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with a white blood cell count > 15,000, high-risk
SSTI locations (face or hand) and bite wounds.
There is a clear need for controlled trials to determine which of these characteristics are reliable
and useful.
Care should also be taken to be alert for conditions that could mimic or masquerade as an
SSTI, as many of these conditions should not be
managed in an OU or would require treatment
other than antibiotics.
19
(Table 44.4)
Management
Antibiotic choice is the primary treatment decision
for OU patients with SSTIs. Recent recommendations have led to a new terminology regarding
types of cellulitis, which leads to logical selection
of antibiotics. Cellulitis can usually be categorized
as “purulent” or “non-purulent.” Patients with
obvious purulence (such as an abscess) should be
treated with antibiotics effective for MRSA (clindamycin or vancomycin). If culture data becomes
available, then antibiotic choice can be adjusted.
Patients without obvious purulence who are not in
a high-risk group for MRSA may be treated with a
beta-lactam antibiotic such as cefazolin or clindamycin. Bite wounds should receive coverage with
antibiotics such as ampicillin/sulbactam to cover
Pasturella species.
Vancomycin has generally been the drug of
choice for hospitalized patients with SSTIs. However, in the OU, there are numerous reasons to
avoid using vancomycin and consider other antibiotics such as clindamycin or cefazolin. Although
clindamycin has not been well studied in the treatment of MRSA infections, it is a logical choice for
patients in the setting of an OU. Clindamycin
doesn’t require monitoring of levels as does vanco-
mycin. It can readily be converted to an oral dose
at the time of discharge. It will also cover betahemolytic Streptococci, making it an ideal choice
for patients with cellulitis that may not appear
purulent, but have other risk factors for MRSA.
The D-zone test for inducible resistance to clindamycin is performed on MRSA isolates that are
resistant to erythromycin, but sensitive to clindamycin. Some patients with mild infections may still
respond to clindamycin in spite of inducible resistance. However, patients with more serious infections or with slow response should be switched to
other antibiotics such as vancomycin or linezolid.
Cefazolin can be used for patients without evidence
of purulence or obvious risk factors for MRSA.
If there is lack of response or progression, then
the antibiotic can be changed. Trimethoprimsulfmethoxazole (TMP-SMZ) is mostly of use for
patients who are being discharged home on oral
antibiotics. It should be used for patients with
purulent cellulitis or MRSA proven by culture,
since it is not sufficiently active against Streptococci.
4
Other antibiotics noted to be useful in the
treatment of hospitalized patients with SSTIs
include linezolid, daptomycin, telavancin, and ceftaroline. Tigecycline (a tetracycline derivative) was
found to be associated with higher mortality rates
in clinical trials and was not included in the IDSA
2011 guidelines.
4
One might argue that management of patients with SSTIs that require less commonly used antibiotics should not take place in an
OU (at least, not without consultation with an
infectious disease specialist).
Discharge or Transfer Criteria
Patients who fail to respond to 24–48 hours of
antibiotic treatment or develop signs of more
serious illness such as necrotizing fasciitis should
be transferred to an inpatient unit. Lack of
response to antibiotics could also indicate the
presence of a condition other than an SSTI or
development of an abscess that was not identified
at admission. Discharge home generally coincides
with the abili ty to transition to oral antibiotic
Table 44.3 Features of Patients with SSTIs to Consider
Exclusion from Observation Unit Placement
Features of SIRS (systemic inflammatory response
syndrome)
White blood cell count > 15,000
18
Wounds (e.g. animal or human bite) with extensive
tissue damage
High-risk locations (face, neck, hand, genitals)
Pain out of proportion to clinical findings
SSTIs = skin and soft tissue infections
Table 44.4 Common Conditions that Mimic SSTIs
Venous thrombotic disease (superficial or deep)
Herpes zoster
Contact dermatitis
Septic bursitis or arthritis, gout
Insect envenomation
Fixed drug eruption
SSTIs = skin and soft tissue infections
Skin and Soft Tissue Infections (SSTI)
048
21:12:33
therapy. Although studies have shown that
patients with SSTIs on intravenous antibiotics
can be safely switched to oral agents after 3 to 4
days, there have been no studies of the population
of patients likely to be cared for in an OU who
may be able to go home in less than 24 hours.
