JournalFeed Weekly Wrap-Up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.

#1: Treating Low Risk PE at Home – The LoPE Study

Spoon Feed
A protocol in select ED patients with low PESI, no RV dysfunction on echo, and no proximal DVT was safe for treating PE as an outpatient.

Why does this matter?
Reducing admission for low risk PE patients would reduce cost, hospital crowding, and may even be safer.  But we need more evidence to make sure we can pull this off without harming people.  Here’s some now.

LoPE on off to the house…
LoPE was a prospective study of 200 patients with confirmed PE who were treated on an outpatient basis.  To be eligible, they had to have PESI <86, no RV dysfunction on echo, and negative leg ultrasound for DVT proximal to the popliteal vein.  They were also excluded for, “hypoxia, hypotension, hepatic or renal failure, contraindication to therapeutic anticoagulation, or another condition requiring hospital admission.”  Most (85%) were started on rivaroxaban or apixaban.  The 90-day composite outcome of all-cause mortality, recurrent symptomatic VTE, and major bleeding occurred in 0.5% (1/200) and was a major bleed.  They obtained follow up on 100%.  Patients seemed to like it; 91% were highly satisfied with this care.  All patients were observed for 12-24 hours (median, 13.5h) in the ED or hospital.

Here is more evidence that in the right patient, this is safe.  The problem is finding the right patient.  They have to be able to get the medication, afford it, understand how to take it, and have follow up, not to mention all the exclusion criteria. It’s not easy.

Management of Low-Risk Pulmonary Embolism Patients Without Hospitalization: The Low-Risk Pulmonary Embolism Prospective Management Study.  Chest. 2018 Aug;154(2):249-256. doi: 10.1016/j.chest.2018.01.035. Epub 2018 Feb 2.

Another Spoonful

emDocs discusses outpatient PE therapy.

#2: Malpractice – Top Diagnoses | How to Not Get Sued

Spoon Feed
Malpractice suits against emergency physicians have some common themes.  This post will help you understand them in brief.

Why does this matter?
Emergency physicians were 15th of 25 specialties for malpractice suits.  There is a 7.5% annual risk of being sued in the ED.  Overall, our risk is moderate and about the average of all specialties.  But no one wants the expense, time, and hassle of a suit, even if found not at fault.  What are the danger diagnoses and ways to reduce this risk?

Let’s be careful out there…

Red flag diagnoses:

  • Chest pain or missed acute myocardial infarction is second most common but has the highest pay out.
  • Missed fractures are the most common but pay out less than MI.
  • This is followed by abdominal pain or missed appendicitis, wounds/retained foreign bodies/tendon injuries, intracranial bleeding, aortic aneurysm, and rarely pediatric fever/missed meningitis

The most common issues that increased risk:

  • diagnostic error (test not ordered or misinterpreted; cognitive error)
  • poor documentation
  • poor communication with patients
  • provider history of ≥2 patient complaints or prior malpractice suit
  • non-EM board certification
  • failure to follow up on pending diagnostic testing
  • provider sleep disruption
  • ED crowding/ nursing flow.

Ways to mitigate this risk:

  • Tort reform has reduced prevalence and cost of suits.
  • Communication is most important, even more so that the injury sustained.
  • Reassessment prior to discharge is key, especially if intoxicated.  Document the following: “stable vital signs, clinical sobriety, ability to care for oneself, no new complaints, and the complete evaluation of all documented triage complaints.”
  • Careful documentation is needed in the ED note and discharge instructions including: purpose of the instructions, diagnosis/expected course, potential complications, how to use medications, and follow-up.
  • Use clinical practice guidelines, which are comparable to having an expert witness if taken to court.
  • Use broad or generalized diagnoses (i.e. “abdominal pain” vs. “gastroenteritis” with subsequent risk of missed appendicitis.)
  • Caution with discharge AMA – ensure patients are: informed of risk, have decision-making capacity, and do not need involuntary psychiatric commitment.
  • Don’t abandon AMA patients.  If they must leave, show you did all you could to set them up for success, i.e. prescription for antibiotic, aiding in follow-up, calling the primary physician, etc.
  • Follow up of pending diagnostic studies ordered in the ED, especially x-rays.
  • Reassessment, especially of intoxicated patients

Malpractice in Emergency Medicine-A Review of Risk and Mitigation Practices for the Emergency Medicine Provider.  J Emerg Med. 2018 Aug 27. pii: S0736-4679(18)30648-6. doi: 10.1016/j.jemermed.2018.06.035. [Epub ahead of print]

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Another Spoonful
A similar pediatric study came out this month as well.  The most common red flag diagnoses were: “cardiac or cardiorespiratory arrest, appendicitis, and disorder of male genital organs.”  Error in diagnosis was the most common contributing factor.  Open in Read by QxMD

#3: Does LR Raise Serum Lactate Compared to NS?

Spoon Feed
A rapid infusion of lactated Ringer’s increased serum lactate but did not raise the serum lactate more so than compared to normal saline.

Why does this matter?
The Centers for Medicare and Medicaid Services have trained us like one of Pavlov’s dogs: lactic acidosis must be due to sepsis. However, many other causes of lactatemia exist. For example, epinephrine, albuterol, anti-retrovirals, metformin, propofol, and alcohols have all been shown to increase lactate.  Although it seems certain that infusing lactated Ringer’s (LR) must increase serum lactate, a prior study suggests that may not be the case. In that study, 1 liter of LR was given over 1 hour.  What if LR is given at higher doses and more quickly, as prescribed for septic shock?

Lactate in, lactate out
This was a double-blind RCT that administered 30cc/kg of lactated Ringer’s or normal saline (NS) via pressure bag to 30 healthy volunteers. Average fluid bolus duration was 47 minutes. Lactate was measured immediately before and 5 minutes after IV fluid bolus. In the LR group, lactate increased by 0.93 mmol/L (p = 0.003). However, compared to NS, which increased by 0.37 mmol/L, there was no statistical difference between the two groups (p = 0.2). This study shows that infusing lactate in the right arm will increase the amount of lactate drawn out of the left arm. Unfortunately, it does not answer what happens in septic patients as their bodies metabolize the infused lactate. What this study does do is remind us that a persistently elevated lactate does not always indicate the need for more fluid. After all, not all lactic acidosis is due to shock.

Does Intravenous Lactated Ringer’s Solution Raise Serum Lactate?  J Emerg Med. 2018 Sep;55(3):313-318. doi: 10.1016/j.jemermed.2018.05.031. Epub 2018 Jul 20.

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