articles - האיגוד הישראלי לרפואה דחופה: Recent Episodes
articles – האיגוד הישראלי לרפואה דחופה
Robert H. Aseltine Jr, PhD1,2; Shane J. Sacco, PhD2,3; Steven Rogers, MD2,4,5 et al
Key Points Question How does the performance of in-person screening compare with risk algorithms in identifying youths at risk of suicide?
Findings In this cohort study of 19 653 youths, a risk algorithm using patients’ clinical data significantly outperformed universal screening instruments in identifying pediatric patients in the emergency department at risk of subsequent suicide attempts. The risk algorithm uniquely identified 127% more patients with subsequent suicide attempts than screening.
Meaning These findings suggest that clinical implementation of suicide risk algorithms will improve identification of at-risk patients and may substantially assist health care organizations’ efforts to meet the Joint Commission’s suicide risk reduction requirement.
Abstract Importance The Joint Commission requires hospitals and behavioral health care organizations to identify patients at risk of suicide (National Patient Safety Goal 15.01.01). Risk algorithms and in-person screening for suicide risk show utility in identifying patients at risk of suicidal behavior, yet there is little research examining their comparative performance in children and adolescents.
Objective To assess the performance of suicide risk screening and risk algorithms in identifying the risk of suicide attempts among pediatric patients in the emergency department (ED).
Design, Setting, and Participants This retrospective cohort study included youths aged 10 to 18 years presenting to the ED of a northeastern US state between September 1, 2019, and August 31, 2021. Patients were screened for suicide risk using the Ask Suicide-Screening Questions survey and the Columbia–Brief Suicide Severity Rating Scale. Electronic health records from this same cohort containing data from May 31, 2017, to the date of their first encounter within this period were extracted to train a risk algorithm. To observe the presence or absence of a suicide attempt, patients were followed up from their first ED encounter for a minimum of 6 months and a maximum of 2.5 years, through March 2, 2022. Data were analyzed from May 2023 to December 2024.
Exposure Assessments from suicide risk screening and a risk algorithm.
Main Outcomes and Measures The occurrence of a suicide attempt following a patient’s first suicide risk screening or first visit in the screening period, if not screened.
Results Among 19 653 patients included in the analysis, the median age was 14.3 (IQR, 12.1-16.2) years, and 10 007 (50.9%) were female. Four hundred ninety-five patients (2.5%) were treated for a suicide attempt. Among patients screening positive for suicide risk in testing samples (mean, 8.1% [95% CI, 7.6%-8.6%]) and patients in the top 8.1% of the distribution on the algorithm, the algorithm correctly identified a mean of 50.7% (95% CI, 47.3%-54.1%) of those who attempted suicide in contrast to 36.5% (95% CI, 31.9%-41.2%) identified by screening. The algorithm uniquely identified 127% more youths who attempted suicide (125) than did screening (55).
Conclusions and Relevance In this cohort study of pediatric patients, the risk algorithm was superior to screening across all performance metrics and could substantially assist health care organizations’ efforts to meet the Joint Commission’s National Patient Safety Goal to reduce the risk of suicide.
The post JAMA: Screening and Risk Algorithms for Detecting Pediatric Suicide Risk in the Emergency Department first appeared on האיגוד הישראלי לרפואה דחופה.
Written by Vivian Lei
Sniffing out the sweet spot for IN midazolam.
Intranasal (IN) midazolam is a popular choice for pediatric procedural sedation in the ED, but dosing practices have historically varied widely. This prospective, double-blind, adaptive selection, randomized clinical trial enrolled 101 children (6 months to 7 years) undergoing laceration repair to identify the optimal dose of IN midazolam (0.2, 0.3, 0.4, or 0.5 mg/kg). The primary outcome was achieving an “adequate sedation state,” defined using the validated Pediatric Sedation State Scale (PSSS) for at least 95% of the procedure, with timely procedure start (<17 min post-dose) and completion. Secondary outcomes included level of sedation, time to onset of minimal sedation, time to recovery, clinician/caregiver satisfaction, and adverse events.
Using an adaptive sequential elimination design, the 0.2 and 0.3 mg/kg groups were dropped early due to lower rates of adequate sedation. The 0.4 and 0.5 mg/kg groups remained through study completion, and no meaningful differences were found between them in secondary outcomes. Adequate sedation was achieved in roughly 65–70% of children in both groups, with a median onset of about 4 minutes and no serious adverse events. Recovery was rapid and satisfaction rates were high. A single paradoxical reaction occurred in a patient receiving the 0.4 mg/kg dose, and minor adverse events were rare.
How will this change my practice?
This study supports 0.4–0.5 mg/kg as the optimal IN midazolam dosing range for simple laceration repair in children. Lower doses are more likely to result in inadequate sedation, which can increase patient distress and long-term negative associations with care. Importantly, higher dosing did not prolong recovery or increase adverse events in this cohort. While success rates remain lower than with IV agents, IN midazolam remains a valuable, needle-sparing option for straightforward, short procedures.
Editor’s note: For over 20 years, I have used 0.5mg/kg, max 10mg, for IN midazolam. Allow 10 minutes to peak. ~Clay Smith
Source
Optimal Dose of Intranasal Midazolam for Procedural Sedation in Children: A Randomized Clinical Trial. JAMA Pediatr. 2025 Jul 28:e252181. doi: 10.1001/jamapediatrics.2025.2181. Epub ahead of print. PMID: 40720114; PMCID: PMC12305440.
The post What’s the Ideal Intranasal Midazolam Dose for Peds Sedation? first appeared on האיגוד הישראלי לרפואה דחופה.
Writing Committee Members*; Daniel W Jones, Keith C Ferdinand, Sandra J Taler, Heather M Johnson 1, Daichi Shimbo 1, Marwah Abdalla 2, M Martine Altieri 3, Nisha Bansal, Natalie A Bello, Adam P Bress 4, Jocelyn Carter 5, Jordana B Cohen, Karen J Collins, Yvonne Commodore-Mensah 6, Leslie L Davis, Brent Egan 7, Sadiya S Khan, Donald M Lloyd-Jones, Bernadette Mazurek Melnyk 8, Eva A Mistry, Modele O Ogunniyi 9, Stacey L Schott 10, Sidney C Smith Jr, Amy W Talbot, Wanpen Vongpatanasin, Karol E Watson 11, Paul K Whelton, Jeff D Williamson 12
Abstract. Aim: The “2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults” retires and replaces the “2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.”
Methods: A comprehensive literature search was conducted from December 2023 to June 2024 to identify clinical studies, reviews, and other evidence performed on human subjects that were published since February 2015 in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.
Structure: The focus of this clinical practice guideline is to create a living, working document updating current knowledge in the field of high blood pressure aimed at all practicing primary care and specialty clinicians who manage patients with hypertension.
Keywords: AHA Scientific Statements; antihypertensive agents; antihypertensive response; blood pressure; blood pressure control; blood pressure determination; blood pressure monitoring; cardiovascular disease; dosage; evaluation; hypertension; lifestyle; major adverse cardiovascular events; patient care team; quality of life; risk factors; time factors.
The post CIRCULATION: 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines first appeared on האיגוד הישראלי לרפואה דחופה.
- Arunashis Sau, PhD1,2; Henry Zhang, BSc1; Joseph Barker, MRes1
- et alJAMA Cardiol Published Online: August 20, 2025doi: 10.1001/jamacardio.2025.2522related icon Related Articlesfigure icon Figuresattach icon Supplemental ContentKey PointsQuestion Can artificial intelligence–enhanced electrocardiography (AI-ECG) be used to identify individuals with risk of incident complete heart block (CHB)?
Findings This cohort study demonstrated that an AI-ECG risk model can predict the risk of incident CHB and is superior to traditional, guideline-based, ECG risk markers.
Meaning The AI-ECG model termed AIRE-CHB could be used to risk-stratify patients at risk of CHB to guide treatment decisions such as rhythm monitoring or empirical pacemaker implantation.
AbstractIntroduction Complete heart block (CHB) is a life-threatening condition that can lead to ventricular standstill, syncopal injury, and sudden cardiac death, and current electrocardiography (ECG)-based risk stratification (presence of bifascicular block) is crude and has limited performance. Artificial intelligence–enhanced electrocardiography (AI-ECG) has been shown to identify a broad spectrum of subclinical disease and may be useful for CHB.
Objective To develop an AI-ECG risk estimator for CHB (AIRE-CHB) to predict incident CHB.
Design, Setting, and Participants This cohort study was a development and external validation prognostic study conducted at Beth Israel Deaconess Medical Center and validated externally in the UK Biobank volunteer cohort.
Exposure Electrocardiogram.
Main Outcomes and Measures A new diagnosis of CHB more than 31 days after the ECG. AIRE-CHB uses a residual convolutional neural network architecture with a discrete-time survival loss function and was trained to predict incident CHB.
Results The Beth Israel Deaconess Medical Center cohort included 1 163 401 ECGs from 189 539 patients. AIRE-CHB predicted incident CHB with a C index of 0.836 (95% CI, 0.819-0.534) and area under the receiver operating characteristics curve (AUROC) for incident CHB within 1 year of 0.889 (95% CI, 0.863-0.916). In comparison, the presence of bifascicular block had an AUROC of 0.594 (95% CI, 0.567-0.620). Participants in the high-risk quartile had an adjusted hazard ratio (aHR) of 11.6 (95% CI, 7.62-17.7; P < .001) for development of incident CHB compared with the low-risk group. In the UKB UK Biobank cohort of 50 641 ECGs from 189 539 patients, the C index for incident CHB prediction was 0.936 (95% CI, 0.900-0.972) and aHR, 7.17 (95% CI, 1.67-30.81; P < .001).
Conclusions and Relevance In this study, a first-of-its-kind deep learning model identified the risk of incident CHB. AIRE-CHB could be used in diverse settings to aid in decision-making for individuals with syncope or at risk of high-grade atrioventricular block.
The post JAMA: Artificial Intelligence–Enhanced Electrocardiography for Complete Heart Block Risk Stratification first appeared on האיגוד הישראלי לרפואה דחופה.
To our incredible emergency medical teams,As the New Year approaches, we want to extend our deepest gratitude for your unwavering dedication, courage, and compassion. You are the first responders, the frontline heroes who rush in when others run out. You face challenges with strength and professionalism, saving lives and bringing comfort in the most difficult moments.May the coming year bring you health, happiness, and peace. We wish you a year filled with fewer emergencies and more moments of calm. Thank you for all that you do.Happy New Year!
לצוותי הרפואה הדחופה המדהימים שלנו,עם התקרבות השנה החדשה, אנו רוצים להביע את תודתנו העמוקה על מסירותכם הבלתי מתפשרת, אומץ לבכם וחמלתכם. אתם הראשונים להגיע, הגיבורים בחזית שרצים פנימה כשכל האחרים רצים החוצה. אתם מתמודדים עם אתגרים בכוח ובמקצועיות, מצילים חיים ומעניקים נחמה ברגעים הקשים ביותר.מי ייתן והשנה הקרובה תביא לכם בריאות, אושר ושלווה. אנו מאחלים לכם שנה עם פחות אירועי חירום ויותר רגעים של שקט. תודה על כל מה שאתם עושים.שנה טובה!The post שנה טובה ומבורכת לכל ציוותי ררפואה דחופה Happy New Year to Emergency Medical Teams first appeared on האיגוד הישראלי לרפואה דחופה.
Lynn L. DeBar, PhD, MPH1; Robert D. Wellman, MS2; Morgan Justice, PhD2
et al
Key PointsQuestion Is acupuncture needling (both a standard acupuncture course and additional maintenance sessions) an effective treatment for older adults with chronic low back pain (CLBP)?
Findings In this randomized clinical trial that included 800 older adults with CLBP, acupuncture needling (both a standard course and additional maintenance sessions) improved pain-related disability with CLBP at 6 months and 12 months, with no statistically discernible benefit of additional maintenance sessions.
Meaning These findings suggest that acupuncture needling is an effective and safe treatment option for older adults with CLBP.
Abstract(opens in new tab) RCT: Acupuncture and Chronic Low Back Pain in Older AdultsVisual Abstract. Importance The study was carried out to inform Medicare acupuncture coverage decisions addressing the gap in evidence on acupuncture effectiveness, specifically for older adults with chronic low back pain (CLBP).
Objective To determine the effectiveness of standard acupuncture (SA) or SA plus maintenance (enhanced acupuncture [EA]) to improve CLBP-related disability relative to usual medical care (UMC) at 3, 6, and 12 months after randomization.
Design, Setting, and Participants This multisite, 3-arm, parallel-group randomized clinical trial of older adults with CLBP collected data from 4 US health care systems in 3 geographic areas and compared SA and EA treatment with UMC only. Study enrollment was conducted from August 12, 2021, to October 27, 2022; follow-up concluded on November 7, 2023.
Interventions Both SA (8-15 treatment sessions over 12 weeks plus UMC) and EA (SA plus 4-6 maintenance sessions during the next 12 weeks) were provided by experienced, community-based licensed acupuncturists. Participants were randomized 1:1:1 to the 3 groups.
Main Outcomes and Measures The primary outcome was CLBP-related disability measured by a baseline-to-6-month change in the Roland-Morris Disability Questionnaire (RMDQ) score. Secondary outcomes included pain intensity and the percentage of participants with clinically meaningful (≥30%) improvements.
Results The trial identified 800 individuals who were randomized to 3 groups (mean [SD] age, 73.6 [6.0] years; 496 females [62.0%]). At 6 months, RMDQ change scores were significantly better in both the SA and EA groups compared with the UMC only group (SA vs UMC: adjusted mean difference, −1.0 [95% CI, −1.9 to −0.1] and EA vs UMC: adjusted mean difference, −1.5 [95% CI, −2.5 to −0.6]). SA and EA change scores did not differ significantly from one another. The relative benefit of acupuncture compared with UMC on disability persisted at 12 months. Pain intensity exhibited a relative benefit of EA over SA at 6 months, and both acupuncture groups had significant improvement over UMC. The adjusted percentage with clinically meaningful improvements in RMDQ at 6 months was greater for SA (39.1% [95% CI, 33.1%-46.1%]; adjusted relative risk, 1.33 [95% CI, 1.04-1.70]) and for EA (43.8% [95% CI, 38.0%-50.4%]; adjusted relative risk, 1.49 [95% CI, 1.19-1.86]) compared with UMC (29.4% [95% CI, 24.3%-35.5%]) and persisted at 12 months. Rates of serious adverse events were low and similar among groups, with less than 1% that was possibly acupuncture-intervention related.