Signs that indicate a patient can be switched to
oral antibiotics and discharged home include
decrease in extent and degree of erythema and
edema, decrease in white blood cell count with
differential shift, absence of fever, and the
patient’s ability to take oral medications. It may
be helpful to draw an outline around the extent of
erythema when a patient presents with an SSTI.
On the other hand, there is some evidence that the
inflammatory response to infection causing fever
and erythema increases during the first 24 hours
of treatment and may not necessarily indicate
treatment failure.
20
There isn’t any evidence to
support a delay in discharge while awaiting confirmation of continued clinical improvement after
switching from intravenous to oral antibiotics.
20
At discharge from the OU, a decision will
need to be made regarding total duration of therapy for treatment. There is little evidence to guide
duration of antibiotic treatment after discharge
from the OU. A study of outpatients receiving
5 days versus 10 days of oral antibiotic therapy
with levofloxacin (not generally a good choice for
the treatment of SSTIs) found no differences in
outcome.
21
The IDSA guidelines recommend 7 to
14 days of therapy, with individualization based
upon clinical response.
4
Considerations regarding follow-up care
should be addressed as well. If a hospital outpatient
pharmacy is available, an attempt should be made
to discharge patients with antibiotics in hand to
enhance compliance. Patients with a primary care
physician should follow-up at some point during
their home treatment to assure progress towards
resolution. Patients without physicians should
return for a “skin check” if feasible or receive a
phone call to assess their status.
Prevention of Recurrent MSRA
Infections
Some patients managed in the OU may present
with recurrent SSTIs presumed to be caused by
MRSA. There is no evidence that decolonization
strategies are useful in the reduction of recurrent
MRSA SSTIs . However, the IDSA recommends
consideration of intranasal mupirocin or bleach
baths for patients with recurrent SSTIs in spite of
optimal wound care and personal hygiene measures.
4
Of note, this recommendation is based on
poor evidence and no clinical trials. It is recognized that mupirocin use could result in the selection of more resistant strains. It is also apparent
that decolonization of the nares fails to address
multiple other sites that are commonly colonized
(axilla and groin).
Conclusion
The rise of community-acquired MRSA has
resulted in a precipitous increase in patients presenting to EDs with SSTIs. These patients have
produced a potential growth industry for OUs
where it is feasible and practical to initiate treatment, assess response, and safely discharge. There
are many unanswered questions that deserve
evidence-based study, such as patient selection,
optimal duration of therapy (intravenous in the
hospital and oral after discharge home), objective
measurements of clinical response, and appropriate management of abscesses. It is likely that
patients with SSTIs can be managed more costeffectively in an observation unit than an inpatient unit, but this too needs further study.
References
1. Pallin DJ, Egan DJ, Pelletier AJ,
et al. Increased US emergency
department visits for skin and
soft tissue infections, and
changes in antibiotic choices,
during the emergence of
community-associated
methicillin-resistant
Staphylococcus aureus. Ann
Emerg Med. 2008;51:291–298.
2. Edelsberg J. Trends in US
hospital admissions for skin
and soft tissue infection. Emerg
Infect Dis. 2009;15(9):
1516–1518.
3. Venkatesh AK, Geisler BP,
Gibson Chambers JJ, et al.
Use of observation care in US
emergency departments,
2001 to 2008. PLoS ONE
2011;6(9):e24326.
Doi:10.1371/journal.
pone.0024326.
4. Liu C, Bayer A, Cosgrove SE,
et al. Clinical practice
guidelines by the Infectious
Diseases Society of America for
the treatment of methicillinresistant Staphylococcus aureus
infections in adults and
children. Clinical Infectious
Diseases 2011;52(3):e18–e55.
Robert S. Bennett
048
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5. Miller LG, PerdreauRemington F, Bayer AS, et al.
Clinical and epidemiologic
characteristics cannot
distinguish communityassociated methicillin-resistant
Staphylococcus aureus
infection from methicillinsusceptible S. aureus infection:
a prospective investigation.
