Empiric antibiotics after cardiac arrest?

The July 2014 EM:RAP Paper Chase reviewed a paper claiming 38% of OHCA (Out of Hospital Cardiac Arrest) patients are bacteremic, and thus we should routinely give antibiotics to post-arrest patients.

We reviewed this paper at the Calgary Journal Club recently and unfortunately, the authors conclusions are more leap of faith than anything else.

This single center, prospective observational trial enrolled a convenience sample of 250 OHCA patients, 77 were excluded and 173 were analyzed.   Anaerobic and aerobic blood cultures were taken at the time of arrest.

65/173 (38%) of cultures were positive, and ED survival was lower in the bacteremic vs. non bacteremic group (25% vs. 40%, p<0.042).  Sounds great until you see there are no differences between groups for length of stay, overall and 28 day mortality (p>0.05).

When critically appraising the article, we find the following.

  • Pros:
    • Prospective, observational study that may become the pilot for further study into bacteremia and OHCA
  • Cons:
    • Single centered
    • Study was not designed to determine the infectious causality of cardiac arrest or factors influencing ROSC
    • Randomly drawn blood cultures, true prevalence of bacteremia is not known
  • Discussion Points – AKA Concerns
    • The results of this study were not generalizable to our population (or most) given that the study was conducted in an inner city hospital in Detroit with an 85% African American population.
    • The definition of bacteremia in the study:
      • It was unclear how many blood cultures were drawn in total
      • There was an unknown timeline of blood culture growth – with late cultures more likely representing a contaminant
      • Their definition led to a huge sensitivity but a low specificity
      • The species distribution heavily favoured skin flora. And some of those species are not pathologic invasive species (eg. S. epidermidis)
    • The question of whether the OHCA caused the bacteremia vs. the bacteremia causing the cardiac cannot be answered based on this paper. It is likely that a large proportion of the bacteremic patients were contaminants. It is also likely that sicker patients received more lines, another potential for skewing these patients towards bacteremia.
    • It was discussed that 69% of bacteremic patients vs only 30% of non-bacteremic OHCA ED survivors received empiric antibiotics. It was thought that this suggests that ED staff are able to identify something different about these patients from the presentation leading them to suspect sepsis. It would have been a nice question to ask the ED staff the question: “What was your working diagnosis?” to see if sepsis was suspected at a time after antibiotic administration.

To summarize, the study results dont’ support the author’s conclusions. The authors speculate on potential causation based on weak data. They cannot imply causation based on this study. We agree with the authors that more study is needed to determine temporal causation regarding bacteremia and cardiac arrest.

It was universally decided that this paper would not change our practice overall and that bacteremia in OHCA is an interesting idea, more investigation is needed. Also, we should really be vigilant for inciting infectious causes of OHCA and initiating antibiotics early when infection is suspected.

Cheers,

Chris 

Coba et al. The Incidence and Significance of Bacteremia in Out of Hospital Cardiac Arrest. Resuscitation 2014.

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What Temperature Should Food Be Cooked To for Botulism Prevention?

Patient Presentation
The mother of an 11-month-old infant telephoned as she was cooking dinner and realized that she had put honey into the family’s stew. The food was being cooked in a home slow-cooker and would be cooked for several hours. She wanted to know if the infant could still eat the food since it would otherwise be appropriate for her. The nurse was not sure and asked the pediatrician who checked several reliable sources on the Internet. The pediatrician felt that although it was unlikely that a small amount of honey in the food would cause problems, the C. botulinum spores would not be killed at this temperature and advised not to feed the stew to the infant. He recommended other age-appropriate foods be offered instead.

Discussion
Clostridium botulinum is a gram-positive, motile, anaerobic rod. C. botulinum produces spores which themselves produce a toxin that causes paralytic disease which may be fatal. About 145 cases per year are reported in the US.

  • Foodborne botulism is caused by eating food contaminated with the spores or toxin. 15% of US cases yearly.
  • Wound botulism is caused by a wound that is infected with the spores which produces toxin causing botulism. 20% of cases yearly.
  • Infantile botulism is considered separate from foodborne botulism and is caused by consuming the spores and the toxin is produced in the infant’s gut causing the disease. Adults can have the same problem but it is extremely rare. 65% of US cases yearly.
  • Iatrogenic – caused by an overdose of botulinum toxin.
  • Inhalation botulism is very rare.

Classic symptoms includes visual changes (e.g. blurred or double vision, ptosis), speech and swallowing difficulties, dry mouth and muscle weakness. Infants have a weak cry, poor tone and weakness, poor feeding and lethargy. If untreated symptoms can progress to paralysis of the extremities, trunk and respiratory muscles. With foodborne disease, symptoms can occur at 6 hours – 10 days after eating the contaminated food but generally within 18-26 hours.

The differential diagnosis for infantile botulism commonly includes meningitis/sepsis, electrolyte abnormalities, congenital myopathy and Werdnig-Hoffman disease.