Conclusions and Relevance The findings of this randomized clinical trial of older adults with CLBP suggest that acupuncture needling provided greater improvements in back pain–related disability at 6 months and at 12 months compared with UMC alone. These findings support acupuncture needling as an effective and safe treatment option for older adults with CLBP.
Trial Registration ClinicalTrials.gov Identifier: NCT04982315
The post JAMA: Acupuncture for Chronic Low Back Pain in Older Adults A Randomized Clinical Trial first appeared on האיגוד הישראלי לרפואה דחופה.
Savannah Pocquette, DO ∙ Katelyn Levy, MD ∙ Jeffrey Gardecki, DO
Keywords1. complex pericardial effusion 2. cardiac tamponade 3. focused cardiac ultrasonography
1 Patient PresentationA 56-year-old man with a history of aortic root aneurysm 3 weeks after surgery from an aortic root replacement with a mechanical valve-conduit presented to the emergency department with exertional dyspnea. He reported a week of progressive worsening of symptoms. He was afebrile with a heart rate of 112 cpm and blood pressure of 110/77 mm Hg. He had clear lungs and a faint systolic murmur without signs of volume overload. A point-of-care cardiac ultrasound was performed (Video 1). The ultrasound findings prompted consultation with cardiothoracic surgery.https://emergencymed.org.il/wp-content/uploads/2025/09/mmc1.mp4Video 1Apical 4 chamber view of the heart demonstrating a large circumferential complex pericardial effusion. Fibrin stranding is demonstrated beating with the atrioventricular valves. Signs of tamponade physiology are seen with both right ventricular and left ventricular collapse in diastole.Download video (mp4, 1 MB)2 Diagnosis: Complex Pericardial Effusion Causing TamponadeThe patient was immediately taken to the operating room for a subxiphoid pericardial window for cardiac tamponade. Emergency physicians can use point-of-care ultrasound for the identification of pericardial effusions, which include states of profound shock and cardiac arrrest.1 The findings on point-of-care ultrasound that were suggestive of cardiac tamponade include the presence of a pericardial effusion with identification of cardiac chamber collapse (Fig).2,3 The specificity for tamponade goes up with progression of the chamber involved from the right atria and ventricle to eventually the left sided cardiac chambers.3 Collapse of the left atrium and ventricle can be seen in the apical 4 chamber clip. Postoperative tamponade can involve the left ventricle and is seen most frequently after valve surgery and in patients on anticoagulation.3,4Conflict of InterestAll authors have affirmed they have no conflicts of interest to declare.References1.Tayal, V.S. ∙ Kline, J.A.Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA statesResuscitation. 2003; 59:315-318Full TextFull Text (PDF)Scopus (0)PubMedGoogle Scholar2.Alerhand, S. ∙ Carter, J.M.What echocardiographic findings suggest a pericardial effusion is causing tamponade?Am J Emerg Med. 2019; 37:321-326Full TextFull Text (PDF)Scopus (73)PubMedGoogle Scholar3.Spodick, D.H.Acute cardiac tamponadeN Engl J Med. 2003; 349:684-690CrossrefScopus (607)PubMedGoogle Scholar4.Pepi, M. ∙ Muratori, M. ∙ Barbier, P. …Pericardial effusion after cardiac surgery: incidence, site, size, and haemodynamic consequencesBr Heart J. 1994; 72:327-331The post Shortness of Breath After Heart Surgery first appeared on האיגוד הישראלי לרפואה דחופה.
Satheesh Gunaga DO1,2,3 , Christopher R. Carpenter MD, MSc4 aura Kennedy MD, MPH5,6 Lauren T. Southerland MD, MPH7
Alexander X. Lo MD, PhD8 Sangil Lee MD, MS9 , Kirby Swan DO1,3 , Fabrice Mowbray PhD, RN10, Rachel M. Skains MD, MSPH11,
Teresita M. Hogan MD12, Martin F. Casey MD, MPH13, Kei Ouchi MD, MPH6,14, Naomi R. George MD, MPH15, Kerstin de Wit MBChB, MD, MSc16,
Cameron J. Gettel MD, MHS17,18, Katherine Selman MD19, Luna C. Ragsdale MD, MPH20,21, Anita N. Chary MD, PhD22,
James D. van Oppen BMBS, PhD23, Glenn Arendts MBBS, PhD2, Charles L. Maddow MD25, Katherine M. Hunold MD, MPH7
,Katren R. Tyler MD26, Danya Khoujah MBBS, MEHP27, la Hwang MD, MPH17,28,29, Shan Liu MD, SD5,6
Abstract The original consensus–based Geriatric Emergency Department (GED)
Guidelines, published in 2014, established a framework of core principles for
delivering high-quality, age-appropriate emergency care for older adults. In
response to significant advances in geriatric emergency medicine research and
evolving clinical priorities, we developed the GED Guidelines 2.0 to ensure
continued relevance, clinical utility, and evidence-based rigor. This concept
paper describes the systematic and iterative process undertaken to update the
guidelines, including the formation of multidisciplinary working groups and the
application of the Grading of Recommendations Assessment, Development,
and Evaluation (GRADE) methodology. Unlike the original GED Guidelines, our
approach prioritized methodological transparency, formalized evidence
grading, and consensus building grounded in systematic reviews and metaanalyses. We describe the identification, recruitment, and collaboration of
multidisciplinary clinical and academic experts working together to improve
the care of older adults in the emergency department. Through this multidisciplinary effort, key geriatric domains were selected, priority topics identified,
and systematic reviews and meta-analyses conducted to generate a robust
evidence base for future guideline and policy development. The GED Guidelines 2.0 represents the first emergency medicine (EM) subspecialty guideline
effort to fully adopt the GRADE framework, offering a novel blueprint for
future EM guideline development.
Keywords: emergency medicine, geriatrics, aged, evidence-based medicine, practice guidelines as topic, health services for the aged, program development
The post A Model for Developing Subspecialty Clinical Practice Guidelines: The Geriatric Emergency Department Guidelines 2.0 first appeared on האיגוד הישראלי לרפואה דחופה.
This episode delivers a deep dive into awake nasotracheal intubation / nasal intubation with a bronchoscope. We cover when to choose the nasal route, how to prepare the patient and equipment, and how to avoid common pitfalls. We break down nostril selection, airway preparation, tube and scope choice, pharmacologic adjuncts, topical anesthesia techniques, and operator positioning. Practical pearls cover managing limited tube lengths, minimizing complications, and ensuring safety. Listeners will leave with a step-by-step framework for successful, atraumatic nasal fiberoptic intubation in high-acuity settings. In a future episode we will go through oral bronchoscopic intubation as well.
When to Go Through the Nose
When you can’t go through the mouth
Airway Cart
A bunch of very specific stuff is needed. It is much easier to have a dedicated place with all of the equipment for awake intubations of all varieties.
Do not improvise or half-ass
Prep
Which Nostril
Occlude one nostril and listen to inhalation and exhalation
When in doubt, go for the right to get faster intubation and lower epistaxis rates[doi: 10.1097/EJA.0000000000001462]
Decide Tube First or Scope First
Place a Nasal Airway – Slit or Non-Slit
Sunmed Adjustable Flange Nasopharyngeal Airways
24 F or 26 F
Usually Stocked are the 18 F
Use the nasal airway for applying the Lidocaine Ointment
Put a slit into the airway if you don’t want to go tube first
Hook Knives
What Tube?
Most tubes get shorter as their ID size decreases
In the Shiley the 6.5 is just as long as the 8.0, but drops dramatically at size 6.0
In the Rusch line, they get progressively smaller all the way down
For Men, you generally need at least 28-30
For Women, 26-28
Estimating formula: Depth at nares (cm) ≈ (Patient height in cm ÷ 10) + 6–7This episode delivers a deep dive into awake nasotracheal intubation / nasal intubation with a bronchoscope. We cover when to choose the nasal route, how to prepare the patient and equipment, and how to avoid common pitfalls. We break down nostril selection, airway preparation, tube and scope choice, pharmacologic adjuncts, topical anesthesia techniques, and operator positioning. Practical pearls cover managing limited tube lengths, minimizing complications, and ensuring safety. Listeners will leave with a step-by-step framework for successful, atraumatic nasal fiberoptic intubation in high-acuity settings. In a future episode we will go through oral bronchoscopic intubation as well.
When to Go Through the NoseWhen you can’t go through the mouth
Airway CartA bunch of very specific stuff is needed. It is much easier to have a dedicated place with all of the equipment for awake intubations of all varieties.
Do not improvise or half-ass
PrepWhich NostrilOcclude one nostril and listen to inhalation and exhalation
When in doubt, go for the right to get faster intubation and lower epistaxis rates[doi: 10.1097/EJA.0000000000001462]
Decide Tube First or Scope FirstPlace a Nasal Airway – Slit or Non-SlitSunmed Adjustable Flange Nasopharyngeal Airways
24 F or 26 F
Usually Stocked are the 18 F
Use the nasal airway for applying the Lidocaine Ointment
Put a slit into the airway if you don’t want to go tube first
Hook Knives
What Tube?Most tubes get shorter as their ID size decreases
In the Shiley the 6.5 is just as long as the 8.0, but drops dramatically at size 6.0
In the Rusch line, they get progressively smaller all the way down
For Men, you generally need at least 28-30
For Women, 26-28
Estimating formula: Depth at nares (cm) ≈ (Patient height in cm ÷ 10) + 6–7
The post PODCAST: Awake NasoTracheal Intubation (AFOI) – When to Pick Your Patient’s Nose! first appeared on האיגוד הישראלי לרפואה דחופה.
Viola I. L. Thulin, MD; Silje M. F. Jordalen, MD; Gard M. S. Myrmel, MD; Ole Christian Lekven, MD; Jeyaseelan Krishnapillai, MD; Ole Thomas Steiro, MD, PhD; Richard Body, MD, PhD; Paul Collinson, MD; Fred S. Apple, PhD; Louise Cullen, MD, PhD; Tone M. Norekvål, PhD; Torbjørn Wisløff, MSc, PhD; Kjell Vikenes, MD, PhD; Rune O. Bjørneklett, MD, PhD; Torbjørn Omland, MD, PhD; Kristin M. Aakre, MD, PhD*
Abstract. Study objective: To compare the effectiveness of high-sensitivity cardiac troponin (hs-cTn) point-of-care testing to central laboratory hs-cTn measurements when investigating patients presenting to the emergency department (ED) with symptoms of acute coronary syndrome.
Methods: The WESTCOR point-of-care study was a single-center prospective randomized controlled trial where we randomized patients presenting with possible acute coronary syndrome in a 1:1 fashion to receive either 0/1-hour centralized hs-cTnT measurements (control) or 0/1-hour point-of-care hs-cTnI testing (intervention). We defined length of stay (LOS) in the ED as the primary endpoint and the minimum clinically meaningful difference as 15 minutes.
Results: We included 1,494 patients in the final analysis, 728 in the point-of-care group, and 766 in the control group. The median (interquartile range) age was 61 (22) years, and 635 (42.5%) were women. Median LOS in the ED was 174 (95% confidence interval [CI] 167 to 181) and 180 (95% CI 175 to 189) minutes in the point-of-care and control group, respectively, resulting in a reduction in median LOS of 6 minutes (95% CI -4 to 17). Acute myocardial infarction, death, or acute revascularization occurred in 83/728 (11.4%) of point-of-care and 72/766 (9.4%) of control patients.
Conclusions: We found that implementing point-of-care hs-cTnI testing in the ED with a 0/1-hour diagnostic algorithm did not lead to a clinically meaningful reduction in ED LOS. We observed no difference in the incidence of myocardial infarction, acute coronary revascularization, or death during 30 days follow-up.
Keywords: Accelerated diagnostic protocol; Acute coronary syndrome; Cardiac biomarkers; Chest pain; Emergency department crowding.
Copyright © 2025 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
PubMed Disclaimer
The post Effectiveness of Point-of-Care High-Sensitivity Troponin Testing in the Emergency Department: A Randomized Controlled Trial first appeared on האיגוד הישראלי לרפואה דחופה.
American Academy of Pediatrics Committee on Pediatric Emergency Medicine; Section on Radiology; American College of Emergency Physicians Pediatric Emergency Medicine Committee; American College of Radiology; Jennifer R Marin 1, Todd W Lyons 2, Ilene Claudius 3, Mary E Fallat 4, Michael Aquino 5, Timothy Ruttan 6, Reza J Daugherty 7Affiliations Expand PMID: 39032991* * DOI: 10.1016/j.annemergmed.2024.03.023 Abstract Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.
The post Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement first appeared on האיגוד הישראלי לרפואה דחופה.
September 25, 2024
Written by Megan Hilbert
AI-enabled ultrasound devices are able to accurately estimate gestational age (GA) between 14 and 27 weeks when employed by novice users. This is particularly of importance in resource poor settings.
Blind sweeps for baby
The World Health Organization (WHO) recommends that all pregnant patients receive at least one ultrasound exam prior to 24 weeks. This can be particularly difficult in LMIC (low- and middle-income countries) where both the equipment and a practiced sonographer can be hard to come by. This was a prospective diagnostic accuracy study run on viable, singleton pregnancy patients, less than 14 weeks gestation in mothers with a BMI < 40 and no known fetal anomaly from Zambia and North Carolina. A baseline GA was established via credentialed sonographers via transvaginal crown-rump length (CRL) (defined as study standard). Patients then underwent a series of 10 second blind sweeps by novice sonographers at the index visit (primary evaluation, < 28 weeks gestation). This same method of blind sweep was employed at a secondary (28 0/6 to 36 6/7 weeks) and tertiary (37 0/6 to 40 6/7 weeks) visit as well. Primary outcome was the difference in mean absolute error (MAE) between the index test and the study standard. Secondary outcome was difference between MAE during the secondary and tertiary windows.