Clin Infect Dis. 2007 Feb 15;
44(4):471–482.
6. Suchard JR. “Spider bite”
lesions are usually diagnosed as
skin and soft-tissue infections.
J Emerg Med Nov 2011;41(5):
473–481.
7. Abrahamian FM, Talan DA,
Moran GJ. Management of
skin and soft-tissue infections
in the emergency department.
Infect Dis Clin N Am 2008;22:
89–116.
8. Chambers HF, Moellering RC
Jr, Kamitsuka P. Management
of skin and soft-tissue
infection. N Engl J Med
2008;359:1063–1067.
9. Hammond SP, Baden LR.
Management of skin and softtissue infection-polling results.
N Engl J Med 2008;359:e20.
10. Lee MC, Rios AM, Aten MF,
et al. Management and
outcome of children with skin
and soft tissue abscesses caused
by community-acquired
methicillin-resistant
Staphylococcus aureus.
Pediatr Infect Dis J 2004;23:
123–127.
11. Schrock JW, Laskey S, Cydulka
RK. Predicting observation
unit treatment failures in
patients with skin and soft
tissue infections. Int J Emerg
Med 2008;1:85–90.
12. Stevens KL, Bisno AL,
Chambers HF, et al. Practice
guidelines for the diagnosis and
management of skin and softtissue infections. Clinical
Infectious Diseases
2005;41:1373–1406.
13. Wong CH, Khin LW, Heng KS,
et al. The LRINEC (laboratory
risk indicator for necrotizing
fasciitis) score: a tool for
distinguishing necrotizing
fasciitis from other soft tissue
infections. Crit Care Med
2004;32(7):1535.
14. Tayal VS, Hasan N, Norton J,
et al. The effect of soft-tissue
ultrasound on the management
of cellulitis in the emergency
department. Academic
Emergency Medicine 2006;
13:384–388.
15. Iverson K, Haritos D, Thomas
R, et al. The effect of bedside
ultrasound on diagnosis and
management of soft tissue
infections in a pediatric ED.
Am J Emerg Med 2012;
30(8):1347–1351.
16. Berger T, Garrido F, Green J,
et al. Bedside ultrasound
performed by novices for the
detection of abscess in ED
patients with soft tissue
infections. Am J Emerg Med
2012; 30(8):1569–1573.
17. Sabbaj A, Jensen B, Browning
MA, et al. Soft tissue infections
and emergency department
disposition: predicting the need
for inpatient admission.
Academic Emergency Medicine
2009;16:1290–1297.
18. Eron LJ, Lipsky BA, Low DE,
et al. Managing skin and soft
tissue infections: expert panel
recommendations on key
decision points. Journal of
Antimicrobial Chemotherapy
2003;52(Suppl. S1):i3–i17.
19. Falagas ME, Vergidis PI.
Narrative review: diseases that
masquerade as infectious
cellulitis. Ann Intern Med
2005;142:47–55.
20. Boyter AC, Stephen J, Fegan
PG, et al. Why do patients with
infection remain in hospital
once changed to oral
antibiotics? J Antimicrob
Chemother 1997; 39: 286–288.
21. Hepburn MJ, Dooley DP,
Skidmore PJ, et al. Comparison
of short-course (5 days) and
standard (10 days) treatment for
uncomplicated cellulitis. Arch
Intern Med 2004;164:1669–1674.
Skin and Soft Tissue Infections (SSTI)
048
21:12:33
Subpart IVH
Chapter
45
Clinical – Gastrointestinal
Abdominal Pain
Louis Graff IV, MD, FACEP, FACP
Abdominal pain is the most common chief complaint in the emergency department (ED) comprising 8% of patients
1
and it is one of the most
difficult to diagnose with a very large differential
diagnosis of serious, dangerous diseases. An
organized approach of evaluation and testing is
needed to have high performance in identifying
these diseases in a timely manner.
Formulating a Diagnostic Approach
Initially the clinician needs to formulate a diagnostic approach by reviewing the patient’s signs
and symptoms considering what possible serious,
dangerous diseases may be affecting the patient.
