WHEN FEMALE VETERANS RETURN HOME

Some bring the enduring effects of trauma with them.

More female veterans of the U.S. military have experienced combat during the past 15 years than have ever before in our nation's history, and their experience, complete with physical and psychological trauma, is beginning to unfold.

In a large survey, it was revealed that 22% of them had experienced enough symptoms of posttraumatic stress disorder (PTSD) within the preceding month to meet the criteria for the diagnosis. In addition to reporting trauma related to combat, 23% of female veterans reported having been sexually assaulted while in military service. The survey administrators found that, compared with other female veterans, those with PTSD suffered from an overall poorer quality of life, in respect of health, characterized by depression, substance abuse, smoking, obesity, multiple sexual partners, sexually transmitted diseases, domestic violence, fibromyalgia, irritable bowel syndrome, panic disorder, and eating disorders.

The study confirms the findings of others that have revealed higher rates of concurrent illnesses among people with PTSD in a general sample. Conclusions about causation cannot be drawn from the study, but the association between PTSD and depression is believed to be great, and the association between depression and poor health is well documented.

Contrary to the common assumption, nearly twice as many women as men suffer from PTSD, and the prevalence of the disorder is twice as great in female veterans as it is in other women. When such veterans present with significant physical or mental illness, or both, they should be screened for symptoms of PTSD as well as for functional impairment; the quality of their lives, in terms of both physical and mental health, should be assessed. A tactful assessment for a history of severe trauma, physical or otherwise, can help guide the treatment plan for many female military veterans and other patients who present with one or more seemingly intractable medical problems.-FM

Dobie DJ, et al. Arch Intern Med 2003;164 (4):394-400.

SUDDEN CARDIAC DEATH

The use of antipsychotic medication is a significant risk factor.

Initially, antipsychotic medications were prescribed for the treatment of schizophrenia, providing, in many cases, such dramatic relief of symptoms that patients who had spent decades in institutions were able to return to life in the community. Antipsychotic medication now is used to relieve the symptoms of other psychiatric disorders, and newer such agents have fewer adverse effects.

However, during the past four decades, some studies and case reports have associated antipsychotic drug use with sudden cardiac death among people diagnosed with schizophrenia. How safe, then, is the use of antipsychotic medication in the general population?

Sudden cardiac death occurs three times more often among people taking antipsychotic medication, according to the findings of a population-based case-control study in which the medical records of 250,000 people in the Netherlands from 1995 to 2001 were analyzed. Only one-fourth of victims who had been taking antipsychotic medication took it for schizophrenia or schizoaffective disorder, three-fourths having been prescribed an antipsychotic agent for the treatment of organic psychosis, dementia, bipolar depression, anxiety, stress, or other psychiatric disorders. Therefore, sudden cardiac death appears to be related to the use of antipsychotic medication, not to schizophrenia itself. Higher dosages of antipsychotic medication were associated with higher rates of sudden cardiac death, which was more likely to occur within the first three months of therapy, with the risk remaining significantly elevated as long as medication use continued.

The ability of antipsychotic agents to prolong the QT interval has been proposed as an explanation for the apparent causal connection. However, at which point prolongation becomes clinically significant is not known, and its role in sudden cardiac death is uncertain-it may be a sign of cardiac toxicity, generally. If there's a causal connection, the mechanism remains to be defined, and conclusions regarding which antipsychotic agents pose the greatest risk could not be drawn from the study data.

Because sudden cardiac death isn't rare, a threefold greater risk of it posed by antipsychotics would seem to be highly significant and of great concern, particularly in view of the fact that that risk subsists among people taking even low doses of antipsychotic agents, and often for psychiatric disorders other than schizophrenia.-FM

Straus, SM, et al. Arch Intern Med 2004; 164(12):1293-7.

SEIZURES AFTER BLUNT HEAD TRAUMA

Should children be hospitalized for them?

Children do not necessarily need to be hospitalized because of seizures succeeding blunt head trauma if the computed tomographic (CT) scan is normal, according to the results of a prospective, observational cohort study.

Of 2,043 children younger than 18 years of age who were evaluated in the ED after blunt head trauma between 1998 and 2001, 63 (3%) presented with posttraumatic seizures and, of those, 10 (16%) had abnormal CT scans warranting hospitalization. Injuries seen on CT scanning included subdural hematoma, intraventricular hemorrhage, depressed skull fracture, and cerebral edema, among others. Of the 10 children hospitalized with one or more of those injuries, two (20%) subsequently suffered repeated seizures and three (30%) required neurosurgical intervention such as craniotomy or intracranial pressure monitoring.

