risk patients that they will do well when you hospitalize them on a telemetry floor. 

- Hopkins

Nakahara S, et al. Evaluation of pre-hospital administration of epinephrine by emergency medical services for patients with out of hospital cardiac arrest in Japan: controlled propensity matched retrospective cohort study. BMJ. 2013;347:f6829.
This is a retrospective cohort study conducted in Japan using their nationwide registry database of patients with out-of-hospital cardiac arrest from January 2007 through December 2010. Patients aged 15-94, who had a bystander-witnessed out-of-hospital cardiac arrest were enrolled. Using this they were able to enroll 1,990 pairs of patients who had VF/VT or PEA and received or did not receive epinephrine and 9,058 pairs of patients with non-VF/VT, non-PEA arrest who did/did-not receive epinephrine. Their primary outcome was neurologically-intact survival at 1 month or at discharge (whichever came first) while their secondary outcome was all survival.

In patients with VF/VT or PEA there was no difference in neurologically intact survival (6.6% in both groups) though all survival was higher in patients that received pre-hospital epinephrine (17.0% versus 13.4%).  In patients with non-VF/VT arrest there was greater neurologically intact survival in the pre-hospital epinephrine group (0.7% versus 0.4%) and all survival (4.0% versus 2.4%).  

There were major limitations to this study, mainly they did not account for in-hospital treatment.  In addition they did not account for distance from the hospital or time to first dose of epinephrine (whether this was pre-hospital or in the hospital). So it makes it hard to generalize this to other populations.  It may be a factor of time to first dose of epinephrine rather than pre-hospital vs. in-hospital epinephrine administration. Furthermore it’s difficult to extrapolate this data to the US – not sure how the US EMS system differs from Japan’s. Nonetheless, it’s an interesting question – how much of what we do leads to a neurologically-intact endpoint and is time to first dose of epinephrine important?

- Chima