Clinical policy

Efficacy, Tolerability, and Safety of Concentrated Intranasal Midazolam Spray as Emergency Medication in Epilepsy Patients During Video-EEG Monitoring

BACKGROUND

An efficient, well tolerated, and safe emergency treatment with a rapid onset of action is needed to prevent seizure clusters and to terminate prolonged seizures and status epilepticus.

OBJECTIVES

This study aimed to examine the efficacy, tolerability, and safety of intranasal midazolam (in-MDZ) spray in clinical practice.

METHODS

In this retrospective, multicenter observational study, we evaluated all patients with peri-ictal application of in-MDZ during video-EEG monitoring at the epilepsy centers in Frankfurt and Marburg between 2 014 and 2017. For every patient, we analyzed the recurrence of any seizure or generalized tonic-clonic seizures after index seizures with and without in-MDZ administration. Treatment-emergent adverse events (TEAEs) were also evaluated.

RESULTS

In-MDZ was used in 243 patients with epilepsy (mean age 35.5 years; range 5-76 years; 46.5% female) for treatment of 459 seizures. A median dose of in-MDZ 5 mg (i.e., two puffs; range 2.5-15 mg) was administered within a median time from EEG seizure onset until in-MDZ application of 1.18 min [interquartile range (IQR) 1.27], while median time from clinical seizure onset until in-MDZ administration was 1.08 min (IQR 1.19). In-MDZ was given within 1 min after EEG seizure onset in 171 seizures. An intraindividual comparison of seizures with and without application of in-MDZ was feasible in 171 patients, demonstrating that in-MDZ reduced the occurrence of any (Cox proportional-hazard model p < 0.001) and generalized tonic-clonic seizure (Cox proportional-hazard model p = 0.0167) over a period of 24 h. The seizure-free timespan was doubled from a median of 5.0 h in controls to a median of 10.67 h after in-MDZ administration. We additionally clustered in-MDZ administrations for the 119 patients who received in-MDZ more than once, comparing them with the index cases without in-MDZ. Even when considering subsequent seizures with in-MDZ administration, a patient receiving in-MDZ is still half as likely to incur another seizure in the upcoming 24 h as compared with when the same patient does not receive in-MDZ (hazard ratio 0.50; 95% CI 0.42-0.60; p < 0.01). In-MDZ was well tolerated without major adverse events. The most common side effects were irritation of the nasal mucosa [37 cases (8.1%)], prolonged sedation [26 cases (5.7%)], and nausea and vomiting [12 cases (2.6%)]. A decline in oxygen saturation was measured after 78 seizures (17%).

CONCLUSION

We conclude that in-MDZ is a safe and efficient treatment option to prevent short-term recurrence of seizures. In-MDZ can be administered very quickly by trained staff within 1-2 min after seizure onset. No major cardiocirculatory or respiratory adverse events were observed.

Standardised assessment of competence in Focused Assessment with Sonography for Trauma

PURPOSE

The aim of this study was to develop and gather validity evidence for a standardised test of competence in Focused Assessment with Sonography for Trauma (FAST) and to define the appropriate cut-off point in simulation-based learning of the FAST protocol.

METHODS

A 20-item simulation-based test for assessing competence in FAST was created. The test was administered to thirteen novices and twelve radiologists experienced in abdominal ultrasound diagnostics. The Contrasting Groups' method was used to establish a credible passing score.

RESULTS

The internal consistency was high (Cronbach's α = 0.90) and the test had good discriminatory ability (P < .001). The mean score was 16.9 (95% CI: 15.5-18.3) in the experienced group and 8.0 (95% CI: 5.8-10.2) in the novice group, corresponding to 85% and 40% of the total score, respectively. A pass/fail standard of 14 points was established using the Contrasting Groups' method.

CONCLUSIONS

The FAST simulation-based test provided valid assessment of competence in FAST. The FAST test could be used to guide training and ensure basic competence of physicians using FAST.

Accuracy of contrast-enhanced ultrasound (CEUS) in the identification and characterization of traumatic solid organ lesions in children: a retrospective comparison with baseline US and CE-MDCT

INTRODUCTION

Localized low-energy abdominal trauma is very frequent in the pediatric population. The findings of several studies have shown that ultrasonography (US) can represent a useful and cost-effective tool in the evaluation of blunt abdominal trauma both in adults and children. However, many parenchymal injuries are not correctly visualized at baseline US examination. The introduction of specific US contrast agents contrast-enhanced ultrasound (CEUS) has enabled a better identification of traumatic organ injuries. The correct use of CEUS could therefore identify and select the children who need further diagnostic investigation computed tomography (CT), avoiding unnecessary radiation and iodinated contrast medium exposure. The purpose of our study was to assess the sensibility and feasibility of CEUS in the assessment of low-energy abdominal trauma compared to baseline US in pediatric patients, using contrast-enhanced MDCT as the reference standard.