The loc ation of the pain can aid the clinician in
his or her diagnostic approach. Right lower quadrant (RLQ) suggests appendicitis, renal colic, or in
women ovarian disease (ovarian cyst, ovarian torsion, tubular abscess or pregnancy). Right upper
quadrant (RUQ) suggests cholecystitis/lithiasis,
localized bowel disease, or renal disease. Flank
pain suggests most commonly renal colic, but
other conditions must be considered such as
aortic dissection. Left lower quadrant (LLQ ) suggests diverticulitis or in women ovarian disease
(ovarian cyst, ovarian torsion, tubular abscess or
pregnancy). The associated symptoms can help
focus the diagnostic approach. The time frame
of presentation can aid the clinician in formulating his or her initial differential diagnosis for that
patient.
Initial Diagnostic Approach
Once an initial differential diagnosis is formulated the physician can decide which initial tests
are appropriate. The testing needs to be selective
with a focus on the most likely diagnoses. There
are tests available that can confirm the diagnosis if
the clinician considers the diagnosis and tests
to rule it out. For most patients with more than
minor abdominal pain, the common tests are
indicated: urinanalysis, cbc, and electrolytes.
Urine pregnancy testing is indicated on all women
of childbearing age unless they have had a hysterectomy, are menopausal, or are known pregnant.
For patients with upper abdominal pain and clinical factors that suggest atherosclerotic disease is
possible (patient age, cardiac risk factors, clinical
presentation), myocardial ischemia needs to be
considered with initial testing with EKG, cardiac
biomarkers (troponin, CKMB, bnp) and then
completion of the rule out evaluation during
observation. Liver function tests and amylase/
lipase are indicated for patients with upper
abdominal pain as well. For patients who may
be at risk of ischemic bowel disease, a lactate
should be ordered. For many conditions the diagnosis is made by imaging. Pelvic ultrasound is
used to diagnose women with lower abdominal
pain who might have ovarian torsion, ovarian
cyst, or ectopic pregnancy. Abdominal ultrasound
is the best test for patients with upper abdominal
pain who might have cholecystitis/lithiasis.
Abdominal CT scan imaging is the definitive test
for many serious dangerous conditions: appendicitis, abdominal aortic aneurysm, ischemic bowel,
bowel obstruction, and volvulus.
Threshold for Testing for High
Reliability
High reliability is dependent upon the clinician
having high-enough suspicion and low-enough
threshold for testing to identify those patients
who have a serious dangerous disease. Abdominal
CT scan imaging is an example of testing in
abdominal pain patients that is crucial for highquality care, but must be limited to selected
patients because of risk to the patient from radiation exposure, increased service time when
ordered, and cost to the patient. The threshold
049
21:12:35
for ordering this test needs to be addressed for
institutions that seek to provide best practice care.
Obtaining the optimal threshold for CT scan
imaging of abdominal pain patients is dependent
upon measuring individual and group performance accuracy in diagnosing serious, dangerous
diseases that present with abdominal pain. The
goal is to identify those patients with acute appendicitis (the most common abdominal surgical
emergency) who present atypically and in whom
the diagnosis of appendicitis would not be evident
without CT scan imaging. Patients who have
risk factors for an atypical presentation of appendicitis (very young, very old, female, very early
presentation, immunosuppressed) are prime candidates for abdominal CT scan imaging. Keep
in mind that for young females the preferred
initial imaging is ultrasound because of their
increased risk from radiation exposure from CT
scan imaging.
The threshold for CT scan imaging is clinically set to obtain as low a missed diagnosis rate as
possible, whi le having as low a utilization of the
CT scan imaging as possible. The method to
achieve this is feedback of performance to the
individual and the group. When the missed diagnosis rate is at a best practice low rate, then that
sets the rate for ordering the test as measured by
CT scan imaging per patients who present with a
chief complaint of abdominal pain. This approach
is only possible with significant performance
improvement resources including an electronic
database and analytic and reporting support.