Twenty of 52 children who had suffered immediate posttraumatic seizures but whose CT scans were normal were hospitalized, three because of the abnormal results of neurologic examinations and two for trauma to other parts of the body; none of them had any further seizures during the week succeeding blunt head injury. The children who had had posttraumatic seizures prior to arrival in the ED but who had normal CT scans and were discharged were evaluated by telephone interview a week after injury-none of them had experienced seizures or displayed evidence of other neurologic complications during that time.

The authors suggest that children who have had posttraumatic seizures, but who have normal neurologic examinations and normal CT scans, are at very low risk for further seizure and may not need to be hospitalized for observation.

The limitations of the study include the small number of children with posttraumatic seizures enrolled and the possible unreliability of data pertaining to seizure reported by patients and parents. The possibility of developing subtle, long-term neurologic deficits after blunt head trauma was not investigated. Children with immediate posttraumatic seizures who have abnormalities on CT scanning are at high risk for neurologic complications, necessitating immediate neurosurgical evaluation and hospitalization. Clinical vigilance including the close observation of children who have seizures after blunt head trauma, despite the presence of normal CT scans and neurologic examinations, remains reasonable until larger, multicenter, prospective cohort studies have been conducted. -FM

Holmes, JF, et al. Ann Emerg Med 2004; 43(6):706-10.

CANNULATION OF THE RADIAL ARTERY

Although rare, its complications can be devastating.

Arterial cannulation can provide valuable information in the care of a critically ill patient, allowing for continuous blood pressure monitoring, and the taking of frequent arterial blood gas samples without repeated puncturing of the artery. Because its complications are rare-they occur in only two cases in 1,000--a periodic review of their signs and symptoms and an algorithm for its treatment can help to prevent serious injury.

While other arteries can be used for cannulation, the radial artery offers advantages in most cases: it's easily accessible, and the hand usually receives blood also from the ulnar artery, and sometimes the median artery, with the palmar arch connecting all three, allowing blood from the ulnar artery to perfuse all parts of the hand. But in about 20% of people, the superficial palmar arch does not form, and the thumb receives its blood supply from the radial artery only. Additionally, conditions such as diabetes, hypertension, peripheral vascular disease, surgery to the artery, collagen vascular disorders, and blood dyscrasias, as well as anticoagulant medications and vasopressors, all increase the risk for complications of cannulation of the radial artery. Those factors should be assessed, and both the radial and ulnar pulses palpated, before a radial artery cannula is inserted. Clinicians may choose to map the hand's blood supply with a Doppler probe or other technologic means before placement of the cannula. To minimize the risk of mechanical damage, a 20-gauge or smaller catheter should be used in the nondominant hand, and the cannula should be removed within 20 to 40 hours.

If neither radial artery is suitable, a few other arteries can be considered. The dorsal artery of the foot rarely is used---it's absent in about 12% of patients, and should not be used if peripheral vascular disease is present or a tibial pulse cannot be palpated. The brachial artery isn't often used because there's not much collateral circulation to the forearm, and cannulation of the axillary artery carries the risk of causing a pneumothorax or injury to the brachial plexus. And often, the temporal artery is small and tortuous. Therefore, if neither radial artery presents a good choice, the femoral artery---a large, easily palpated vessel---is used; complications include retroperitoneal hematoma and perforation of a viscus, and contraindications of it include previous vascular procedures performed in the groin and peripheral vascular disease.

When a radial artery cannula is in place, the hand must be assessed frequently and the cannula removed immediately if signs of ischemia arise. Possible injuries caused by such cannulation include thrombosis, laceration of or other damage to the artery; compartment syndrome; nerve injury; infection; and necrosis of the skin, thumb, or other part of the hand. Surgery may be necessary, but many critically ill patients are unable to tolerate it---sometimes the hand can only be splinted and observed until the condition improves. But amputation or the debridement of necrotic areas may become necessary. -FM

Wallach, SG. Am J Crit Care 2004; 13(4):315-9.

ALBUMIN OR SALINE FOR FLUID RESUSCITATION

They may be equally effective in most patients in the ICU.

A recent study of a large, heterogeneous ICU population revealed that fluid resuscitation with saline and that with albumin were associated with comparable survival rates.

In a double-blind, multicenter trial, 6,997 ICU patients who needed fluid administration to maintain or increase intravascular volume were randomized to receive either 4% albumin (n = 3,497) or normal saline (n = 3,500). Rates and volumes of resuscitation fluids received were determined according to the individual patient's clinical needs, as was the administration of other fluids. At baseline, the albumin group had a higher mean central venous pressure, but the groups were comparable in all other characteristics.