MATERIALS AND METHODS

We retrospectively reviewed 73 children (51 M and 22 F; mean age 8.7 ± 2.8 years) who presented in our Emergency Department between October 2012 and October 2013, with history of minor abdominal trauma according to the Abbreviated Injury Scale and who underwent US, CEUS, and CE-MDCT. Inclusion criteria were: male or female, aged 0-16, hemodynamically stable patients with a history of minor blunt abdominal trauma. Exclusion criteria were adulthood, hemodynamical instability, history of major trauma. Sensitivity, specificity, PPV, NPV, and accuracy were determined for US and CEUS compared to MDCT.

RESULTS

6/73 patients were negative at US, CEUS, and MDCT for the presence of organ injuries. In the remaining 67 patients, US depicted 26/67 parenchymal lesions. CEUS identified 67/67 patients (67/67) with parenchymal lesions: 21 lesions of the liver (28.8 %), 26 lesions of the spleen (35.6 %), 7 lesions of right kidney (9.6 %), 13 lesions of left kidney. MDCT confirmed all parenchymal lesions (67/67). Thus, the diagnostic performance of CEUS was better than that of US, as sensitivity, specificity, PPV, NPV, and accuracy were 100, 100, 100, 100, and 100 % for CEUS and 38.8, 100, 100, 12.8, and 44 % for US. In some patients CEUS identified also prognostic factors as parenchymal active bleeding in 8 cases, partial devascularization in 1 case; no cases of vascular bleeding, no cases of urinoma. MDCT confirmed all parenchymal lesions. Parenchymal active bleeding was identified in 16 cases, vascular bleeding in 2 cases, urinoma in 2 cases, partial devascularization in 1 case.

CONCLUSIONS

CEUS is more sensitive and accurate than baseline US and almost as sensitive as CT in the identification and characterization of solid organs lesions in blunt abdominal trauma. CT is more sensitive and accurate than CEUS in identifying prognostic indicators, as active bleeding and urinoma. CEUS should be considered as a useful tool in the assessment and monitoring of blunt abdominal trauma in children.

Development and evaluation of a novel, real time mobile telesonography system in management of patients with abdominal trauma: study protocol

BACKGROUND

Despite the use of e-FAST in management of patients with abdominal trauma, its utility in prehospital setting is not widely adopted. The goal of this study is to develop a novel portable telesonography (TS) system and evaluate the comparability of the quality of images obtained via this system among healthy volunteers who undergo e-FAST abdominal examination in a moving ambulance and at the ED. We hypothesize that: (1) real-time ultrasound images of acute trauma patients in the pre-hospital setting can be obtained and transmitted to the ED via the novel TS system; and (2) Ultrasound images transmitted to the hospital from the real-time TS system will be comparable in quality to those obtained in the ED.

METHODS

Study participants are three healthy volunteers (one each with normal, overweight and obese BMI category). The ultrasound images will be obtained by two ultrasound-trained physicians The TS is a portable sonogram (by Sonosite) interfaced with a portable broadcast unit (by Live-U). Two UTPs will conduct e-FAST examinations on healthy volunteers in moving ambulances and transmit the images via cellular network to the hospital server, where they are stored. Upon arrival in the ED, the same UTPs will obtain another set of images from the volunteers, which are then compared to those obtained in the moving ambulances by another set of blinded UTPs (evaluators) using a validated image quality scale, the Questionnaire for User Interaction Satisfaction (QUIS).

DISCUSSION

Findings from this study will provide needed data on the validity of the novel TS in transmitting live images from moving ambulances to images obtained in the ED thus providing opportunity to facilitate medical care of a patient located in a remote or austere setting.

Accuracy of FAST scan in blunt abdominal trauma in a major London trauma centre

INTRODUCTION

Blunt abdominal trauma (BAT) is a leading cause of morbidity and mortality. Rapid diagnosis and treatment with the Advanced Trauma Life Support guidelines are vital, leading to the development of Focused Assessment with Sonography in Trauma (FAST).

METHODS

A retrospective study carried out from January 2007-2008 on all patients who presented with BAT and underwent FAST scan. All patients subsequently had a CT scan within 2 h of admission or a laparotomy within two days. The presence of intra-peritoneal free fluid was interpreted as positive.