Figure 45.1 shows the graph over time of the
rate of CT scan imaging in abdominal pain
patients versus the rate of failure to diagnose
acute appendicitis. The national average for the
misseddiagnosisofappendicitisisapproximately 8% for emergency physicians, which
results in a doubling of the perforation rate and
the accompanying complications.
2
Performance
is improved by two components of performance
feedback. First is feedback to individual practitioners of their individual missed diagnosed
cases as they occur and sharing the story of
lessons learned with the group. Second is periodic feedback to individu al practitioners of their
performance on the rate of abdominal CT scan
imaging in abdominal pain patients versus their
rate of missed diagnosis of appendicitis. Yearly
feedback may be all that is practical, but abdominal CT scan imaging rates may be possible
monthly if there is sufficient technologic and
staff support.
Efforts to improve performance need to focus
on the group as well as the individual. All clinicians follow their own individual performance
as well as the group as a whole. It is a neverending quest to reach zero missed diagnoses with
satisfaction, when performance reaches best
practice level. The challenge is particularly difficult for those patients who often present atypically with their condition and who are often
not diagnosed by even the most astute physician
(the very elderly, the very young, and the
immunosuppressed).
2
Figure 45.1 Institution’s Appendicitis
Evaluation Rate versus Appendicitis
Missed Diagnosis Rate
Abdominal Pain
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21:12:35
Role of Observation
Many patients with abdominal pain benefit from
observation rather than disposition after the initial evaluation and testing. A period of observation can clarify the patient’s clinical findings and
improve the physician’s estimate of the patient’s
probability of disease/risk of adverse event.
A period of observation can improve the performance of the diagnostic test. Or a period of
observation can make available a definitive test on
an outpatient basis that is not available 24 hours a
day, 7 days a week.
Clarity of the patient’s clinical findings may
occur with observation with signs and symptoms
improving or worsening during observation,
thereby, helping the physician in their formulation of the patient’s probability of diagnosis. For
abdominal pain patients with the diagnosis of
possible appendicitis, it is often difficult upon
presentation to make the diagnosis.
The appendicitis score is a 10-point system of
clinical symptoms and findings with the higher
the score, the more likely the patient has appendicitis. At time of presentation, patients whose diagnosis is made have a score on average of 6 points
but 20% of patients who are taken to surgery have
false positive surgery (normal appendix at surgery) and they have a score of 6 points as well.
1
That is, they initially have a very similar clinical
picture. Patients whose diagnosis is missed have
on average 2 points.
2
This is very similar to what
the findings are in patients with abdominal pain
who do not have appendicitis and are not taken
to surgery.
Observation helps the clinician better discriminate which patients with abdominal pain have disease. For example, when considering appendicitis
the clinical findings and probability of diagnosis
changes dramatically with 12 hours of observation (Figure 45.2).
3
Patients who do not have
appendicitis improve and their appendicitis score
drops on average 3 points,
3
while those with
appendicitis on average increase their score 1
point.
3
This makes it less likely that 1 out of
5 patients will be taken to unnecessary surgery.
This makes it less likely that 1 out of 10 patients
will have their diagnosis missed, which doubles
the risk of perforation and the concomitant complications. Even more important, many patients
will be able to avoid abdominal CT scan imaging
and ionizing radiation exposure and the longterm risks from radiation.
4
Thus, for many
abdominal pain patients the best initial decision
for the patient is to delay the decision on disposition to allow tincture of time to aid the physician
in his or her decision.
Improvementintheperformanceofthe
diagnostic testing can improve du ring observation. For example, in abdominal pain patients
with possible ACS, only one-half of those with
injury (acute MI) have a positive cardiac biomarker test upon presentation.
5
The cardiac
musclehasbeendamagedyetthecardiacbiomarker is not significantly increased in the
blood. But after 8 to 10 hours nearly 100% of
those with injury will have a positive cardiac
biomarker test identifying their acute myocardial infarction.
Observation can also make it possible for the
patient to receive definitive tests safely as outpatients. For many conditions, the definitive test
needed to clarify a patient’s condition is only
available during selected time periods of the
day. For patients with possible ACS, those with
Figure 45.2 Appendicitis Score
Before and After Observation
(from Graff LG, et al. Ann Emerg Med 1991; 20:
503–507).