Twenty-eight days after randomization, 20.9% of the patients in the albumin group and 21.1% of those in the saline group had died, representing a relative risk ratio of 0.99 in survival time, a difference not statistically significant. There were no significant differences between the two groups in new organ failures, the length of ICU or hospital stay, or the number of days of mechanical ventilation or renal replacement therapy. There was a small trend toward longer survival with albumin among patients with severe sepsis, and a larger one toward longer survival with saline among patients with brain injury, but because the subgroups were small, those results could be attributable to chance. In patients with brain injury, survival and functional neurologic status at six months are more appropriate outcomes to measure, an additional reason to exercise caution in interpreting trends in that subgroup.

More study of the subpopulations identified is necessary, but having found evidence of the equivalent effectiveness of albumin and saline in intravascular volume resuscitation in critically ill patients in the ICU, the study authors recommend choosing one rather than the other according to patient tolerance of the treatment, as well as to safety and cost. -FM

Finfer S, et al. N Engl J Med 2004;350 (22):2247-56.

DIAGNOSING MENINGITIS IN ADULTS

Which clinical signs and symptoms are significant?

Bacterial meningitis can be a devastating disease, but when it's treated early, suffering, morbidity, and mortality can be greatly diminished. But diagnosis is challenging. In the ED, which signs and symptoms indicate the need for a lumbar puncture to determine whether or not to initiate a course of antibiotics?

Newman comments on a rational clinical examination review in which the usefulness of various signs and symptoms in the diagnosis of meningitis were investigated in studies conducted from 1966 to the present. Unfortunately, only one of them was a prospective clinical trial, all the rest being retrospective reviews, and the possibility of extracting from them data concerning a question that they weren't designed to address is limited.

According to the review, only 50% of patients who had meningitis presented with headache. Fever was the most common sign, present in 85% of patients, nuchal rigidity was present in 79%, and altered mental status was present in 67%. In 99% of cases of meningitis, at least one of those three signs was present and, in 95%, at least two of them were. Newman concludes that, if none of the three classic signs is present, meningitis can be ruled out. Nausea, vomiting, focal neurologic signs, and rash were present in fewer than 50% of cases.

In one study involving 30 cases of suspected meningitis, all the patients with headache who had the disease had a symptom known as "jolt accentuation," in which the headache increased in severity when the head was turned rapidly from side to side. The sensitivity of jolt accentuation, therefore, was 100%. Unfortunately, the sign's specificity was low; about half of the patients who turned out not to have meningitis also had it. But its high degree of sensitivity makes it worth investigating in future studies.

Because 95% of patients in the review who had meningitis had at least two of the three classic signs of the disease, should all patients who present with fever and neck stiffness, fever and altered mental status, or neck stiffness and altered mental status be evaluated for it by lumbar puncture? The author suggests that, in light of current knowledge, lumbar puncture to assess for the presence of lymphocytes in the cerebrospinal fluid is the wisest course of action. Patients with only fever, neck stiffness, or altered mental status need additional evaluation that may include lumbar puncture. Bacterial and viral meningitis, which have very different outcomes, present very similarly, early in the course of illness. Treatment with antibiotics in all cases in which lymphocytes are present in the cerebrospinal fluid, until culture results become available, is advised.-FM

Newman, DH. Ann Emerg Med 2004; 44(1):71-3.

CHEST TUBE REMOVAL CAN BE PAINFUL

Appropriately timed analgesia can ease the procedure.

Often, chest tubes are inserted during cardiac surgery and removed early in recovery, and patients have complained that the removal can be severely painful and distressing, and that they receive little help coping with the procedure. Furthermore, nurses have reported that a routine prescription for analgesia during chest tube removal is written for only 16% of their patients. And because there is no guidance found in the literature, and there aren't any national standards for the chest tube removal procedure, improvement in clinical practice is needed in this area.

Researchers conducted a randomized, controlled, double-blind study in which two analgesics and two types of information provided to patients were compared, to discover which interventions most effectively reduced pain and distress, without inducing sedation, during chest tube removal.

Morphine, an opioid, and ketorolac, a nonsteroidal antiinflammatory drug (NSAID), have both been used for relief of pain during chest tube removal, although low doses of morphine (3 mg or less) have not been particularly successful.

Information given to the patient on what to expect during a procedure can diminish anxiety, distress, and pain, while improving ability to cope, as well as hemodynamic status and physical recovery.

The investigators did not impose treatment conditions under which no analgesia was administered or no information was provided. All patients received information on the procedure itself, and one group received, in addition, morphine 4 mg IV, 20 minutes beforehand. A second group received the procedure information, the morphine, and information concerning sensations that might be felt. A third group received the procedural information and ketorolac 30 mg IV, 60 minutes before chest tubes were removed. A fourth group received the procedural information, the ketorolac, and the sensory information.