RESULTS

100 patients with BAT presented; 71 had complete data. The accuracy of FAST in BAT was 59.2%; in these 31 (43.7%) were confirmed by CT and 11 (15%) by laparotomy. There were 29 (40.8%) inaccurate FAST scans, all confirmed by CT. FAST had a specificity of 94.7% (95% CI: 0.75-0.99) and sensitivity of 46.2% (95% CI: 0.33-0.60). Positive Predictive Value of 0.96 (0.81-0.99) and Negative Predictive Value of 0.39 (0.26-0.54). Fisher's exact test shows positive FAST is significantly associated with Intra-abdominal pathology (p=0.001). Cohen's chance corrected agreement was 0.3. 21 out of 28 who underwent laparotomies had positive FAST results indicating accuracy of 75% (95% CI: 57%-87%).

CONCLUSION

Patients with false negative scans, requiring therapeutic laparotomy is concerning. In unstable patients FAST may help in triaging and identifying those requiring laparotomy. Negative FAST scans do not exclude abdominal injury. Further randomised control trials are recommended if the role of FAST is to be better understood.

Clinical policy: critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma

This clinical policy from the American College of Emergency Physicians is an update of the 2004 clinical policy on the critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma. A writing subcommittee reviewed the literature as part of the process to develop evidence-based recommendations to address 4 key critical questions: (1) In a hemodynamically unstable patient with blunt abdominal trauma, is ultrasound the diagnostic modality of choice? (2) Does oral contrast improve the diagnostic performance of computed tomography (CT) in blunt abdominal trauma? (3) In a clinically stable patient with isolated blunt abdominal trauma, is it safe to discharge the patient after a negative abdominal CT scan result? (4) In patients with isolated blunt abdominal trauma, are there clinical predictors that allow the clinician to identify patients at low risk for adverse events who do not need an abdominal CT? Evidence was graded and recommendations were based on the available data in the medical literature related to the specific clinical question.

Comparison of a multimedia simulator to a human model for teaching FAST exam image interpretation and image acquisition

OBJECTIVES

This study compared the effectiveness of a multimedia ultrasound (US) simulator to normal human models during the practical portion of a course designed to teach the skills of both image acquisition and image interpretation for the Focused Assessment with Sonography for Trauma (FAST) exam.

METHODS

This was a prospective, blinded, controlled education study using medical students as an US-naïve population. After a standardized didactic lecture on the FAST exam, trainees were separated into two groups to practice image acquisition on either a multimedia simulator or a normal human model. Four outcome measures were then assessed: image interpretation of prerecorded FAST exams, adequacy of image acquisition on a standardized normal patient, perceived confidence of image adequacy, and time to image acquisition.

RESULTS

Ninety-two students were enrolled and separated into two groups, a multimedia simulator group (n = 44), and a human model group (n = 48). Bonferroni adjustment factor determined the level of significance to be p = 0.0125. There was no difference between those trained on the multimedia simulator and those trained on a human model in image interpretation (median 80 of 100 points, interquartile range [IQR] 71-87, vs. median 78, IQR 62-86; p = 0.16), image acquisition (median 18 of 24 points, IQR 12-18 points, vs. median 16, IQR 14-20; p = 0.95), trainee's confidence in obtaining images on a 1-10 visual analog scale (median 5, IQR 4.1-6.5, vs. median 5, IQR 3.7-6.0; p = 0.36), or time to acquire images (median 3.8 minutes, IQR 2.7-5.4 minutes, vs. median = 4.5 minutes, IQR = 3.4-5.9 minutes; p = 0.044).

CONCLUSIONS

There was no difference in teaching the skills of image acquisition and interpretation to novice FAST examiners using the multimedia simulator or normal human models. These data suggest that practical image acquisition skills learned during simulated training can be directly applied to human models.

Contrast-enhanced US evaluation in patients with blunt abdominal trauma()

INTRODUCTION

To evaluate the use of contrast-enhanced ultrasonography (CEUS) in patients with blunt abdominal trauma.

MATERIALS AND METHODS

A total of 133 hemodynamically stable patients were evaluated using ultrasonography (US), CEUS and multislice Computer Tomography (CT) da eliminare.

RESULTS

In 133 patients, CT identified 84 lesions: 48 cases of splenic injury, 21 of liver injury, 13 of kidney or adrenal gland injury and 2 of pancreatic injury. US identified free fluid or parenchymal abnormalities in 59/84 patients positive at CT and free fluid in 20/49 patients negative at CT. CEUS revealed 81/84 traumatic injuries identified at CT and ruled out traumatic injuries in 48/49 negative at CT. Sensitivity, specificity, positive and negative predictive values for US were 70.2%, 59.2%, 74.7% and 53.7%, respectively; for CEUS the values were 96.4%, 98%, 98.8% and 94.1%, respectively.