Louis Graff IV
049
21:12:35
unstable angina cannot be identified by cardiac
biomarker testing (by definition positive cardiac
biomarker test means myocard ial injury [infarction]). The tests that identify unstable angina are
an exercise stress test or cardiac imaging, which
are o nly available during limited time periods
during the day. With the evaluation of patients
in observation over 8 to 24 hours it is possible to
perform these tests, identify those with unstable
angina, and safely discharge home those with a
negative te st.
Observation is, thus, crucial in the evaluation
of patients with abdominal pain. It improves
diagnostic performance.
3
It improves cost effect-
iveness.
1
It improves pa tient outcomes including
patient satisfaction with their medical care.
1
References
1. American College of
Emergency Physicians Practice
Management Committee:
Management of observation
units. Ann Emery Med
1988;17:1348–1352.
2. Graff L, Russell J, Seashore J,
et al. False-negative and falsepositive errors in abdominal
pain evaluation: failure to
diagnose acute appendicitis
and unnecessary surgery.
Acad Emerg Med 2000; 7:
1244–1255.
3. Graff L, Radford M, Werne C.
Probability of appendicitis
before and after observation.
Ann Emerg Med 1991; 20:
503–507.
4. Brenner DJ, Hall EJ. Computed
Tomography—An Increasing
Source of Radiation Exposure.
N Engl J Med 2007; 357:
2277–2284.
5. Hedges JR, Young GP, Henkel
GF, et al. Serial ECGs are less
accurate than serial CK-MB
results for emergency
department diagnosis of
myocardial infarction. Ann
Emerg Med. 1992 Dec;
21(12):1445–1450.
Abdominal Pain
049
21:12:35
Subpart IVH
Chapter
46
Clinical – Gastrointestinal
Upper Gastrointestinal (GI) Bleeding
Abhinav Chandra, MD, FACEP
Introduction
Upper gastrointestinal bleeding (UGIB) is a
common emergency with an annual incidence
of 50 to 150 per 100,000 of the population. Mortality from UGIB is around 10%, and may reach
35% in patients hospitalized with other concomitant medical conditions. It results in 250,000
to 300,000 hospitalizations per year, costing
$2.5 billion dollars.
1
Patients with UGIB may
present in shock and require fluid resuscitation
and admission. However, most episodes are selflimited, and 70–80% of patients experience only a
single episode. Failure to accurately identify those
at high risk for rebleed may result in significant
morbidity and mortality. As a result, many
patients are admitted to the hospital at a significant cost.
2
Patient Criteria
Inclusion criteria – UGIB, hemodynamically
stable after emergency department (ED) evaluation and treatment, normal mentation (or at
baseline), no significant comorbidities, age <
70 years.
Exclusion criteria – Variceal Bleeding, age
70, pulse rate > 100 beats per minute, systolic
blood pressure < 100 mmHg, hemoglobin ≤ 10
g/dL, use of anticoagulants, abnormal mental
status, bright red blood per rectum, comorbidities (coronary artery disease, renal disease, hepatic disease, malignancy, or congestive heart
failure).
Discussion
Patients with UGIB may be appropriate for observation. After ED evaluation and resuscitation, those
who require extended care and are considered low
risk by one of two validated scoring systems are
ideal candidates. Although four risk stratification
scoring systems are commonly mentioned (Rockall
score, the Baylor bleeding score, the Cedars-Sinai
Medical Centre Predictive Index, and the Blatchford score),
3
the Blatchford and Rockall scoring
systems are the two validated tools most commonly used to risk stratify patients.
The objective of the Blatchford
4
system is to
identify those patients who need endoscopy to
control the bleeding. It is derived from the initial
triage history, physical examination, and laboratory data, without endoscopy data. The following
variables are used to determine the Blatchford
score: blood urea nitrogen, hemoglobin, systolic
blood pressure, heart rate, syncope, melena, heart
disease, and liver disease. This system was derived
from 1,748 patients presenting with UGIB at
1 of 19 hospitals in western Scotland. The logistic
regression model was built by stepwise selection
of explanatory variables – clinical and laboratory
data obtained at the time of admission.