Learning Point
There is no vaccine for C. botulinum, and anti-toxin is not useful for prevention. Heating to high temperatures will kill the spores. Temperature greater than boiling (212°F) is needed to kill spores so pressure cookers are recommended for home canning (reaching at least 250-250°F). The toxin is heat-labile though and can be destroyed at > 185°F after five minutes or longer, or at > 176°F for 10 minutes or longer. Boiling homecanned foods for 10 minutes or longer is recommended.

Home canned foods should follow strict hygienic practices to reduce contamination, especially low acidic foods such as asparagus, green beans, beets and corn. But any food has the potential to be contaminated. Boiling home-canned foods for 10 minutes is recommended to ensure safety.

Potatoes baked in aluminum foil do not kill spores and may actually help spores germinate and produce toxin if held at room temperature. Potatoes in foil must be kept hot before consumption or refrigerated. Oils that are infused with herbs or garlic should be refrigerated.

Honey can contain spores of C. botulinum and has been a source of infection for infants. Children less than 12 months old should not be fed honey. For persons older than 1 year it is safe.

All leftover food should be refrigerated within 2 hours after cooking and within 1 hour if the ambient temperature is > 90°F.

If ever in doubt about potential safety the food should not be consumed.

Questions for Further Discussion
1. What food sources are potentially contaminated with C. botulinum?
2. How is botulism treated?
3. What other cultural practices can put an infant at risk for C. botulinum?
4. Why is Botox® safe?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Botulism

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Schneider KR, Silverberg R, Chang A, Goodrich Schneider RM. Preventing Foodborne Illness: Clostridium botulinum. University of Florida IFAS Extension. Available from the Internet at http://edis.ifas.ufl.edu/fs104 (cited 2/17/15).

UCSB Science Line. What Kills Botulism?. University of California Santa Barbara. Available from the Internet at
http://scienceline.ucsb.edu/getkey.php?key=1307
(cited 2/17/15).

Centers for Disease Control. Botulism Facts for HealthCare Providers. Available from the Internet at http://emergency.cdc.gov/agent/botulism/hcpfacts.asp (rev. 4/19/2006, cited 2/17/15).

Centers for Disease Control. Botulism Overview for Clinicians: Prevention. Available from the Internet at http://emergency.cdc.gov/agent/Botulism/clinicians/prevention.asp (rev. 10/06/2006, cited 2/17/15).

World Health Organization. Botulism. Available from the Internet at http://www.who.int/mediacentre/factsheets/fs270/en/ (rev. 8/13, cited 2/17/15).

Centers for Disease Control. Botulism. Available from the Internet at http://www.cdc.gov/nczved/divisions/dfbmd/diseases/botulism/ (rev. 4/25/14, cited 2/17/15).

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

Being Expert Enough….

I reckon that I am lucky to be a rural doctor.  It wasn’t an area of medicine to which I was exposed as a student or trainee, and it was only good fortune that lead to my career evolving the way it has. Rural medicine offers all of the “best bits” of medicine without the tedium of being confined to one area as a “partialist”. Whilst much of the work of a rural generalist involves office-based primary care, we also have responsibility for emergency medicine via the local hospital and some of us will participate in elective and emergency procedural skills, such as anaesthesia, obstetrics and surgery.

Swiss Amry Knife

It’s no secret that my interests revolve around trauma, prehospital care and anaesthesia, particularly in the rural context. But I am also interested in palliative care, paediatrics, chronic pain, depression, internal medicine and chronic disease management. As my colleague Casey Parker at BroomeDocs put it, the generalist rural doctor is the “swiss army knife” compared to the partialists “scalpel”. Each has their uses. In the bush, you need the multitool!

And therein is the dilemma for the generalist – how to maintain skills and clinical knowledge across such a  broad array of clinical arenas? Particularly in fast-moving areas such as emergency medicine and critical care, where evidence-base may be rapidly evolving?

The answer, of course, is to use FOAMed – Free Open Access Medical Education – the rapid dissemination of ideas and learning resources, via the tools of Web2.0, to allow distributed, non-hierarchical, asynchronous learning “anywhere – anytime – anyone”.  To my mind, FOAMed is particularly useful for those seeking to develop mastery, rather than teach the basics (for that, it remains textbooks and standard alphabet courses).  The use of Web2.0 (blogs, podcasts, social media such as twitter, Google+, even Facebook) affords rapid sharing of ideas amongst peers – and extends the reach from local colleagues to allow exchange with a global community of like-minded peers and experts….all of whom willing to share ideas and content for free.

This is not a new concept in medicine – as Joe Lex points out, it dates back to Hippocrates “and to teach them this art – if they desire to learn it – without fee and covenant” – this is from the Hippocratic Oath and sharing of knowledge is part of being a clinician.  But for some, the technology and terminology in social media and FOAMed can be a barrier.

This is a shame. FOAMed has been a revelation for my practice.  A few years ago I was “comportable” in my practice. I met the required needs of credentialling (attendance at an entry-level emergency course every triennium), easily accrued my CPD points with my College and felt pretty happy in my practice. But I was not challenged. My interest in trauma and airway management lead to some online resources, at about the same time that Chris Nickson and Mike Cadogan were launching the “lifeinthefastlane” website for emergency physicians and the concept of FOAMed.