At the primary evaluation, the index test MAE (SE) was 3.19 (0.13) days compared to 3.03 (0.12) days for the study standard (difference 0.16, 95%CI -0.14 to 0.45 days) and, therefore, was considered equivalent as it fell within the predefined range of -2 to 2 days established by the researchers. In the secondary window, the index test MAE (SE) was 6.07 (0.26) days with the study standard being 7.12 (0.30) days. This resulted in a difference of -1.06 (95%CI -1.72 to -0.40) days, which also met equivalence. This equivalence did not hold in the tertiary time frame.
Limitations of this study include that this was completed on singleton pregnancies, in relative non-obese patients, and in those with no defined fetal anomalies. Also concerning is that novice sonographers may be unable to identify abnormalities, meaning that the AI would likely perform poorly in those cases and result in grossly abnormal estimates.
How will this change my practice?
Moral: This deep learning model can accurately estimate GA in patients less than 37 weeks of gestation with blind sweeps alone, obviating the need for a high-specification machine or credentialed sonographer. Caveat: This is great as long as the pregnancy is relatively uncomplicated. Given that I have previous training, I would definitely be interested in trying this AI at my rural community sites, but I would be hesitant in trusting it implicitly for those who have no prior ultrasound experience.
Editor’s note: I’m solidly in the “blind squirrel” category when it comes to ultrasound. This use of AI is very exciting for those of us for whom most of bedside ultrasonography is kind of a “blind sweep.” ~Clay Smith
Source
Diagnostic Accuracy of an Integrated AI Tool to Estimate Gestational Age From Blind Ultrasound Sweeps. JAMA. 2024 Aug 1. doi: 10.1001/jama.2024.10770. Epub ahead of print. PMID: 39088200.
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Cecilia Karlsson, MD, PhD1,2; Line Kristin Johnson, PhD3; Peter J. Greasley, PhD4; et al
Key Points Question Does Roux-en-Y gastric bypass (RYGB) affect cardiovascular risk factors independent of caloric restriction and weight loss?
Findings In this nonrandomized controlled study, patients with severe obesity undergoing RYGB demonstrated a clinically meaningful reduction in major atherogenic blood lipids, which was not seen in patients undergoing an isocaloric very low-energy diet with a matching weight loss.
Meaning Surgery-specific changes on major atherogenic blood lipids seem to be independent of weight loss and may explain at least part of the long-term cardiovascular benefits of RYGB.
AbstractImportance Roux-en-Y gastric bypass (RYGB) is associated with reduced cardiovascular (CV) risk factors, morbidity, and mortality. Whether these effects are specifically induced by the surgical procedure or the weight loss is unclear.
Objective To compare 6-week changes in CV risk factors in patients with obesity undergoing matching caloric restriction and weight loss by RYGB or a very low-energy diet (VLED).
Design, Setting, and Participants This nonrandomized controlled study (Impact of Body Weight, Low Calorie Diet, and Gastric Bypass on Drug Bioavailability, Cardiovascular Risk Factors, and Metabolic Biomarkers [COCKTAIL]) was conducted at a tertiary care obesity center in Norway. Participants were individuals with severe obesity preparing for RYGB or a VLED. Recruitment began February 26, 2015; the first patient visit was on March 18, 2015, and the last patient visit (9-week follow-up) was on August 9, 2017. Data were analyzed from April 30, 2021, through June 29, 2023.
Interventions VLED alone for 6 weeks or VLED for 6 weeks after RYGB; both interventions were preceded by 3-week LED.
Main Outcomes and Measures Between-group comparisons of 6-week changes in CV risk factors.
Results Among 78 patients included in the analyses, the mean (SD) age was 47.5 (9.7) years; 51 (65%) were women, and 27 (35%) were men. Except for a slightly higher mean (SD) body mass index of 44.5 (6.2) in the RYGB group (n = 41) vs 41.9 (5.4) in the VLED group (n = 37), baseline demographic and clinical characteristics were similar between groups. Major atherogenic blood lipids (low-density lipoprotein cholesterol, non–high-density lipoprotein cholesterol, apolipoprotein B, lipoprotein[a]) were reduced after RYGB in comparison with VLED despite a similar fat mass loss. Mean between-group differences were −17.7 mg/dL (95% CI, −27.9 to −7.5), −17.4 mg/dL (95% CI, −29.8 to −5.0) mg/dL, −9.94 mg/dL (95% CI, −15.75 to −4.14), and geometric mean ratio was 0.55 U/L (95% CI, 0.42 to 0.72), respectively. Changes in glycemic control and blood pressure were similar between groups.
Conclusions and Relevance This study found that clinically meaningful reductions in major atherogenic blood lipids were demonstrated after RYGB, indicating that RYGB may reduce CV risk independent of weight loss.
Trial Registration ClinicalTrials.gov Identifier: NCT02386917
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Movement Disorders: Official Journal of the Movement Disorder SocietyTAKE-HOME MESSAGE* Although previous research has suggested that GLP-1 receptor agonists (GLP-1RAs) may have a disease-modifying effect on the development of Parkinson’s disease (PD), the results of the population studies have not been consistent. The current study compared the risk of PD in older adults (age, ≥66 years) with type 2 diabetes (N = 89,074) based on whether they received GLP-1RAs (n = 30,091) or dipeptidyl peptidase 4 inhibitors (DPP4is; n = 58,983) using Medicare administrative data from 2016 to 2020. The crude incidence rate of PD was lower among GLP-1RA users than among DPP4i users. GLP-1RA users had a 23% lower risk of PD than DPP4i users. * The study concluded that the new use of GLP-1RAs was significantly associated with a decreased risk of PD compared with DPP4is consistently across sex, race, and GLP-1RA types.
– Leila Montaser Kouhsari, MD, PhDAbstract BackgroundPrevious studies have suggested that glucagon-like peptide-1 receptor agonists (GLP-1RAs) may have a disease-modifying effect in the development of Parkinson’s disease (PD), but population studies yielded inconsistent results.
ObjectiveThe aim was to compare the risk of PD associated with GLP-1RAs compared to dipeptidyl peptidase 4 inhibitors (DPP4i) among older adults with type 2 diabetes (T2D).
MethodsUsing U.S. Medicare administrative data from 2016 to 2020, we conducted a population-based cohort study comparing the new use of GLP-1RA with the new use of DPP4i among adults aged ≥66 years with T2D. The primary endpoint was a new diagnosis of PD. A stabilized inverse probability of treatment weighting (sIPTW)–adjusted Cox proportional hazards regression model was employed to estimate the hazard ratio (HR) and 95% confidence intervals (CI) for PD between GLP-1RA and DPP4i users.
ResultsThis study included 89,074 Medicare beneficiaries who initiated either GLP-1RA (n = 30,091) or DPP4i (n = 58,983). The crude incidence rate of PD was lower among GLP-1RA users than DPP4i users (2.85 vs. 3.92 patients per 1000 person-years). An sIPTW-adjusted Cox model showed that GLP-1RA users were associated with a 23% lower risk of PD than DPP4i users (HR, 0.77; 95% CI, 0.63–0.95). Our findings were largely consistent across different subgroup analyses such as sex, race, and molecular structure of GLP-1RA.
ConclusionAmong Medicare beneficiaries with T2D, the new use of GLP-1RAs was significantly associated with a decreased risk of PD compared to the new use of DPP4i. © 2024 International Parkinson and Movement Disorder Society.
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September 4, 2024
Written by Seth Walsh-Blackmore
Attempting initial vascular access in the field by intraosseous (IO) vs. intravenous (IV) route made no difference in survival to hospital discharge for out-of-hospital cardiac arrest (OHCA), despite greater IO success rates.
The only VICTOR was the trial.
Intraosseous access has superior success rates by paramedics in the field compared to intravenous access, but we lack high-level evidence that this improves outcomes for OHCA.1,2,3
The VICTOR trial is a cluster RCT from Taiwan comparing upper extremity IV access to humeral IO in non-traumatic OHCA patients aged 20-80 years receiving resuscitation measures. Four urban paramedic ambulance teams were randomly assigned biweekly to an IV or IO protocol. A single attempt at humeral IO or two attempts at upper extremity IV access were allowed, after which the patient was transported to the hospital without additional attempts. If successful, 1 mg of epinephrine was administered. Additional resuscitative interventions were per local protocol.
After randomization and exclusion, 741 IO and 991 IV patients were included. Baseline characteristics, response/transport time, shockable rhythm, and bystander CPR were balanced. Successful access was obtained in 94% of the IO group vs 58% of the IV group, and administration of epinephrine and other medications differed by similar margins.
There was no significant difference in the primary outcome of survival to hospital discharge (IO: OR for survival 1.04, 95%CI 0.76-1.42). Secondary outcomes, including prehospital return of circulation (OR 1.23, 95%CI 0.89-1.69) and favorable neurologic outcome (OR 1.17, 95%CI 0.82-1.66), also lacked significant differences. The study was powered to detect a 5% difference and was potentially underpowered.
How will this change my practice?
The near equivalent outcomes may say more about the benefit of epinephrine in these patients than the IO, given IO’s higher success rate. I hope to see this design replicated in a traumatic arrest, where vascular access may be have greater impact.
Source
Intraosseous versus intravenous vascular access in upper extremity among adults with out-of-hospital cardiac arrest: cluster randomised clinical trial (VICTOR trial). BMJ. 2024 Jul 23:386:e079878. doi: 10.1136/bmj-2024-079878. PMID: 39043416.
The post IO or IV for OHCA? first appeared on האיגוד הישראלי לרפואה דחופה.
Michelle M. J. Nassal, MD, PhD;AndoniElola,PhD;Elisabete Aramendi,PhD;XabierJaureguibeitia, PhD; Jonathan R. Powell, MPA;AhamedIdris,MD; BanuPriyaRayaKrishnamoorthy,BS;MohamudR.Daya,MD;TomP.Aufderheide,MD;JestinN.Carlson,MD;ShannonW.Stephens,CCEMT-P; Ashish R. Panchal, MD,PhD;HenryE.Wang,MD
Abstract Importance: While widely measured, the time-varying association between exhaled end-tidal carbon dioxide (EtCO2) and out-of-hospital cardiac arrest (OHCA) outcomes is unclear.
Objective: To evaluate temporal associations between EtCO2 and return of spontaneous circulation (ROSC) in the Pragmatic Airway Resuscitation Trial (PART).
Design, setting, and participants: This study was a secondary analysis of a cluster randomized trial performed at multicenter emergency medical services agencies from the Resuscitation Outcomes Consortium. PART enrolled 3004 adults (aged ≥18 years) with nontraumatic OHCA from December 1, 2015, to November 4, 2017. EtCO2 was available in 1172 cases for this analysis performed in June 2023.
Interventions: PART evaluated the effect of laryngeal tube vs endotracheal intubation on 72-hour survival. Emergency medical services agencies collected continuous EtCO2 recordings using standard monitors, and this secondary analysis identified maximal EtCO2 values per ventilation and determined mean EtCO2 in 1-minute epochs using previously validated automated signal processing. All advanced airway cases with greater than 50% interpretable EtCO2 signal were included, and the slope of EtCO2 change over resuscitation was calculated.
Main outcomes and measures: The primary outcome was ROSC determined by prehospital or emergency department palpable pulses. EtCO2 values were compared at discrete time points using Mann-Whitney test, and temporal trends in EtCO2 were compared using Cochran-Armitage test of trend. Multivariable logistic regression was performed, adjusting for Utstein criteria and EtCO2 slope.
Results: Among 1113 patients included in the study, 694 (62.4%) were male; 285 (25.6%) were Black or African American, 592 (53.2%) were White, and 236 (21.2%) were another race; and the median (IQR) age was 64 (52-75) years. Cardiac arrest was most commonly unwitnessed (n = 579 [52.0%]), nonshockable (n = 941 [84.6%]), and nonpublic (n = 999 [89.8%]). There were 198 patients (17.8%) with ROSC and 915 (82.2%) without ROSC. Median EtCO2 values between ROSC and non-ROSC cases were significantly different at 10 minutes (39.8 [IQR, 27.1-56.4] mm Hg vs 26.1 [IQR, 14.9-39.0] mm Hg; P < .001) and 5 minutes (43.0 [IQR, 28.1-55.8] mm Hg vs 25.0 [IQR, 13.3-37.4] mm Hg; P < .001) prior to end of resuscitation. In ROSC cases, median EtCO2 increased from 30.5 (IQR, 22.4-54.2) mm HG to 43.0 (IQR, 28.1-55.8) mm Hg (P for trend < .001). In non-ROSC cases, EtCO2 declined from 30.8 (IQR, 18.2-43.8) mm Hg to 22.5 (IQR, 12.8-35.4) mm Hg (P for trend < .001). Using adjusted multivariable logistic regression with slope of EtCO2, the temporal change in EtCO2 was associated with ROSC (odds ratio, 1.45 [95% CI, 1.31-1.61]).
Conclusions and relevance: In this secondary analysis of the PART trial, temporal increases in EtCO2 were associated with increased odds of ROSC. These results suggest value in leveraging continuous waveform capnography during OHCA resuscitation.
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נכתב על ידי מייקל סטוקר
בדום לב לא טראומטי מחוץ לבית החולים (OHCA), מתן מינון ראשוני של אפינפרין IM על ידי EMS לפני הכנסת IV או IO היה קשור לשיפור תוצאות ההישרדות.