4
Next,
they prospectively validated this derivation on a
group of 197 consecutive adult patients admitted
with upper gastrointestinal hemorrhage during
a subsequent 3-month period in three hospitals
in western Scotland. The receiver operating
characteristic (ROC) curve in the validation set
was 0.92 (CI
95%
0.88–0.95). A score of 5 or less
was associated with a < 2% chance for need for
intervention.
4
The Rockall score5was first reported in
1995 and is one of the best known. The data
presented was prospectively collected as part of a
national audit of the management and outcome of
acute upper gastrointestinal hemorrhage at four
health regions in England. Seventy-four hospitals
participated in the initial audit, which lasted from
June to October 1993. A total of 4,185 cases of
acute upper gastrointestinal hemorrhage identified over 4 months in 1993 and an additional
1,625 cases identified over a 3-month period in
1994 were included in the study. This study identified five independent variables that were
predictive of rebleeding or death {age (points
050
21:14:20
0–2), presence of shock (points 0–2), comorbidity
(points 0–3), diagnosis (points 0–2), and endoscopic stigmata of recent hemorrhage (points
0–2)}. The maximum possible score was 11, and
a low-risk score was determined as a score of 0 to
2.
6
This was prospectively validated by Hay et al.
7
in 299 patients and demonstrated only 0.6% of
patients had subsequent complications. This was
also validated by Tham et al.
8
in 102 patients. The
low-risk group of patients had no adverse
outcomes.
In summary, these two risk stratification
systems may be utilized to identify patients at
low risk and potentially able to be discharged after
early endoscopy. Patien ts with portal hypertension, with varicosities, taking anticoagulants, and
with unstable vital signs are not ideal candidates
for a clinical decision unit. The ideal patients are
< 60 years old, without significant comorbidities,
and felt to be reliable and compliant.
Management
Nonvariceal UGIB patients can be optimally managed initially in an ED-based Clinical Decision
Unit (CDU) for up to 24 hours with hydration,
proton pump inhibitors, serial hemoglobin/
hematocrit measurements, serial orthostatics,
and gastroenterology consult for early endoscopy,
defined as within 24 hours of presentation.
The use of proton pump inhibitors (PPI) has
been debated and evaluated in several trials. One
study by Dr. Alan Barkum
9
analyzed data from
the Canadian Registry on nonvariceal UGIB.
This trial analyzed 1,869 patients with UGIB.
Decreased rebleeding was significantly and independently associated with PPI use (85% of
patients, mean daily dose 56 ± 53 mg) regardless
of endoscopic stigmata, (odds ratio [OR]:0.53,
95% confidence interval, 95% CI:0.37–0.77). PPI
use (OR:0.18, 95% CI:0.04–0.80) was independently associated with decreased mortality in
patients.
9
Based on this and other trials, a Con-
sensus Panel
10
recommended that PPIs should be
provided, in the form of a bolus and then followed
by an infusion, to patients with UGIB.
Outcome
Though some clinical trials have been performed
in the care and treatment of nonvariceal UGIB,
none have been in an ED-based CDU. Thus, the
evidence about the success of observation care has
been extrapolated from clinical trials performed
around the world by gastroenterologists and other
nonemergency medicine specialists and from one
ED study.
11
Trials have validated scoring systems, demonstrated decreased length of stay, decreased
readmissions for bleeding, and decreased cost.
Dr. Wrenn
11
and his team demonstrated the
safety of rapid ED evaluation. Wrenn et al. studied a cohort of 96 patients presenting with UGIB
who were followed in the ED for 6 hours. Thirtyeight of these patients were considered low risk as
defined by lack of orthostatics, lack of underlying
significant comorbid disease, hemoglobin concentration > 10 gm/dL, age < 60 years old, and
felt to be reliable and compliant. Of the 38,
33 were discharged and 31 followed-up. None
required readmission or transfusion.
11
A trial by Rockall et al.6evaluated the safety of
early discharge after endoscopy. They concluded
that approximately 33% of low-risk UGIB patients
are eligible for discharge after endoscopic evaluation. The rebleed rate was less than 5% and a
mortality rate in this gro up was 0.1%.