Since then I’ve been swept up in a rich learning environment, that has forced me to be challenged, to engage in discussion of concepts in my areas of interest which I would never have been able to do before. It’s made me submit papers for publication, to abandon traditionally safe roles (such as directing on EMST) and join the faculty of more modern courses, to speak at conferences, lead simulation training with paramedic and nursing colleagues and to run airway workshops. I feel connected to a rich information flow, of which I was previously oblivious. And trather than drown in a sea of information overload, apropriate use of filters allows me to receive and engage only in content which interests me.

It’s well worth exploring.

And so leads to the topic of this post – “Being Expert Enough”. I am helping out at the inaugural “Critically Ill Airway” workshop at The Alfred in May – the brainchild of Chris Nickson and anaesthetic/intensive care/emergency medicine colleagues. It should be a good course – Scott Weingart is an external consultant, there will be the likes of Andy Buck from ETMcourse and many others as Faculty.

“This is the challenge and discipline of rural medicine – our specialty is providing care across a broad range without immediate backup”

I will be speaking to a topic dear to my heart – that of the “occasional intubator” – this is pretty much is the default setting for much of the work we do as rural doctors, and requires us to have sufficient expertise to be safe and competent without backup across a large range of competencies.

https://vimeo.com/122820309

To that end, Chris is ‘flipping the classroom’ and including some content prior to the airway course itself. Above is a “teaser” of my lecture and skills station for the CIA course. It should be fun…

Even if airway management in the critically unwell is not your “thing”, do consider exploring FOAMed – I reckon it’s the best paradigm for post-Fellowship learning.  I am glad that both RAGP and ACRRM are allowing such online learning to be counted for CPD, not so much for the need for points – but because with increasing interaction amongst clinicians comes acceleration in learning and knowledge translation…which flows to us being better clinicians and patient benefit.

For us rural generalists, separated by distance and needing to maintain knowledge across a broad array of domains, FOAMed means that deficits in knowledge are no longer an excuse as the weak link in patient care.

LINK – REGISTER HERE for CRITICALLY ILL AIRWAY COURSE, May 7-8 The Alfred, Melbourne

 

 

 

 

 

 

Head in the clouds – critical incident reporting in healthcare

Aviation and healthcare have a significantly different approach to communicating outcomes of critical incidents, writes Todd Fraser

In 2002, two aircraft crashed into each into other in otherwise empty skies over Southern Germany. Both were destroyed, resulting in the deaths of 71 people.
Both aircraft were functioning completely normally, the crew were very experienced, the weather was good for flying and both aircraft were fitted with functioning communication and alert systems.
This was a phenomenal catastrophe. How a sequence of events that led to this crash could line up to create this perfect storm are hard to fathom, but they did.
The ensuing investigation attributed blame to factors commonly seen in these incidents, just like they are in healthcare :
  • Excessive workloads
  • Violation of workplace regulations
  • Faulty or disabled instrumentation systems
  • A disordered command structure
  • Dysfunctional communication
Humans are designed to make mistakes. We can, do and will always make mistakes, no matter how hard we try. So we design systems to prevent, minimise or mitigate them.
Both aircraft carried the “Traffic Collision Avoidance System”, or TCAS. When the TCAS senses an approaching aircraft that is a potential threat, it automatically instructs the crew to take action to avoid a collision.
Yet they still crashed.
If the pilots of both planes had followed the instructions given by the TCAS, the accident would not have occurred. Unfortunately, the pilot of one of the planes was given conflicting instructions - the air traffic controller told him to descend while the TCAS told him to climb. And the pilot didn’t know which one to follow, because there was no protocol in place to deal with this scenario. The planes descended into one another and everyone on board was killed.
In the final devastating chapter of this story, the air traffic controller in charge at Swiss company “Skyguide” at the time of the accident was stabbed to death by a relative of one of the victims.
If you thought this horrible chain of events could not get any worse, it did.
This scenario – confusion resulting from conflicting instructions of the TCAS and the air traffic controller, resulting in near-miss incidents – had occurred five times in the previous year.
FIVE TIMES.
On five occasions, the industry missed the opportunity to implement and communicate a solution on an industry-wide basis, resulting in the deaths of 72 people.
Aviation is an industry that prides itself on safety, on distributing cautionary information globally, and this incident provoked a significant re-evaluation of its processes.
So why is a medical specialist writing about this type of incident?
Because if this gives you pause to consider your mode of transport for your next holiday, consider how well the healthcare system deals with similar incidents.
When it comes to effectively communicating industry wide, healthcare is so far behind aviation it’s not funny.
It’s time to do better.
To paraphrase George Santayana, if we fail to learn from the near misses and critical incidents that occur in our industry then we are condemned to repeat them.
“Mistakes were made by us also, and we regret them deeply. We acknowledge our responsibility…and we ask the families of the victims for forgiveness”. 
Alain Rossier, Skyguide Chief Executive
About the Author
Dr Todd Fraser is an intensive care and retrieval medicine specialist, podcast editor of the Society of Critical Care Medicine, and founder of Osler Technology, a clinical performance management platform for acute healthcare providers.

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