אפי בירך עוזר ליותר חולים לשרוד? מחקר זה של מרכז יחיד לפני ואחרי חקר את ההשפעה של מינון IM ראשוני של אפינפרין ב-OHCA על תוצאות ההישרדות. לאחר שלב טרום התערבות עם פרמדיקים בעקבות פרוטוקולים סטנדרטיים של ACLS (IV/IO), שלב ההתערבות (IM) ראה תוספת של מינון ראשוני של 5 מ”ג אפינפרין IM בזמן שניסיונות לבסס גישה IV/IO נמשכו. 1,405 חולי OHCA מבוגרים (קבוצת IM, n = 420) ללא קשר לקצב הראשוני נכללו לאחר אי הכללות כגון ROSC לפני אפינפרין דום לב טראומטי. הדמוגרפיה הייתה דומה בין הקבוצות, כאשר הבדלים בגיל ובהחייאה של עובר אורח העדיפו את קבוצת ה-IM. לאחר התאמה לדמוגרפיה, החייאה של עובר אורח וזמן תגובה ל-EMS, קבוצת ה-IM ראתה שיפור בכל תוצאות ההישרדות שנמדדו: הישרדות לאשפוז בבית החולים (37.1% לעומת 31.6%; יחס סיכויים מותאם[aOR] 1.37, 95%CI 1.06-1.77), הישרדות עד לשחרור מבית החולים (11.0% לעומת 7.0%; aOR 1.73, 95%CI 1.10-2.71), והישרדות חיובית מבחינה נוירולוגית (9.8% לעומת 6.2%; aOR 1.72CI, 1.72. -2.76). כפי שניתן לצפות, הזמן עד אפינפרין ראשון היה קצר יותר גם בקבוצת ה-IM. היו שורה של מגבלות, מגודל המדגם וחריגות פרוטוקול ועד למגיפת COVID-19 במהלך שלב ההתערבות; עם זאת, המטרה של מתן מוטיבציה לחקירה נוספת הושגה.
איך זה ישנה את הנוהג שלי? המחקר הזה אינו גורם משנה בפני עצמו, ובכל זאת אני אופטימי בזהירות. ככל שהרפואה הופכת יותר ויותר מתוחכמת, האם זה לא יהיה נהדר אם אפינפרין IM פשוט היה “הדבר הגדול הבא” בטיפול ב-OHCA? צריך להיות כאן מספיק פוטנציאל לתועלת כדי להצדיק חקירה קפדנית – תביא את ה-RCTs!
מקור מתן אדרנלין תוך שרירי מוקדם קשור לשיפור ההישרדות מדום לב מחוץ לבית החולים . הַחיָאָה. 2024 אוגוסט;201:110266. doi: 10.1016/j.resuscitation.2024.110266. Epub 2024 9 ביוני. PMID: 38857847.
The post אדרנלין IM עבור החייאה מחוץ לבית חולים OHCA – מהיר וטוב יותר? first appeared on האיגוד הישראלי לרפואה דחופה.
EmadAwada,b,*,BrentKlapthora,MichaelH.Morgana,ScottT.Youngquista,c
Abstract Objective: Optimal timing for subsequent defibrillation attempts for Out-of-hospital cardiac arrest (OHCA) patients with recurrent VF/pVT is uncertain. We investigated the relationship between VF/pVT duration and return of spontaneous circulation (ROSC) in OHCA patients with recurrent shockable rhythms.
Methods: We analyzed data from the Salt Lake City Fire Department (SLCFD) spanning from 2012 to 2023. The implementation of rhythm-filtering technology since 2011 enabled real-time rhythm interpretation during CPR, with local protocols allowing early defibrillation for recurrent/refractory VF/pVT cases. We included patients experiencing four or five episodes of VF and pVT rhythms and employed generalized estimating equation (GEE) regression analysis to examine the association between VF/pVT durations preceding recurrent defibrillation and return of spontaneous circulation (ROSC).
Results: Analysis of 622 appropriate shocks showed that patients achieving ROSC had significantly shorter median VF/pVT duration than those who did not achieve ROSC (0.83 minutes vs. 1.2 minutes, p = 0.004). Adjusted analysis of those with 4 VF/pVT episodes (N = 142) revealed that longer VF/pVT durations were associated with lower odds of achieving ROSC (odds ratio: 0.81, 95% CI: 0.72-0.93, p = 0.005). Every one-minute delay in intra-arrest defibrillation is predicted to decrease the likelihood of achieving ROSC by 19%.
Conclusion: Every one-minute increase in intra-arrest VF/pVT duration was associated with a statistically significant 19% decrease in the chance of achieving ROSC. This highlights the importance of reducing time to shock in managing recurrent VF/pVT. The findings suggest reevaluating the current recommendations of two minutes intervals for rhythm check and shock delivery.
Keywords: Cardiac arrest; Defibrillation; Emergency medical services; Shockable rhythm; Time to shock.
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Jan Rudolph, MD; Christian Huemmer, PhD; Alexander Preuhs, PhD; Giulia Buizza, PhD; Boj F. Hoppe, MD; Julien Dinkel, MD; Vanessa Koliogiannis, MD; Nicola Fink, MD; Sophia S. Goller, MD; Vincent Schwarze, MD; Nabeel Mansour, MD; Vanessa F. Schmidt, MD; Maximilian Fischer, MD; Maximilian Jörgens, MD; Najib Ben Khaled, MD; Thomas Liebig, MD; Jens Ricke, MD; Johannes Rueckel, MD; and Bastian O. Sabel, MD
Abstract Background: Chest radiographs (CXRs) are still of crucial importance in primary diagnostics, but their interpretation poses difficulties at times.
Research question: Can a convolutional neural network-based artificial intelligence (AI) system that interprets CXRs add value in an emergency unit setting?
Study design and methods: A total of 563 CXRs acquired in the emergency unit of a major university hospital were retrospectively assessed twice by three board-certified radiologists, three radiology residents, and three emergency unit-experienced nonradiology residents (NRRs). They used a two-step reading process: (1) without AI support; and (2) with AI support providing additional images with AI overlays. Suspicion of four suspected pathologies (pleural effusion, pneumothorax, consolidations suspicious for pneumonia, and nodules) was reported on a five-point confidence scale. Confidence scores of the board-certified radiologists were converted into four binary reference standards of different sensitivities. Performance by radiology residents and NRRs without AI support/with AI support were statistically compared by using receiver-operating characteristics (ROCs), Youden statistics, and operating point metrics derived from fitted ROC curves.
Results: NRRs could significantly improve performance, sensitivity, and accuracy with AI support in all four pathologies tested. In the most sensitive reference standard (reference standard IV), NRR consensus improved the area under the ROC curve (mean, 95% CI) in the detection of the time-critical pathology pneumothorax from 0.846 (0.785-0.907) without AI support to 0.974 (0.947-1.000) with AI support (P < .001), which represented a gain of 30% in sensitivity and 2% in accuracy (while maintaining an optimized specificity). The most pronounced effect was observed in nodule detection, with NRR with AI support improving sensitivity by 53% and accuracy by 7% (area under the ROC curve without AI support, 0.723 [0.661-0.785]; with AI support, 0.890 [0.848-0.931]; P < .001). Radiology residents had smaller, mostly nonsignificant gains in performance, sensitivity, and accuracy with AI support.
Interpretation: We found that in an emergency unit setting without 24/7 radiology coverage, the presented AI solution features an excellent clinical support tool to nonradiologists, similar to a second reader, and allows for a more accurate primary diagnosis and thus earlier therapy initiation.
Keywords: AI assistance; artificial intelligence; chest radiography; emergency unit.
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Michael A. Smyth, PhD1,2; Imogen Gunson, MSc3; Alison Coppola, MClinRes4; et al
Abstract Importance: Termination of resuscitation (TOR) rules may help guide prehospital decisions to stop resuscitation, with potential effects on patient outcomes and health resource use. Rules with high sensitivity risk increasing inappropriate transport of nonsurvivors, while rules without excellent specificity risk missed survivors. Further examination of the performance of TOR rules in estimating survival of out-of-hospital cardiac arrest (OHCA) is needed.
Objective: To determine whether TOR rules can accurately identify patients who will not survive an OHCA.
Data sources: For this systematic review and meta-analysis, the MEDLINE, Embase, CINAHL, Cochrane Library, and Web of Science databases were searched from database inception up to January 11, 2024. There were no restrictions on language, publication date, or time frame of the study.
Study selection: Two reviewers independently screened records, first by title and abstract and then by full text. Randomized clinical trials, case-control studies, cohort studies, cross-sectional studies, retrospective analyses, and modeling studies were included. Systematic reviews and meta-analyses were reviewed to identify primary studies. Studies predicting outcomes other than death, in-hospital studies, animal studies, and non-peer-reviewed studies were excluded.
Data extraction and synthesis: Data were extracted by one reviewer and checked by a second. Two reviewers assessed risk of bias using the Revised Quality Assessment Tool for Diagnostic Accuracy Studies. Cochrane Screening and Diagnostic Tests Methods Group recommendations were followed when conducting a bivariate random-effects meta-analysis. This review followed the Preferred Reporting Items for a Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) statement and is registered with the International Prospective Register of Systematic Reviews (CRD42019131010).
Main outcomes and measures: Sensitivity and specificity tables with 95% CIs and bivariate summary receiver operating characteristic (SROC) curves were produced. Estimates of effects at different prevalence levels were calculated. These estimates were used to evaluate the practical implications of TOR rule use at different prevalence levels.
Results: This review included 43 nonrandomized studies published between 1993 and 2023, addressing 29 TOR rules and involving 1 125 587 cases. Fifteen studies reported the derivation of 20 TOR rules. Thirty-three studies reported external data validations of 17 TOR rules. Seven TOR rules had data to facilitate meta-analysis. One clinical study was identified. The universal termination of resuscitation rule had the best performance, with pooled sensitivity of 0.62 (95% CI, 0.54-0.71), pooled specificity of 0.88 (95% CI, 0.82-0.94), and a diagnostic odds ratio of 20.45 (95% CI, 13.15-31.83).
Conclusions and relevance: In this review, there was insufficient robust evidence to support widespread implementation of TOR rules in clinical practice. These findings suggest that adoption of TOR rules may lead to missed survivors and increased resource utilization.
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TAKE-HOME MESSAGE* Drawing data from the Swedish National Airway Register, this retrospective cohort study compared the number and severity of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) with subsequent incidence of myocardial infarction (MI) and pulmonary embolism (PE). Reviewing data from more than 66,422 patients with COPD followed for a total duration exceeding 265,000 patient-years, the authors found that the number and severity of AECOPD correlated with an increased long-term risk of both MI and PE. * The immediate association between AECOPD and PE/MI is well-established, but there was less evidence connecting these conditions over longer periods of time. The authors advocate that additional evaluation is needed for cardiovascular prevention strategies among patients who experience frequent AECOPD.
– Emmett Kistler, MDABSTRACT BackgroundAcute exacerbations of COPD (AECOPDs) are increasingly recognized as episodes of heightened risk of cardiovascular events. It is not known whether exacerbation history is differentially associated with future myocardial infarction (MI) or pulmonary embolism (PE).Research QuestionIs the number and severity of AECOPDs associated with increased risk of MI or PE in a real-life cohort of patients with COPD?Study Design and MethodsWe identified a cohort of 66422 patients (≥30yr) with a primary diagnosis of COPD in the Swedish National Airway Register January 2014 to June 2022, with complete data on lung function. Patients were classified by moderate (prescription of oral corticosteroids) and severe (hospitalization) exacerbations the year before index date and were followed until Dec 2022 for hospitalization or death from MI or PE, corresponding to >265 000 patient-years, with a maximum follow-up time of 9 years. Competing-risk regression, according to Fine-Gray, was used to calculate subdistribution hazard ratios (SHRs) with 95% confidence intervals (CI).ResultsCompared with no AECOPDs in the baseline period, AECOPD number and severity was associated with increased long term risk of both MI and PE in a gradual fashion, ranging from a SHR of 1.10 (0.97-1.24) and 1.33 (1.11-1.60), respectively, for one moderate exacerbation, to 1.82 (1.36-2.44) and 2.62 (1.77-3.89), respectively, for two or more severe exacerbations. In a time-restricted follow-up sensitivity analysis, the associations were stronger during the first year of follow up and diminished over time.InterpretationThe risk of MI and PE increases with the frequency and severity of AECOPD in this large real life cohort of patients with COPD.The post Association Between Exacerbation History and Risk of Myocardial Infarction and Pulmonary Embolism in COPD first appeared on האיגוד הישראלי לרפואה דחופה.
August 21, 2024
Written by Megan Hilbert
Using the aortic dissection detection (ADD) risk score in addition to point-of-care ultrasound (POCUS) and D-dimer, providers can increase their diagnostic accuracy and ensure that the appropriate patients are receiving advanced imaging to make the diagnosis of acute aortic syndrome (AAS).
PROFUNDUS? Wow, that’s deep…
Acute aortic syndromes (AAS) – dissection, intramural hematoma, penetrating ulcer – have high mortality, but low relative incidence. Resource utilization and administration of ionizing radiation are two very important considerations when working in the ED. ED providers must navigate through the minefield of a high-risk differential while not over-testing. It is a tightrope, particularly in patients where aortic pathology is a consideration. This was a prospective management outcome study that evaluated protocol safety, efficiency, feasibility, as well as adherence to this standard protocol. It also evaluated the adjusted safety and efficiency of the modified protocol when adding on age-adjusted D-dimer.
The protocol:
- The ADD is calculated (guideline-compliant clinical score – see MDCalc)
- POCUS (suprasternal and parasternal view) is completed looking for direct signs of aortic pathology (intimal flap, thickening of the wall, outpouching) vs indirect signs (thoracic aortic dilation, pericardial effusion, moderate aortic valve regurgitation).
- D-dimer is collected (age-adjusted interpretation)
Integrated pre-test probability (iPTP) is then calculated (see graphic). Those with low pre-test probability as calculated by the modified protocol could forgo advanced imaging.