6
In a trial by Longstretch et al.12, the investigators prospectively identified low-risk upper gastrointestinal hemorrhage patients using Rockall’s
criteria. Only one patient in 34 was readmitted for
rebleed and there were no deaths. He calculated
that approximately $1000 dollars was saved in
hospital costs per outpatient treated.
12
The key to the care of a patient with UGIB is
appropriate risk stratification and endoscopic
evaluation. The identification of low-risk findings
on endoscopy in the alimentary tract allows for
discharge, while the findings of high-risk features
support further care. These findings have been
reported in prior publications.
In an analysis of data from 37 prospective
trials in which patients did not receive endoscopic
therapy, Laine and Peterson
13
found that the rate
of further bleeding was less than 5% in patients
with a clean ulcer base and increased to 10% in
patients with a flat spot. These patients would be
appropriate for outpatient care after completion
of observation.
A consensus statement by Barkun et al.
10
summarized high-risk endoscopic features and their
rebleed rates. The bleeding risks were 22% in
those with an adherent clot, 43% in those with a
nonbleeding visible vessel, and 55% in those with
active bleeding (oozing and spurting). Other such
Upper Gastrointestinal (GI) Bleeding
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21:14:20
endoscopic features at high risk for rebleeding
include ulcer size (> 1 or 2 cm) and the site of
bleeding (the posterior lesser gastric curvature
and posterior duodenal wall).
10
In low-risk patients, Longstretch et al.,
12
Cipolletta et al.14, and Lee et al.15demonstrated
cost reductions of 43–91% with the use of early
endoscopy in randomized controlled studies. As
mentioned, in the Longstretch et al. study, there
was only one admission for rebleeding in 34
patients, no deaths and about $1,000 savings in
hospital costs per outpatient treated.
12
In the
Cipolletta et al. study, 95 consecutive patients at
low risk for recurrent bleeding were randomized
for either early discharge and outpatient care
(N = 48) or hospital care (N = 47) and then
followed up at 30 days for morbidity and mortality. In their trial, all patients underwent endoscopy within 12 hours of the onset of hemorrhage,
which should be easily accomplished from a clinical decision unit. No patient underwen t surgery
or died. Rates of recurrent bleeding were 2.1% in
the early discharge group and 2.2% in the hospitaltreated group (one patient in each group). Median
costs were $340 for the outpatient group and
$3940 for the hospital group (p = 0.001).
14
Lee’s trial showed similar results. In his trial, all
eligible patients with UGIB were randomized after
admission to undergo endoscopy in 1 to 2 days
(control) or early endoscopy in the ED. Patients
with low-risk findings on early endoscopy were
discharged directly from the ED and followed
up at 30 days. In 110 consecutive patients with
nonvariceal UGIB, discharge from the ED
occurred in 26 of 56 (46%) patients. No patient
discharged from the ED suffered an adverse outcome. The hospital stay (median of 1 day [interquartile range of 0 to 3 days] versus 2 days
[interquartile range of 2 to 3 days], p =0.0001)
and the cost of care ($2068 [interquartile range of
$928 to $3960] versus $3662 [interquartile range
of $2473 to $7280], p = 0.00006) were significantly
less for the early endoscopy group.
15
Our understanding of gastrointestinal hemorrhage is in its infancy. The potential for increasing
the CDU’s role in managing gastrointestinal
bleeding is exponential. Future investigations
need to be done in the clinical decision unit in
order to validate the results of prior studies. Information is needed to develop scoring systems for
identifying low-risk patients and to identify
lesions at high risk for recurrence of lower gastrointestinal bleeding. Finally, trials need to be conducted to demonstrate the impact on cost as a
result of observation care under the direction of
Emergency Medicine.
Conclusion
Patients may be placed in an OU for nonvariceal
upper gastrointestinal hemorrhage. These patients
can be safely stratified to discharge versus admission based on a validated, prognostic scoring
system, and can have an early endoscopic procedure within 24 hours of observation care in a
clinical decision unit.
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