The sample of 74 cardiac patients all derived comparable degrees of benefit from each of the four study conditions, and because a statistical power analysis indicated that the differences in effect sizes were so small that 344 patients would have to be enrolled in the study in order to detect statistically significant differences among the study treatment conditions, and that there would still likely be no real clinical difference, the study was stopped.

The patients in the study reported only mild pain intensity and distress, compared with those in previous studies, in which chest tube removal was described as moderately to severely painful. Patients described the pain as "fearful," although that was not one of the words offered among the selection of descriptive words in the script The reasons for that are unknown and suggest the need for research into the origin of anxiety among patients undergoing chest tube removal.

Both analgesics worked equally well and without inducing sedation, meaning that clinicians can use morphine, an opioid, in patients who cannot tolerate NSAIDs, or ketorolac, an NSAID, in those who do not respond well to morphine.

The authors emphasize that adequate doses of analgesic must be used, and that the chest tube must be removed when it is at peak effect. -FM

Puntillo K, Ley SJ. Am J Crit Care 2004; 13(4):292-301.

NEBULIZED LIDOCAINE USED IN NASOGASTRIC TUBE INSERTION

It's associated with diminished discomfort.

A new study shows that the use of nebulized lidocaine immediately before nasogastric tube insertion significantly diminishes the discomfort patients often experience during the procedure.

In this double-blind, placebo-controlled study, 50 adult patients presenting to the EDs of two urban university hospitals from July 2000 to October 2002 were randomly assigned to receive either nebulized lidocaine (400 mg, 4 mL of 10% solution) (the experimental group, n = 29) or nebulized normal saline solution (4 mL) (the control group, n = 21) directly before nasogastric tube insertion. Afterward, patients were asked to rate discomfort according to a visual analog scale and nurses were asked to rate the difficulty of insertion according to a Likert scale. The nurses were asked also to state which solution they thought had been used.

The use of nebulized lidocaine significantly reduced patients' discomfort (mean visual analog scale score, 37.7 mm), compared with the use of nebulized normal saline solution (mean visual analog scale score, 59.3 mm). Nurses in the blinded lidocaine-solution group believed that insertion was less difficult, compared with those in the normal-saline group, although the difference was not statistically significant (62% and 43%, respectively). Epistaxis occurred in 17% of patients in the lidocaine group and in none in the normal saline group.

Several limitations restrict the generalizability of the study results. The sample size wasn't large enough, for example, leading to convenience sampling and assembly bias, and the number of patients in each of the lidocaine and normal saline solution subgroups was uneven. Further, the method of nasogastric tube placement and the time at which the visual analog scale score was taken weren't standardized. Nevertheless, the researchers suggest that the use of nebulized lidocaine should be studied further and compared with the application of 2% lidocaine gel (a common practice) because of the present encouraging results and the lower cost associated with nebulization. -JC

Cullen L, et al. Ann Emerg Med 2004;44 (2):131-7.

TRIAGE: LICENSED NURSES OR UNLICENSED PERSONNEL?

Waiting periods are shorter with the former.

ED triage systems employing licensed nurses are associated with shorter waiting periods before treatment and less chance of patients leaving without being seen, compared with those that use unlicensed assistive personnel, according to a recent study.

Using a retrospective chart review, a nurse researcher at a military hospital compared the triage time (from sign-in to triage), waiting period (from triage to treatment), treatment time (from treatment to discharge), and patient satisfaction (the number of patients who voluntarily left without being seen) in a triage system using unlicensed assistive personnel and in another system, implemented in September 1997, using licensed nurses. The chart of every fifth patient presenting to the ED during the evening shift in April 1997 (n = 323) and April 1998 (n = 281) was reviewed to assess the differences. All charts between January 1997 and April 1998 were reviewed to determine the number of patients who, of their own volition, left the ED without being seen (n= 343).

The use of licensed nurses was found to be associated with an average waiting period, between triage and treatment, of 54 minutes, representing a 57% reduction compared with the use of unlicensed assistive personnel. Although licensed nurses performed other duties, such as providing antipyretics, ordering laboratory tests and radiographs per standing orders, and transporting patients to radiology, the average triage time was comparable to that associated with the use of unlicensed assistive personnel. In addition, when licensed nurses were used in triage, the proportion of patients who left without being seen decreased by 85%.

The results suggest that licensed nurses have knowledge and decision-making abilities that result in shorter triage waiting periods. Further, the authority of triage nurses to order laboratory tests and radiographs per standing order may be useful to implement in other EDs. -JC

Paulson DL. J Emerg Nurs 2004;30(4): 307-11.