Results:
Adding POCUS to the ADD was able to accomplish a 20% net reclassification improvement (24%/-4% for events/non-events, p < 0.001). This resulted in 6% of study participants being reclassified as high-risk by POCUS, with 39% of those having a diagnosis of AAS (wow!). In low-risk patients, the addition of the age-adjusted D-dimer ruled out AAS with 100% sensitivity and 59% specificity (p<0.001). It also was able to rule out 6% more low pre-test probability patients as compared to the standard protocol alone. This corresponded to 2 of 5 less orders for CTA.
How will this change my practice?
This was a well done study that looked to improve our efficiency at diagnosing acute aortic syndromes. With the statistics reported in this paper, I will feel much more confident in not pursuing further advanced imaging if my ultrasound and age-adjusted D-dimer don’t support aortic pathology as the presenting etiology.
Editor’s note: It’s not clear the primary POCUS views studied (parasternal long and suprasternal) were sufficientl. A significant number of patients also had views of the abdominal aorta, apical 4/5 chamber and subcostal 4-chamber. Consider expanding your POCUS to include these as well until more details regarding the POCUS algorithm are available. ~ Nick Zelt
Source
Diagnosis of acute aortic syndromes with ultrasound and d-dimer: the PROFUNDUS study. Eur J Intern Med. 2024 Jun 12:S0953-6205(24)00234-6. doi: 10.1016/j.ejim.2024.05.029. Epub ahead of print. PMID: 38871565.
From cited articleThe post PROFUNDUS – POCUS-Plus for Aortic Syndromes first appeared on האיגוד הישראלי לרפואה דחופה.
August 19, 2024
Written by Aaron Lacy
This comprehensive article on bougie use during emergency airway management covers all things bougie, with a lot of technical tips. We cover the highlights.
Bougie = Life
This article goes into a lot of detail regarding bougie use, including general principles and microskills. If you are on the fence about when to use a bougie, you can familiarize yourself with that literature here, here, and here. If you intubate, I recommend reading the whole article (with video examples), but I picked a few things here that are the biggest issues I see repeatedly while teaching bougie use during intubation.
Preparation:
- These authors specifically recommend against “preloading” the bougie. I couldn’t agree more; there is no evidence to support this, and it hampers your ability to utilize the bougie to its full extent. Even if a solo operator, this technique is likely not necessary.
- If you want to pre-curve your bougie be aware it can lose its shape if you do it too soon before intubation, these authors suggest keeping it in a “snail-tail” spiral up until induction.
From cited articleThe Procedure:
- Avoid getting “hung-up”: 1) Rotate the bougie 90° after insertion through the cords. 2) Subsequently, perform a 90° counterclockwise rotation when sliding the endotracheal tube over the bougie to prevent the bevel of the tube from getting caught on the right arytenoid (what I learned as BLT: Bougie Left Turn) can help the procedure go smoothly.
From cited article* Hold your glottic view until the tube is in and the bougie is out: Premature withdrawal of the laryngoscope before the ETT visualized passing through the cords and until appropriate depth will cause collapse of soft tissue structures and may inhibit your ability to pass the tube over the bougie. This is a recognized airway error – so hold your hard earned glottic view until the tube is in.
How will this change my practice?
The evidence is either equivocal or supports using the bougie as a primary introducer during intubation. I always go bougie first, but not all fall into this camp. The bougie isn’t a magic wand, however, and takes time to master. As an educator and trainee supervisor, I always advocate for gaining proficiency and microskills with the bougie by using it for every intubation, so when an airway is going bad it’s not your first time picking one up.
Source
Managing Emergency Endotracheal Intubation Utilizing a Bougie. Ann Emerg Med. 2024 2024 Jun 22:S0196-0644(24)00232-4. DOI: 10.1016/j.annemergmed.2024.04.021. PMID: 38912998.
The post Best Tips for Bougie Use in Airway Management first appeared on האיגוד הישראלי לרפואה דחופה.
אינטובציה של קנה הנשימה של מבוגרים החולים במחלה קשה היא הליך מסוכן הדורש הכנה, מומחיות וגמישות של הרופא.
אי אינטובציה בניסיון ראשון שכיח בקרב יותר מ-1.5 מיליון מבוגרים החולים במחלה קשה שעוברים אינטובציה מחוץ לחדר הניתוח מדי שנה. אי אינטובציה בניסיון הראשון קשור לסיכון מוגבר לסיבוכים מסכני חיים.
כדי לבצע אינטובציה חירום של קנה הנשימה בבטחה, על הרופאים לפתח היכרות אינטימית עם אנטומיית דרכי הנשימה, שיטות מניפולציה של אנטומיה זו, והביטחון להשתמש בטכניקות משניות ושלישוניות כאשר הניסיון הראשון של אינטובציה אינו מוצלח. שליטה בלרינגוסקופיה ישירה (DL) נחוצה כדי להשיג מומחיות בניהול דרכי הנשימה, להבטיח גיבוי הולם ל-Video laryngoscopy (VL), ולתת לרופאים את הכישורים הדרושים לאינטובציה בכל סביבה.
תוצאות הניסוי של Direct Versus Video Laryngoscope (DEVICE) שפורסם לאחרונה מספקות ראיות משכנעות לכך שהניסיון הראשון של אינטובציה חירום של קנה הנשימה צריך להיעשות עם VL.
עם זאת, ממצאים אלה אינם מונעים את הצורך של קלינאים המבצעים אינטובציה קנה הנשימה בדחיפות לרכוש ולשמור על מיומנות ב-DL, הן כדי לשפר את המיומנות עם VL והן כדי לספק מרווח בטיחות למקרים שבהם סרטי לרינגוסקופי וידאו נכשלים או אינם זמינים.
הטענה לנטוש את ההוראה של אינטובטורים מתחילים ביסודות של DL מניחה מראש שהמכניקה של DL אינה רלוונטית ל-VL. להיפך, הכוחות המכניים המופעלים על להב DL כדי לעקור את הלשון והרקמות הרכות של ההיפופרינקס ולהעלות את האפיגלוטיס הם אותם מיומנויות הנחוצות לשימוש ב-VL להשגת נוף וליצירת מקום הולם למעבר בוגי או צינור אנדוטרכיאלי . המיומנות הטכנית שהושגה באמצעות חזרות DL אינה ניתנת להחלפה ומודיעה על טכניקת VL מומחים. למרבה הצער, התפתחות ההיכרות האינטימית עם משחק הגומלין בין להב הלרינגוסקופ למבנים האנטומיים של דרכי הנשימה מתדרדרת מהקלות שבה ניתן לקבל מבט גרון באמצעות VL. היכרות זו חיונית בפתרון בעיות כאשר, אפילו עם VL, תצוגות גרון קשות, כולל בניהול של שיבושים באנטומיה, אנגיואדמה ודרכי נשימה מזוהמות, וביישום נכון של טכניקות משלימות כגון גרון דו-מנואלי והרמה עורפית. הכשרת קלינאים ללא DL מסתכנת בכישלון בפיתוח כישוריהם בלרינגוסקופיה עצמה.
למרות הנוכחות ההולכת וגוברת של VL, יותר מ-80% מהאינטובציות החירום ברחבי העולם מבוצעות עם לרינגוסקופ ישיר.
במקומות רבים של תרגול, אפילו במדינות בעלות הכנסה גבוהה, יש רק לרינגוסקופ וידאו בודד. בהגדרות כאלה, הסתמכות על הזמינות של VL עבור כל האינטובציות תהיה לא בטוחה. ייתכן שיהיה צורך לבצע אינטובציה של שני חולים בו-זמנית, כשל טכנולוגי עלול להתרחש ככל שהמכשירים מזדקנים, או שגורמים אנושיים עשויים להשפיע על הזמינות של VL – למשל, ניתן להשליך בטעות רכיבים הניתנים לשימוש חוזר כמו שרביטים סיבים אופטיים בתוך מעטפת הפלסטיק החד-פעמית המיועדת. לכסות אותם. במדינות בעלות הכנסה נמוכה ובינונית, במסגרות מרוחקות וחמורות, במהלך אירועי נפגעים המוניים, ובסביבה טרום-אשפוזית, VL פשוט עשוי להיות לא זמין. למרות שנסיבות אלו עשויות להיראות שוליות או בלתי סבירות, רוב המחנכים יסכימו כי הוראה ושמירה על מיומנות בקריקוטירואידוטומיה צריכה להיות חובה, למרות השימוש בהצלה כירורגית רק ב-0.28% מהאינטובציות.
המתאמנים יתרגלו במגוון מסגרות במהלך הקריירה שלהם, ואנו מחויבים ללמד מיומנויות מקיפות של ניהול דרכי אוויר שיאפשרו להם לשגשג בסביבות מגוונות, כולל כאלו עם גישה מוגבלת לטכנולוגיות מתקדמות.
מחנכים בדיסציפלינות הטיפול הקריטי חייבים לחשוף את המתאמנים לשיטה הבסיסית ביותר של ניהול דרכי הנשימה הסופי כדי להפוך אותם למומחי דרכי אוויר חירום. המתאמנים צריכים לחוות חשיפה מתקדמת ל-DL באמצעות חינוך דידקטי, סימולציה, מעבדות גופות, ולאחר מכן זמן בסביבה הבטוחה והמבוקרת יחסית של חדר הניתוח. ברגע שהמתאמנים מרגישים בנוח עם היסודות של אינטובציה, רופאים מפקחים ב-ED ו-ICU צריכים לעודד את השימוש בגיאומטריה סטנדרטית VL עבור ניסיונות ראשונים. בחולים נורמליים מבחינה פיזיולוגית, המפקחים יכולים להפוך את מסך הווידאו מחוץ לטווח הראייה של המתאמן, במקום זאת להשתמש בתצוגת הווידאו כדי לספק משוב בזמן אמת על מיקום הלהב והמכניקה. על המפקחים להתנגד לדחף להיכנע ולחשוף את מסך הווידאו, בהיעדר חוסר רוויה צפוי או כשל בטכניקת DL אופטימלית. אין תחליף להבנת החשיבות של מיקום נכון, אפיגלטוסקופיה מתקדמת ולרינגוסקופיה, ויישום בזמן של לרינגוסקופיה דו-מנואלית כפי שנלמד באמצעות ביצועים חוזרים ונשנים של DL. איננו יכולים לאפשר ל-DL ללכת בדרך של המלקחיים המיילדותיים – טכניקה שעלולה להציל חיים
The post נקודה: לרינגוסקופיה ישירה: אבן הבניין למומחיות בדרכי האוויר? כֵּן first appeared on האיגוד הישראלי לרפואה דחופה.
TAKE-HOME MESSAGE * This single-arm multicenter study assessed the safety and effectiveness of a novel patch-wearable cardioverter-defibrillator designed to improve compliance and enhance protection against sudden cardiac arrest (SCA) among 305 patients at a risk for SCA due to ventricular tachycardia/fibrillation who were unsuitable for or refused an ICD. The results showed low rates of clinically significant cutaneous adverse effects (2.30%) and inappropriate shocks (0.36/100 patient-months). The device demonstrated high patient compliance, with a median wear time of 23.5 hours per day, and achieved successful conversion of ventricular arrhythmias in most patients. * These findings suggest that the novel patch-wearable cardioverter-defibrillator may offer a safe and effective alternative for protection against SCA in high-risk patients. CardiologyWritten byPiotr Horbal DO Written byJohn Hummel MDA wearable cardioverter-defibrillator (WCD) offers a temporary bridge therapy for patients at an increased risk for sudden cardiac arrest (SCA) owing to ventricular arrhythmias but do not meet the criteria for ICDs. Studies such as the Vest Prevention of Early Sudden Death Trial and ASSURE WCD Clinical Evaluation—Detection and Safety Study have shown that the greatest limitation to the effectiveness of traditional garment-based WCDs was patient compliance.
The Jewel — a novel water-resistant patch-WCD (P-WCD) — comprises two main adhesive patches: the upper adhered to the right anterior chest wall and the lower to the left lateral torso. Unlike garment-based WCDs, the P-WCD can be worn continuously for up to a week, including during activities and showering. This study assessed whether this difference improved patient compliance while meeting the safety and effectiveness endpoints.
This was a prospective single-arm study conducted at 30 US cities, enrolling 305 patients at a risk for SCA. Notable findings include a median wear time of 23.5 hours per day and a clinically significant cutaneous adverse device effect rate of only 2.3%, meeting the primary safety endpoint. Of 11 shocks, 9 were deemed appropriate, with an inappropriate shock rate of 0.36 per 100 patient-months, which was well below the primary effectiveness endpoint goal of 2 per 100 patient-months.
The JEWEL IDE study provides evidence that the Jewel P-WCD is a safe and effective viable alternative to garment-based devices owing to its ease of use. One of the most striking findings is the improved wear time as 64% of the arrhythmic deaths in the Vest Prevention of Early Sudden Death Trial occurred in patients who were not wearing the garment WCD. The device delivers multiple escalating shock energies, provides warning prompts to bystanders, and allows patients the ability to defer shocks. Clinicians now appear to have a WCD that may allow improved compliance to protect patients susceptible to SCA.
abstractThis abstract is available on the publisher’s site.
Access this abstract now Full Text Available for ClinicalKey Subscribers
BACKGROUNDFor many patients, sudden cardiac arrest (SCA) risk is elevated temporarily. Wearable cardioverter-defibrillators (WCDs) can monitor and treat SCA during these temporary periods. Traditional WCDs can be uncomfortable, require frequent maintenance, and cannot be used when showering, resulting in poor compliance and avoidable SCA deaths. The Jewel is a novel, water-resistant patch-wearable cardioverter-defibrillator (P-WCD) with a machine learning detection algorithm designed to improve compliance and protection against SCA.
OBJECTIVESThis study aims to demonstrate the safety and clinical effectiveness of a novel P-WCD.