CONCLUSIONS

The study showed that CEUS is more accurate than US and nearly as accurate as CT, and CEUS can therefore be proposed for the initial evaluation of patients with blunt abdominal trauma.

Avoiding cavity surgery in penetrating torso trauma: the role of the computed tomography scan

INTRODUCTION

Surgical decision-making in torso trauma is complex. This paper looks at the role of the computed tomography (CT) scan in this decision-making process.

PATIENTS AND METHODS

Patients with significant torso trauma (high velocity gunshot wound [HVGSW], blast, stab) admitted to a military role 2 (enhanced) hospital facility during a 7-week period of Operation HERRICK 9 (Afghanistan, October to November 2008) are reported. The management of those patients undergoing a CT scan as part of the decision-making process at the time of admission is discussed.

RESULTS

Twenty eight patients with significant torso trauma were admitted to the facility during the study period; HVGSW (n = 15), blast (n = 9), stab (n = 4). Thirteen patients underwent a CT scan as part of the surgical decision-making process; HVGSW (n = 5), blast (n = 8). Imaging confirmed torso integrity in 12 patients, one of whom subsequently had a laparotomy for vascular control for on-table haemorrhage during lower limb surgery. One patient had a confirmed thoraco-abdominal injury, which was treated conservatively with tube thoracostomy and 'active observation'.

CONCLUSIONS

A CT scan formed part of the surgical decision-making process in about half of the patients admitted with significant torso trauma, and helped prevent unnecessary laparotomy in this forward military environment. Those patients with a blast injury were more likely to undergo CT scanning than those where the mechanism of injury was a HVGSW.

Contrast-enhanced ultrasonography in blunt abdominal trauma: considerations after 5 years of experience

PURPOSE

The aim of the study was to evaluate the diagnostic capability of contrast-enhanced ultrasonography (CEUS) in a large series of patients with blunt abdominal trauma.

MATERIALS AND METHODS

We studied 133 haemodynamically stable patients with blunt abdominal trauma. Patients were assessed by ultrasonography (US), CEUS and multislice computed tomography (MSCT) with and without administration of a contrast agent. The study was approved by our hospital ethics committee (clinical study no. 1/2004/O).

RESULTS

In the 133 selected patients, CT identified 84 lesions; namely, 48 splenic, 21 hepatic, 13 renal or adrenal and two pancreatic. US identified free fluid or parenchymal alterations in 59/84 patients with positive CT and free fluid in 20/49 patients with negative CT. CEUS detected 81/84 traumatic lesions identified on CT and ruled out traumatic lesions in 48/49 patients with negative CT. The sensitivity, specificity and positive and negative predictive values of US were 70.2%, 59.2%, 74.7% and 53.7%, respectively, whereas those of CEUS were 96.4%, 98%, 98.8% and 94.1%, respectively.

CONCLUSIONS

Our study showed that CEUS is an accurate technique for evaluating traumatic lesions of solid abdominal organs. The technique is able to detect active bleeding and vascular lesions, avoids exposure to ionising radiation and is useful for monitoring patients undergoing conservative treatment.

Routine versus selective computed tomography of the abdomen, pelvis, and lumbar spine in blunt trauma: a prospective evaluation

BACKGROUND

Discussion still remains whether computed tomography (CT) of the abdomen, pelvis, and lumbar spine should be performed routinely after blunt trauma with high energy impact or only in restricted situations. The purpose of this study was to evaluate the additional value of a routine CT algorithm as compared with a more restricted, selective CT algorithm.

MATERIALS

This prospective study consisted of 465 patients that met the inclusion criteria of our high-energy trauma protocol. All patients underwent physical examination, abdominal ultrasound (AUS), and conventional radiography (CR) of the pelvis and lumbar spine and subsequently routine CT of the abdomen, pelvis, and lumbar spine. Before CT, a subgroup of patients with abnormal physical examination or CR or AUS was prospectively defined as the selective CT group. Type and extent of injuries and impact on treatment were recorded for both the routine CT group and the selective CT subgroup.

RESULTS

Of all patients, 42 received selective CT of the abdomen, 71 of the pelvis, and 48 of the lumbar spine. Compared with the algorithm with selective CT, routine CT revealed additional traumatic injuries in 15% of the patients in the abdomen, in 2.4% in the pelvis and in 8.2% in the lumbar spine. This resulted in an overall change of treatment in 6.4% (95% confidence interval, 3.7-9.0) of the patients who would not have received CT in a selective CT algorithm.