METHODSThe Jewel IDE Study, a prospective, single-arm study conducted at 30 U.S. sites, enrolled patients at SCA risk due to ventricular tachycardia/ventricular fibrillation who were not candidates for or refused an implantable defibrillator. The primary safety endpoint was <15% patients with clinically significant cutaneous adverse device effects and the primary effectiveness endpoint was <2 inappropriate shocks/100 patient-months. Secondary endpoints were ≥1 successful ventricular tachycardia/ventricular fibrillation conversion and wear time compliance of >14.1 h/d.
RESULTSA total of 305 patients (mean age: 57.9 years; 30.2% female, 27.9% non-White) were enrolled, of which 290 had available device data. The clinically significant cutaneous adverse device effect rate was 2.30% (upper 1-sided 98% CI: 4.80); none were severe. No device-related deaths or serious adverse events were reported. The inappropriate shock rate was 0.36/100 patient-months (upper 1-sided 98% CI: 1.53). Of 11 shocks in 9 patients, 9 shocks were adjudicated to be appropriate. Eight of 9 shocks were successful with a single shock. Median wear time compliance was 23.5 (20.7-23.9) h/d.
CONCLUSIONSThe novel P-WCD is a safe and effective WCD with high patient compliance. There were no deaths due to noncompliance and a high number of successful conversions (Jewel IDE study [A Clinical Evaluation of the Jewel P-WCD in Subjects at High Risk for Sudden Cardiac Arrest]; NCT05201495).
The post A Patch-Wearable Cardioverter-Defibrillator for Patients at a Risk for Sudden Cardiac Arrest first appeared on האיגוד הישראלי לרפואה דחופה.
אחד הנושאים ה”חמים” בעולם הרפואה בכלל וה EMS בפרט בשנים האחרונות הינו נושא תרומת האיברים (בעיקר כליות) ממטופלים שחוו OHCA, ואשר פעולות ההחייאה בהם נכשלו. המטרה = להגדיל משמעותית את פוטנציאל תרומת האיברים בכדי לקצר את זמני ההמתנה הארוכים. כידוע, תוחלת החיים הממוצעת של מטופל על המודיאליזה הינה קצרה משמעותית – שלא לדבר על איכות החיים. המאמר המצ”ב סוקר בצורה יפה את הנושא מ”זווית הראיה” של מערך ה EMS בפריז וסביבותיה. המחברים שלפו נתונים מתוך רשם ההחייאה הפריזאי הקיים מזה שנים רבות. במהלך 10 שנים בוצעו כ 20000 החייאות ע”י צוותי ה ALS (הכוללים בפריז רופא + אחות מומחית + נהג אמבולנס). פוטנציאל המטופלים המתאימים לתכנית DCD (Donation after Cardiac Death) עומד על מס’ מאות מידי שנה. אנו ביצענו עבודה דומה ליפני כשנה על “רשם ההחייאה של מד”א”. הפוטנציאל בארץ עומד גם הוא על מס’ מאות מקרים בשנה, כאשר בפועל מתבצעות רק השתלות בודדות במסלול זה מידי שנה (בסקירה שניתנה בכנס האחרון הוצגו נתונים על כ 50 השתלות במסלול זה שבוצעו במשך 8 שנים !!!). הסיבות לפער הזה הן רבות ומגוונות, וכוללות – מודעות והיערכות של צוותי ה EMS, מודעות והיערכות של בתי החולים, הקצאת משאבים, תיאום בין גופים שונים במערכת, ועוד. משהב”ר החליט לשים את הנושא בפוקוס בשנים הקרובות – ואנו כמובן נרתמים למשימה. הנושא מועבר במסגרת השתלמויות ה ALS שחודשו לאחרונה, וכן במפגשים מקצועיים ייעודיים במרחבים. תזכורת – הבסיס מפורט בפרוטוקול הייעודי הדן ב”פינוי מטופל תוך המשך ביצוע פעולות החייאה”.
The post Potential kidney donors among patients with outof- hospital cardiac arrest and a termination of resuscitation rule first appeared on האיגוד הישראלי לרפואה דחופה.
August 6, 2024
Written by Shannon Markus
Diagnosing patients with a posterior circulation TIA who are experiencing isolated episodic dizziness can be challenging, especially when considering the difficulty in assessing individual symptoms and the small absolute number of these patients. The authors lay out a pragmatic approach for assessment and diagnosis, but the data to support a reliable clinical decision-making tool is weak.
Differential for dizzy got me in a tizzy…
Dizziness is arguably EM’s most loathed complaint. Symptoms can be nebulous and challenging to describe with precision. Diagnosing ED patients with episodic dizziness requires a broad differential that includes posterior circulation TIAs (pcTIA). An estimated 70,000 ED patients/year ultimately have pcTIAs, with a higher risk of subsequent stroke, and starting prevention measures after identification will prevent some strokes. Admittedly, the number of missed pcTIA diagnoses is very low.
Diagnostic difficulties in patients with acute dizziness are common and result from underuse of the physical examination and overreliance on brain imaging. The authors based their recommendations on studies that evaluated rates of (1) pcTIA “misses”, (2) stroke after pcTIA, and (3) posterior stroke patients who retroactively recalled isolated episodic dizziness. The authors suggest familiarizing oneself with clinical variables that help to distinguish pcTIA from vestibular migraine (most common cause of episodic vestibular syndrome), BPPV, and orthostatic hypotension, and provide a table to simplify the differences. For example, vestibular migraine patients tend to be younger, female, fewer vascular risks, multiple previous attacks, and commonly have concurrent HA. pcTIA patients are generally older, male, more vascular risks, fewer previous attacks, and rarely have HA.
Their diagnostic algorithm suggests the following steps:
- Step 1: Determine whether the episodic vestibular syndrome is triggered through history-taking and bedside tests.
- Step 2: Think algorithmically. Consider using vascular risk calculators like ABCD2 to stratify patients at higher risk of CVA.
- Step 3: Become more familiar with vestibular migraine.
How will this change my practice?
A very small proportion of all-comer ED patients with isolated dizziness have true pcTIA, and as it is, there are not very many missed diagnoses. I’m not sure that their algorithmic approach will improve my ability to find the needle in the haystack, but may make me more confident in foregoing advanced imaging in patients whom I think have an alternative diagnosis, reducing exposure, time, and healthcare costs.
Source
Recognizing Posterior Circulation Transient Ischemic Attacks Presenting as Episodic Isolated Dizziness. Ann Emerg Med. 2024 May 23:S0196-0644(24)00214-2. doi: 10.1016/j.annemergmed.2024.04.006. Epub ahead of print. PMID: 38795083.
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Yunyun Xiong, M.D., Ph.D., Bruce C.V. Campbell, M.B., B.S., Ph.D., Lee H. Schwamm, M.D., Xia Meng, M.D., Ph.D., Aoming Jin, Ph.D., Mark W. Parsons, M.B., B.S., Ph.D., Marc Fisher, M.D., Yong Jiang, Ph.D., Fengyuan Che, M.D., Lihua Wang, M.D., Ph.D., Li Zhou, M.D., Hongguo Dai, M.D., Xintong Liu, M.D., Yuesong Pan, Ph.D., Chunmiao Duan, M.D., Yuming Xu, M.D., Ph.D., Anding Xu, M.D., Ph.D., Lixia Zong, M.D., Ph.D., Zefeng Tan, M.D., Ph.D., Wanxing Ye, Ph.D., Hao Wang, M.D., Ziran Wang, M.D., Manjun Hao, M.D., Zhixin Cao, M.D., Liyuan Wang, M.D., Shuangzhe Wu, M.D., Hao Li, Ph.D., Zixiao Li, M.D., Ph.D., Xingquan Zhao, M.D., Ph.D., and Yongjun Wang, M.D., for the TRACE-III Investigators*
Abstract Background: Tenecteplase is an effective thrombolytic agent for eligible patients with stroke who are treated within 4.5 hours after the onset of stroke. However, data regarding the effectiveness of tenecteplase beyond 4.5 hours are limited.
Methods: In a trial conducted in China, we randomly assigned patients with large-vessel occlusion of the middle cerebral artery or internal carotid artery who had salvageable brain tissue as identified on perfusion imaging and who did not have access to endovascular thrombectomy to receive tenecteplase (at a dose of 0.25 mg per kilogram of body weight; maximum dose, 25 mg) or standard medical treatment 4.5 to 24 hours after the time that the patient was last known to be well (including after stroke on awakening and unwitnessed stroke). The primary outcome was the absence of disability, which was defined as a score of 0 or 1 on the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability), at day 90. The key safety outcomes were symptomatic intracranial hemorrhage and death.
Results: A total of 516 patients were enrolled; 264 were randomly assigned to receive tenecteplase and 252 to receive standard medical treatment. Less than 2% of the patients (4 in the tenecteplase group and 5 in the standard-treatment group) underwent rescue endovascular thrombectomy. Treatment with tenecteplase resulted in a higher percentage of patients with a modified Rankin scale score of 0 or 1 at 90 days than standard medical treatment (33.0% vs. 24.2%; relative rate, 1.37; 95% confidence interval, 1.04 to 1.81; P = 0.03). Mortality at 90 days was 13.3% with tenecteplase and 13.1% with standard medical treatment, and the incidence of symptomatic intracranial hemorrhage within 36 hours after treatment was 3.0% and 0.8%, respectively.
Conclusions: In this trial involving Chinese patients with ischemic stroke due to large-vessel occlusion, most of whom did not undergo endovascular thrombectomy, treatment with tenecteplase administered 4.5 to 24 hours after stroke onset resulted in less disability and similar survival as compared with standard medical treatment, and the incidence of symptomatic intracranial hemorrhage appeared to be higher. (Funded by the National Natural Science Foundation of China and others; TRACE-III ClinicalTrials.gov number, NCT05141305.).
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Written by Shannon Markus
For acute ischemic stroke patients with recent DOAC ingestion who (1) had their DOAC level measured, (2) had DOAC reversal with idarucizumab, or (3) inadvertently received thrombolytics with DOAC subsequently discovered, there was not evidence of increased significant intracranial hemorrhage associated with off-label thrombolytic therapy.
Whoops, just thrombolysed your thin blood…One in six patients with acute stroke who would otherwise qualify for IV thrombolysis (IVT) are prescribed direct oral anticoagulants (DOAC). Current guidelines advise against IVT in these patients due to a presumed increased risk of intracranial hemorrhage. The authors aimed to determine the risk of symptomatic ICH (sICH) associated with use of IVT (specifically, alteplase) in an multicenter retrospective cohort study comparing 832 patients with DOAC use within 48h to over 30,000 controls without recent DOAC use. Of the DOAC group, 30.3% received DOAC reversal (all idarucizumab), 27% had DOAC-level measurements, and 42.7% received IVT without measuring levels or reversal (inadvertent IVT with DOAC use subsequently discovered).
Compared with controls, DOAC patients were older, had a higher prevalence of hypertension, had a higher degree of prestroke disability, had a longer time from symptom onset to treatment, experienced more severe stroke, and were more likely to have a large vessel occlusion. Yet surprisingly, after adjustment for stroke severity and other sICH predictors, recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (aOR 0.57, 95%CI, 0.36-0.92). The unadjusted rate of sICH was 2.5% in DOAC patients compared with 4.1% in controls. After adjustment, DOAC use was not associated with increased risk of sICH, regardless of which selection strategy group the patient was in.
The study likely has significant selection bias toward patients with a low probability for sICH, especially in the subgroup of patients who underwent IVT without confirmed low DOAC plasma levels or reversal. It is also likely underpowered, but the results are still pretty compelling.
How will this change my practice?
While I think unilaterally deciding to give thrombolytics to an acute stroke patient with a currently recognized contraindication would be reckless, these data help me rest a bit more easily if I’m able to confirm low DOAC plasma level, reverse a patient’s anticoagulation, or find out after they’ve been given a thrombolytic that they recently took their DOAC. Since several former contraindications to thrombolytics have been eliminated or relaxed, I wouldn’t be surprised if there was future consensus that DOACs aren’t a contraindication to IVT after all.
SourceIntravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants. JAMA Neurol. 2023 Mar 1;80(3):233-243. doi: 10.1001/jamaneurol.2022.4782. Erratum in: JAMA Neurol. 2023 Apr 1;80(4):422. doi: 10.1001/jamaneurol.2022.5395. PMID: 36807495; PMCID: PMC9857462.
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Sneha Krishna MBBS, Alex Prins FACEM, Adam Morton FRACPAbstract This manuscript seeks to describe diagnostic considerations in individuals with diabetes mellitus presenting to the ED with abdominal pain. It highlights the importance of early investigation with computerised tomography to differentiate aetiologies that compel early surgical intervention from those which may be treated conservatively.
Key findings* A major challenge in evaluating abdominal pain in individuals with diabetes mellitus is differentiating those with non-surgical pathology from those causes which mandate urgent surgical intervention. * Clinical signs, laboratory changes, and electrocardiography may be misleading in individuals with diabetes mellitus and abdominal pain. * Early computerised axial tomography imaging may be useful in differentiating aetiologies of abdominal pain in individuals with diabetes mellitus presenting to the Emergency Department. The post Review article: Abdominal pain and diabetes mellitus in the emergency department first appeared on האיגוד הישראלי לרפואה דחופה.
Robert J Petrella 1Affiliations Expand PMID: 38795081* Abstract In the coming years, artificial intelligence (AI) and machine learning will likely give rise to profound changes in the field of emergency medicine, and medicine more broadly. This article discusses these anticipated changes in terms of 3 overlapping yet distinct stages of AI development. It reviews some fundamental concepts in AI and explores their relation to clinical practice, with a focus on emergency medicine. In addition, it describes some of the applications of AI in disease diagnosis, prognosis, and treatment, as well as some of the practical issues that they raise, the barriers to their implementation, and some of the legal and regulatory challenges they create.
Copyright © 2024 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
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July 26, 2024
Written by Jason Lesnick
This RCT of U.S. patients being evaluated for acute MI using a 0/1 hour hs-cTnI protocol, compared to standard care with a 0/3 hour hs-cTnI protocol, didn’t find a difference in the percentage of patients discharged from the ED nor in the rates of 30 day death or MI.
Are high sensitivity troponins helping in U.S. EDs?
This study, the RACE-IT trial, was a stepped-wedge, randomized trial of 32,609 consecutive patients being evaluated for ACS in Michigan across 9 EDs from July 2020 to April 2021.
It measured the proportion of patients safely discharged from the ED without 30-day death or MI using either a 0/1 hour accelerated protocol or a 0/3 hour standard care protocol. The secondary outcomes included 30 day death, MI, or coronary revascularization in discharged patients.
The protocol utilized is below.
From cited articleThe authors found the accelerated protocol (57.8% discharged) was not superior to standard care (59.5%) with regard to the proportion of patients discharged. The accelerated protocol and standard care groups both had rates of death or MI at 30 days of 0.4%.
How will this change my practice?
It won’t immediately change my practice, as my institution is switching to a hs-cTn pathway based on High STEACS. I am optimistic about the future of implementing hs-cTn pathways from an efficiency standpoint, because this trial found 85% of the 10,445 patients had MI excluded after the first troponin.
Source
Rapid Acute Coronary Syndrome Evaluation Over One Hour With High-Sensitivity Cardiac Troponin I: A United States-Based Stepped-Wedge, Randomized Trial. Ann Emerg Med. 2024 Jun 15:S0196-0644(24)00235-X. doi: 10.1016/j.annemergmed.2024.04.024. Epub ahead of print. PMID: 38888531.
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Carmen Andrea Pfortmueller1* , Wojciech Dabrowski2 , Rob Wise3,4,5, Niels van Regenmortel6,7 and Manu L. N. G. Malbrain2,8,9
Abstract In this review, we aimed to comprehensively summarize current literature on pathophysiology, relevance, diagnosis and treatment of fuid accumulation in patients with sepsis/septic shock. Fluid accumulation syndrome (FAS) is defned as fuid accumulation (any degree, expressed as percentage from baseline body weight) with new onset organ-failure. Over the years, many studies have described the negative impact of FAS on clinically relevant outcomes. While the relationship between FAS and ICU outcomes is well described, uncertainty exists regarding its diagnosis, monitoring and treatment. A stepwise approach is suggested to prevent and treat FAS in patients with septic shock, including minimizing fuid intake (e.g., by limiting intravenous fuid administration and employing de-escalation whenever possible), limiting sodium and chloride administration, and maximizing fuid output (e.g., with diuretics, or renal replacement therapy). Current literature implies the need for a multi-tier, multi-modal approach to de-resuscitation, combining a restrictive fuid management regime with a standardized early active de-resuscitation, maintenance fuid reduction (avoiding fuid creep) and potentially using physical measures such as compression stockings. Trial registration: Not applicable. Keywords Fluids, Resuscitation, De-resuscitation, Fluid accumulation, Safety, Monitoring
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July 19, 2024
Written by Samuel Rouleau
An analysis of the NEAR database demonstrated a lower first-pass success rate of 89.2% for patients with anatomically difficult airways (ADA) compared to 93.7% in the control group. First-pass success for physiologic difficult airways (PDA) was 92.9% and fell to 87.4% for those with both ADA/PDA.
Rain is wet and first-pass success for anatomically difficult airways
This retrospective analysis of the NEAR database included 13,938 patients over the age of 14 who underwent rapid sequence intubation (RSI) in the emergency department (ED). 3664 were classified as ADA, 1304 as PDA, 7103 as both PDA and ADA, and 1867 as neither. Compared to the control group, those with ADA were almost half as likely to have first pass success (aOR 0.53, 95%CI 0.40–0.68), but the group with lowest first-pass success were those with both ADA/PDA (aOR 0.44, 95%CI 0.34–0.56). Importantly, in those with only PDA, there was no association with lower rate of first-pass success. The rate of peri-intubation cardiac arrest was the same in those with PDA and both ADA/PDA at 1.5%. Specifically, the authors include a great discussion of how obesity can be both anatomically difficult (poor view) and physiologic difficult (post-intubation hypoxemia) (check out supplemental tables 2 and 3).
I have a few concerns that limit my enthusiasm. The control group is 13% of the entire cohort, and over half are defined as having both ADA and PDA. Either the NEAR database is composed of extremely difficult intubations, or the criteria used to classify ADA and PDA are entirely too sensitive. This, compared with the large potential for bias in how the data were collected, limits the strength of the findings of this study. Lastly, I have a personal rule that when the statistic methodology seems overly complicated, this may indicate a weakness in study design.
How will this change my practice?
Simply put, no!
- Overall, I find that identifying and creating a plan for the anatomically difficult airway is well-emphasized, and we should take this same approach for physiologic difficult airways.
- I would be curious for a study on awake intubation versus RSI in physiologic difficult airways. (I think we should probably be doing more awake intubations than we are now).
Source
First-Attempt Success Between Anatomically and Physiologically Difficult Airways in the National Emergency Airway Registry. Anesth Analg. 2024;138(6):1249-1259. doi:10.1213/ANE.0000000000006828
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Juan Pernía 1, Teresa Cancho 1, Inés Segovia 1, Pilar de Ponga 2, Elena Granda 1, Roberto Velasco 3 4Affiliations expand PMID: 38729752 * DOI: 10.1136/emermed-2023-213466 Abstract Background and objectives:* The ability to rule appendicitis in or out using ultrasound is limited by studies where the appendix is not visualised. We determined whether the absence of indirect ultrasound signs can rule out appendicitis in children undergoing a radiology-performed ultrasound in which the appendix is not visualised METHODS: This was a single-centre retrospective observational study of patients aged 3-13 with a clinical suspicion of acute appendicitis evaluated in a Paediatric Emergency Department in Spain from 1 January 2013 to 31 December 2019. For those patients who had formal ultrasound, direct and indirect findings of ultrasound were abstracted from the ultrasound report. The surgical pathology report was established as the gold standard in patients who underwent an appendectomy. In those who did not, appendicitis was considered not to be present if there was no evidence in their charts that they had undergone an appendectomy or conservative therapy for appendicitis during the episode. The main outcome variable was the diagnosis of acute appendicitis. For patients undergoing ultrasound, the independent association of each indirect ultrasound sign with the diagnosis of appendicitis in patients without a visualised appendix was analysed using logistic regression.
Results: We included 1756 encounters from 1609 different episodes. Median age at the first visit of each episode was 10.1 years (IQR, 7.7-11.9) and 921 (57.2%) patients were men. There were 730 (41.6%) encounters with an Alvarado score ≤3, 695 (39.6%) with a score 4-6 and 331 (18.9%) with a score ≥7. Appendicitis was diagnosed in 293 (17.8%) episodes. Ultrasonography was performed in 1115 (61.6%) encounters, with a visualised appendix in 592 (53.1%).The ultrasound findings independently associated with appendicitis in patients without a visualised appendix were the presence of free intra-abdominal fluid in a small quantity (OR:5.0 (95% CI 1.7 to 14.6)) or in an abundant quantity (OR:30.9 (95% CI 3.8 to 252.7)) and inflammation of the peri-appendiceal fat (OR:7.2 (95% CI 1.4 to 38.0)). The absence of free fluid and inflammation of the peri-appendiceal fat ruled out acute appendicitis in patients with an Alvarado score <7 with a sensitivity of 84.6% (95% CI 57.8 to 95.7) and a negative predictive value of 99.4% (95% CI 97.8 to 99.8).
Conclusions: Patients with an Alvarado score <7 and without a visualised appendix on ultrasound but who lack free fluid and inflammation of the peri-appendiceal fat are at very low risk of acute appendicitis.
Keywords: Diagnostic Techniques and Procedures; Observational Study; pediatric emergency medicine; ultrasonography.
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Adesuwa Akhetuamhen 1, Kristin Bibbins-Domingo 2, Jahan Fahimi 3, Valy Fontil 4, Robert Rodriguez 3, Ralph C Wang 3Affiliations expand PMID: 38679548 * DOI: 10.1016/j.jemermed.2024.01.006 Abstract Background:* Fewer than one-half of U.S. adults with hypertension (HTN) have it controlled and one-third are unaware of their condition. The emergency department (ED) represents a setting to improve HTN control by increasing awareness of asymptomatic hypertension (aHTN) according to the 2013 American College of Emergency Physicians asymptomatic elevated blood pressure clinical policy.
Objective: The aim of the study was to estimate the prevalence and management of aHTN in U.S. EDs.
Methods: We examined the 2016-2019 National Hospital Ambulatory Medical Care Surveys to provide a more valid estimate of aHTN visits in U.S. EDs. aHTN is defined as adult patients with blood pressure ≥ 160/100 mm Hg at triage and discharge without trauma or signs of end organ damage. We then stratified aHTN into a 160-179/100-109 mm Hg subgroup and > 180/110 mm Hg subgroup and examined diagnosis and treatment outcomes.
Results: Approximately 5.9% of total visits between 2016 and 2019 met the definition for aHTN and 74% of patients were discharged home, representing an estimated 26.5 million visits. Among those discharged home, emergency physicians diagnosed 13% (95% CI 10.6-15.8%) and treated aHTN in 3.9% (95% CI 2.8-5.5%) of patients in the higher aHTN subgroup. In the lower aHTN subgroup, diagnosis and treatment decreased to 3.1% (95% CI 2.4-4.1%) and 1.2% (95% CI 0.7-2.0%), respectively.
Conclusions: Millions of ED patients found to have aHTN are discharged home without diagnosis or treatment. Although management practices follow clinical policy to delay treatment of aHTN, there are missed opportunities to diagnosis aHTN.
Keywords: antihypertension; asymptomatic hypertension; blood pressure; hypertension; population health.
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July 5, 2024
Written by Vivian Lei
Prehospital providers tend to underestimate the time to ED arrival for EMS ground transports.
An underestimated ETA
This was a prospective observational study on the accuracy of the pre-arrival ETA provided by EMS ground units bringing patients to the ED at WellSpan York Hospital in southern Pennsylvania, a large level 1 trauma center, regional chest pain center, and stroke center. The researchers analyzed 1176 EMS transports (86% medical, 14% trauma) and recorded the pre-arrival ETA and actual time of arrival (ATA). Median ETA was 5 minutes (interquartile range, IQR 5-10 min) and median ATA was 10 minutes (IQR 7-12 min), with a mean difference (ATA-ETA) of 3 minutes (IQR 1-5 min). The time needed to transport was underestimated in 81.7% of cases, overestimated in 10.3%, and accurate within 1 minute in 8.0%. These differences were similar across subgroups, including medical patients, trauma patients, medical command calls, trauma bay activations, potential acute coronary syndrome (ACS), and suspected strokes.
How will this change my practice?
This small single-site study suggests ground EMS units generally underestimate the time to ED arrival, but perhaps not by a clinically significant amount of time. In practice, that extra 3 minutes spent waiting for the patient to arrive certainly may be clinically important depending on the number of resources and individuals that are engaged, such as with major trauma activations or cardiac arrests. Subgroup analysis in this study was limited by small sample sizes for certain patient populations, and more data would help clarify what factors might lead to greater inaccuracies in pre-arrival ETA.
Source
Accuracy of Prehospital Services’ Estimated Time to Arrival for Ground Transport to the Emergency Department. J Emerg Med. 2024 May;66(5):e581-e588. doi: 10.1016/j.jemermed.2023.12.010. Epub 2023 Dec 14. PMID: 38553364.
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Ryuichiro Yagi, MD, MPH1,2; Yuichiro Mori, MD, MPH3; Shinichi Goto, MD, PhD1,4; et alTaku Iwami, MD, PhD5; Kosuke Inoue, MD, PhD6,7Author Affiliations Article InformationJAMA Intern Med. Published online July 1, 2024. doi:10.1001/jamainternmed.2024.2270Key Points Question What is the evidence on the clinical utility of routine resting electrocardiogram (ECG) screening on cardiovascular risk assessment in the working-age population?Findings In this nationwide cohort study of more than 3.5 million working-age Japanese adults enrolled in the nationwide annual health check program, baseline ECG findings were associated with the risk of cardiovascular events. Furthermore, the presence and the number of baseline minor ECG abnormalities were associated with developing new major ECG abnormalities.
Meaning The results of this study suggest that routine ECG screening may help identify individuals at high risk of developing cardiovascular events.
AbstractImportance The resting electrocardiogram (ECG) is commonly performed for cardiovascular disease (CVD) screening purposes in Japan. However, evidence is limited regarding the prognostic significance of ECG in clinical practice settings.
Objective To investigate the association between ECG abnormalities and CVD outcomes in a working-age population.
Design, Setting, and Participants This nationwide cohort study included individuals aged 35 to 65 years from the Japan Health Insurance Association database, which covers approximately 40% (30 million) of the working-age population in Japan. Data from April 1, 2015, to March 31, 2022, were included, and analysis was conducted from October 1, 2022, to April 11, 2024.
Exposures Baseline ECG status (normal, 1 minor abnormality, ≥2 minor abnormalities, or major abnormality).
Main Outcomes and Measures The primary outcome was a composite of overall death and CVD hospital admission due to myocardial infarction, stroke, or heart failure. The secondary outcome was developing a new major ECG abnormality over the years of screening.