CONCLUSIONS

Compared with an algorithm with selective CT, an algorithm with routine CT finds substantially more clinically relevant diagnoses, even in patients with unsuspicious clinical examination, normal CR, and normal AUS.

Advances in Abdominal Trauma

Emergency practitioners routinely encounter patients who suffer from abdominal trauma, be it blunt or penetrating. These injuries are often confounded by altered mental status, distracting injuries, or lack of historical information, and may present challenges in management. However, in the last several years new approaches to the diagnosis and management of abdominal trauma, including bedside ultrasound, newer generation computed tomography scans, laparoscopy, and the ability for selected nonoperative management expedite identification of life threatening injury and offer new options in treatment.

The Utility of Sonography for the Triage of Blunt Abdominal Trauma Patients to Exploratory Laparotomy

OBJECTIVE

The purpose of this study was to assess the utility of focused abdominal sonography for trauma (FAST) in the triage of hypotensive and normotensive blunt abdominal trauma patients to exploratory laparotomy.

MATERIALS AND METHODS

Data entered in a trauma registry database were retrospectively reviewed and were correlated with medical records, radiology reports, and surgical laparotomy reports. In the setting of blunt abdominal trauma, hypotensive patients were compared with normotensive patients who underwent FAST.

RESULTS

During the 6-year study period, 4,029 patients with blunt abdominal trauma underwent sonography, 122 of whom were hypotensive on arrival and underwent FAST. Of 87 hypotensive patients with positive findings on FAST, 69 (79%) were taken directly to exploratory laparotomy without the need for CT. In predicting the need for therapeutic laparotomy in hypotensive patients, the sensitivity of FAST was 85%, specificity was 60%, and accuracy was 77%. Of the 3,907 normotensive patients, 3,584 had negative FAST findings, whereas 323 had positive FAST findings. In normotensive patients, the sensitivity of FAST was 85%, specificity was 96%, and accuracy was 96%. In the combined patient population (all hypotensive and normotensive patients), 4,029 patients with blunt abdominal trauma underwent sonography: 3,619 had negative and 410 had positive FAST findings. In all patients regardless of blood pressure, the sensitivity of FAST was 85%, specificity was 96%, and accuracy was 95%.

CONCLUSION

Hypotensive patients screened in the emergency department with positive FAST findings may be triaged directly to therapeutic laparotomy, depending on the results of the sonography examination, without the need for CT.

Blunt abdominal trauma: emergency contrast-enhanced sonography for detection of solid organ injuries

OBJECTIVE

The objective of our study was to prospectively compare the diagnostic value of sonography and contrast-enhanced sonography with CT for the detection of solid organ injuries in blunt abdominal trauma patients.

SUBJECTS AND METHODS

Sonography, contrast-enhanced sonography, and CT were performed to assess possible abdominal organ injuries in 69 nonconsecutive hemodynamically stable patients with blunt abdominal trauma and a strong clinical suspicion of abdominal lesions. Sonography and contrast-enhanced sonography findings were compared with CT findings, the reference standard technique.

RESULTS

Thirty-two patients had 35 abdominal injuries on CT (10 kidney or adrenal lesions, seven liver lesions, 17 spleen lesions, and one retroperitoneal hematoma). Sixteen lesions were detected on sonography, and 32 were seen on contrast-enhanced sonography. The sensitivity and specificity of sonography were 45.7% and 91.8%, respectively, and the positive and negative predictive values were 84.2% and 64.1%, respectively. Contrast-enhanced sonography had a sensitivity of 91.4%, a specificity of 100%, and positive and negative predictive values of 100% and 92.5%, respectively.

CONCLUSION

Contrast-enhanced sonography was found to be more sensitive than sonography and almost as sensitive as CT in the detection of traumatic abdominal solid organ injuries. It can therefore be proposed as a useful tool in the assessment of blunt abdominal trauma.

Traumatic, pericardio-diaphragmatic rupture: An extremely rare cause of pericarditis

A 54-year-old man with a recent history of blunt abdominal trauma presented to the Emergency Department with severe pain in the chest and abdomen. He was tachycardic, tacypneic, and hypoxic. An electrocardiogram (EKG) at that time showed ST elevation and PR depression consistent with acute pericarditis, and a computed tomography (CT) scan subsequently showed herniation of abdominal contents into the pericardium and left hemithorax. After surgical repair of the diaphragmatic defect and intrapericardial hernia, the EKG findings resolved. He recovered over the course of several weeks and was subsequently discharged home.