Results Of 3 698 429 individuals enrolled in the nationwide annual health check program (mean [SD] age, 47.1 [8.5] years; 66.6% male), 623 073 (16.8%) had 1 minor ECG abnormality, 144 535 (3.9%) had 2 or more minor ECG abnormalities, and 56 921 (1.5%) had a major ECG abnormality. During a median follow-up of 5.5 (IQR, 3.4-5.7) years, baseline ECG abnormality was independently associated with an increased incidence of the composite end points of overall death and CVD admission compared with normal ECG (incidence rates per 10 000 person-years: 92.7 [95% CI, 92.2-93.2] for normal ECG, 128.5 [95% CI, 127.2-129.9] for 1 minor ECG abnormality, 159.7 [95% CI, 156.6-162.9] for ≥2 minor ECG abnormalities, and 266.3 [95% CI, 259.9-272.3] for a major ECG abnormality; adjusted hazard ratios: 1.19 [95% CI, 1.18-1.20] for 1 minor ECG abnormality, 1.37 [95% CI, 1.34-1.39] for ≥2 minor ECG abnormalities, and 1.96 [95% CI, 1.92-2.02] for a major ECG abnormality). Furthermore, the presence and number of minor ECG abnormalities were associated with an increased incidence of developing new major ECG abnormalities (incidence rates per 10 000 person-years: 85.1 [95% CI, 84.5-85.5] for normal ECG, 217.2 [95% CI, 215.5-219.0] for 1 minor ECG abnormality, and 306.4 [95% CI, 302.1-310.7] for ≥2 minor ECG abnormalities; and adjusted hazard ratios: 2.52 [95% CI, 2.49-2.55] for 1 minor ECG abnormality and 3.61 [95% CI, 3.55-3.67] for ≥2 minor ECG abnormalities). Associations were noted regardless of baseline CVD risk.
Conclusions and Relevance The findings of this study suggest that the potential role of routine ECG screening for early prevention of CVD events, along with the optimal follow-up strategy, should be examined in future studies.
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June 26, 2024
Written by Jason Lesnick
This systematic review and meta-analysis (SRMA) found that current rates of central venous catheter (CVC)-associated complications occurred in about 3% of line placements.
Authors analyzed all associations about central lines
This SRMA included 130 English-language observational studies and RCTs done from 7/2015-9/2023 in adult patients that reported complication rates of short-term CVCs. 214,325 central catheter placements were examined, and 53.1% of included studies were ICU focused while 40.8% of studies focused on operating room CVC placement. Bayesian random-effects meta-analysis was applied to summarize event rates. Rates of placement complications (events/1000 catheters with 95% credible interval [CrI]) and use complications (events/1000 catheter-days with 95% CrI) were estimated.
Placement failure occurred at a rate of 20.4/1000 catheters placed (95%CrI 10.9-34.4), while other complications occurred as follows: arterial cannulation (2.8, 0.1-10), arterial puncture (16.2, 11.5-22), PTX (4.4, 2.7-6.5), malfunction (5.5, 0.6-38), infection (4.8, 3.4-6.6), and DVT (2.7, 1.0-6.2). The authors estimated that 30.2 (21.8-43.0) of 1000 patients with a CVC for 3 days would develop one or more serious complications. They also found ultrasound use to be associated with lower rates of arterial puncture (risk ratio 0.20, 0.09-0.44; 13.5 events vs 68.8 events/1000 catheters) and PTX (RR 0.25, 0.08-0.80; 2.4 events vs 9.9 events/1000 catheters).
Site-specific complications were as follows; PTX: subclavian 7.8/1000 (4.3-13.0) vs IJ 1.9/1000 (0.93-3.5); CLABSI: subclavian 2.5/1000, femoral 2.7/1000, IJ 3.8/1000, but the 95% CrIs overlapped across all 3 insertion sites.
How will this change my practice?
The authors conclude 3% of CVC placements were associated with major complications and that ultrasound might decrease risk of PTX and arterial puncture; it should be noted only 8 of the 130 included studies were done exclusively in the ED, and almost every variable examined had high rates of heterogeneity. That said, I will continue to use ultrasound whenever I am placing a CVC (unless it is a crash line). Personally, I prefer IJ and femoral lines to reduce the possibility of PTX. In fact, if US was used for IJ CVCs, the PTX rate was only 0.4/1000. It’s also interesting to compare CVC to peripheral complication rate when using vasoactive medications (including this study and this study we have previously covered here on JournalFeed). I wonder how these data and other similar data will shape future protocols regarding CVC use.
Source
Complication Rates of Central Venous Catheters: A Systematic Review and Meta-Analysis. JAMA Intern Med. 2024 May 1;184(5):474-482. doi: 10.1001/jamainternmed.2023.8232. Erratum in: JAMA Intern Med. 2024 May 20;: PMID: 38436976.
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Tan N Doan PhD, Stephen Rashford MBBS, FACEM, Emma Bosley PhDFirst published: 28 May 2024https://doi-org.bengurionu.idm.oclc.org/10.1111/1742-6723.14447SECTIONSPDFAbstractObjectiveExtracorporeal CPR (E-CPR) has been primarily limited to the in-hospital setting. A few systems around the world have implemented pre-hospital mobile E-CPR in the form of a dedicated cardiac vehicle fitted with specialised equipment and clinicians required for the performance of E-CPR on-scene. However, evidence of the outcomes and cost-effectiveness of mobile E-CPR remain to be established. We evaluated the cost-effectiveness of a hypothetical mobile E-CPR vehicle operated by Queensland Ambulance Service in the state of Queensland, Australia.
MethodsWe adapted our published mathematical model to estimate the cost-effectiveness of pre-hospital mobile E-CPR relative to current practice. In the model, a specialised cardiac vehicle with mobile E-CPR capability is deployed to selected OHCA patients, with eligible candidates receiving pre-hospital E-CPR in-field and rapid transport to the closest appropriate centre for in-hospital E-CPR. For comparison, non-candidates receive standard ACLS from a conventional ambulance response. Cost-effectiveness was expressed as Australian dollars ($, 2021 value) per quality-adjusted life year (QALY) gained.
ResultsPre-hospital mobile E-CPR improves outcomes compared to current practice at a cost of $27 323 per QALY gained. The cost-effectiveness of pre-hospital mobile E-CPR is sensitive to the assumption around the number of patients who are the targets of the vehicle, with higher patient volume resulting in improved cost-effectiveness.
ConclusionsPre-hospital E-CPR may be cost-effective. Successful implementation of a pre-hospital E-CPR programme requires substantial planning, training, logistics and operational adjustments.
The post Cost-effectiveness analysis of an ambulance service-operated specialised cardiac vehicle with mobile extracorporeal cardiopulmonary resuscitation capacity for out-of-hospital cardiac arrests in Queensland, Australia first appeared on האיגוד הישראלי לרפואה דחופה.
Alan J Pearce PhD, Peter Wirth MBBS, FACEM, Michelle Fitts PhDFirst published: 04 June 2024https://doi-org.bengurionu.idm.oclc.org/10.1111/1742-6723.14452SECTIONSPDFTOOLSSHAREAbstractAttention and awareness regarding concussion injury in Australia have significantly increased in the last decade. Although most of this increase is because of discussion regarding concussions from sporting endeavours, the majority of concussions are from non-sport environments including motor vehicle crashes, workplace incidents, falls, accidents, assault and intimate partner violence. In all cases, hospital EDs are the first point of contact, yet as argued in our Opinion here, there are concerns regarding the consistency of care protocols, because of a number of reasons, as well as management and follow-up clinical practices. Our Opinion is to provide a constructive discussion as well as calling for ACEM to support research to provide evidence-based data. Finally, we provide some recommendations that could be implemented immediately to improve clinical practice for presentations of concussion injuries in EDs.
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Pharmacists in Trauma: a randomised controlled trial of emergency medicine pharmacists in trauma response teams1. http://orcid.org/0000-0002-6889-2338Cristina Roman1,2,3,4, 2. Michael Dooley1,3, 3. http://orcid.org/0000-0003-0183-7761Mark Fitzgerald5,6,7, 4. De Villiers Smit2,4, 5. Peter Cameron2,4, 6. http://orcid.org/0000-0002-0508-2450Biswadev Mitra2,4 1. Correspondence to Dr Cristina Roman, Pharmacy Department, Alfred Health, Melbourne, VIC 3001, Australia; c.roman@alfred.org.au Abstract Background Analgesia is an important component for patient well-being, but commonly delayed during trauma resuscitation. The Pharmacists in Trauma trial assessed the effects of integrating pharmacists into trauma response teams to improve analgesia delivery and medication management.
Methods This unblinded randomised trial compared emergency medicine (EM) pharmacist involvement in trauma callouts versus standard care at an Australian level 1 trauma centre. Randomisation was performed via an online single sequence randomisation service. Eligible patients included those managed with a trauma callout during working hours of an EM pharmacist. Pharmacists were able to prescribe medications using a Partnered Pharmacist Medication Charting model. The primary outcome was the proportion of patients who had first dose analgesia within 30 min compared using the χ2 test.
Results From 15 July 2021 until 31 January 2022, there were 119 patients randomised with 37 patients excluded as no analgesia was required. There were 82 patients included for analysis, 39 in the control arm and 43 in the intervention arm. The primary outcome was achieved in 25 (64.1%) patients in the control arm and 36 (83.7%) patients in the pharmacist arm (relative risk 1.31; 95% CI 1.0 to 1.71; p=0.042). Time to analgesia in the control arm was 28 (22–35) mins and 20 (15–26 mins) with pharmacist involvement; p=0.025. In the pharmacist arm, the initial dose of analgesia was prescribed by the pharmacist for 38 (88.4%) patients. There were 27 other medications prescribed by the pharmacist for the management of these patients. There were no differences in emergency and trauma centre or hospital length of stay.
Conclusion Addition of the EM pharmacist in trauma response teams improved time to analgesia. Involvement of an EM pharmacist in trauma reception and resuscitation may assist by optimising medication management, with members of the team more available to focus on other life-saving interventions.
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Pieter Francsois Fouche 1, Christopher Stein 2, Martin Nichols 3, Benjamin Meadley 4, Jason C Bendall 3, Karen Smith 5, David Anderson 6, Suhail A Doi 7Affiliations expand PMID: 37999653* * DOI: 10.1016/j.annemergmed.2023.10.004
AbstractStudy objective: Traumatic injury causes a significant number of deaths due to bleeding. Tranexamic acid (TXA), an antifibrinolytic agent, can reduce bleeding in traumatic injuries and potentially enhance outcomes. Previous reviews suggested potential TXA benefits but did not consider the latest trials.
Methods: A systematic review and bias-adjusted meta-analysis were performed to assess TXA’s effectiveness in emergency traumatic injury settings by pooling estimates from randomized controlled trials. Researchers searched Medline, Embase, and Cochrane Central for randomized controlled trials comparing TXA’s effects to a placebo in emergency trauma cases. The primary endpoint was 1-month mortality. The methodological quality of the trials underwent assessment using the MASTER scale, and the meta-analysis applied the quality-effects method to adjust for methodological quality.
Results: Seven randomized controlled trials met the set criteria. This meta-analysis indicated an 11% decrease in the death risk at 1 month after TXA use (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.84 to 0.95) with a number needed to treat of 61 to avoid 1 additional death. The meta-analysis also revealed reduced 24-hour mortality (OR 0.76, 95% CI 0.65 to 0.88) for TXA. No compelling evidence of increased vascular occlusive events emerged (OR 0.96, 95% CI 0.73 to 1.27). Subgroup analyses highlighted TXA’s effectiveness in general trauma versus traumatic brain injury and survival advantages when administered out-of-hospital versus inhospital.
Conclusions: This synthesis demonstrates that TXA use for trauma in emergencies leads to a reduction in 1-month mortality, with no significant evidence of problematic vascular occlusive events. Administering TXA in the out-of-hospital setting is associated with reduced mortality compared to inhospital administration, and less mortality with TXA in systemic trauma is noted compared with traumatic brain injury specifically.
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June 21, 2024
Written by Megan Hilbert
Reliance on landmark guidance for chest tube placement may pose significant safety issues in pediatric patients.
Scan that chest before you do the rest!
Previous literature has demonstrated that landmark guided placement of chest tubes in the fifth intercostal space (ICS) may not always be safe in adults. This observational study examined the safety of landmark guidance in 150 pediatric patients (50 in each age group: 1-5, 6-12, and 13-17 years). The primary aim was to use an ultrasound to determine the percentage of patients where this approach would be deemed “unsafe,” defined as visualization of the diaphragm crossing the superior margin of the sixth rib during either tidal respiration or maximal respiration while completing a point-of-care ultrasound. See figure. Left is safe; right is unsafe.
From cited articleThe authors found that the diaphragm crossed this space 10.3% (95%CI 6.45-16.1) of the time during tidal respirations and 27.2% (95%CI 19.0-37.3) of the time during maximal respiration. Secondary analysis (univariate and multivariate) determined that this was more likely to occur on the right side of the body (45.0%, 95%CI 36.1-54.3) as well as in individuals with a higher BMI (increase of 10% or more with each additional 1-kg/m2; P=0.003).
While there are specific concerns with pediatric patients (such as anatomical differences, i.e. abdominal organ size), these findings are mostly consistent with adult data. This was a convenience sample and did not evaluate safety in children < 1 year of age. Having said that, it’s a well done observational study that highlights an important concern that necessitates further investigation in the future.
How will this change my practice?
Doing a procedure on a pediatric patient can be nerve-wracking. Any additional safety measure that I can undertake to improve my success and limit potential complications is definitely something I am willing to do. So, next time I consider a chest tube on a pediatric patient you can bet that I am going to throw a probe on their chest and make sure my approach is as safe as it can be.
Source
Ultrasound Investigation of the Fifth Intercostal Space Landmark for Chest Tube Thoracostomy Site Selection in Pediatric Patients. Pediatr Emerg Care. 2024 Apr 23. doi: 10.1097/PEC.0000000000003207. Epub ahead of print. PMID: 38713844.
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Jagoda, Andy, MD ; Gupta, Kanika, MD
Up to 5% of the population will experience at least 1 nonfebrile seizure at some point during their lifetime. The management of a patient who has had a first-time seizure is driven by the history and physical examination. In almost one-half of these patients, the cause of their seizure is not identified. In general, patients with comorbidities, a focal neurologic examination, or who have not returned to a normal baseline mental status require an extensive diagnostic evaluation including a noncontrast head computed tomography (CT) scan in the emergency department (ED). Adults with a first-time seizure, with no comorbidities, and who have returned to a normal baseline require only serum glucose and electrolyte determination. Women of reproductive age also require a pregnancy test. Patients with a normal neurologic examination, normal laboratory results, and no signs of structural brain disease do not require hospitalization or antiepileptic medications. Initiation of antiepileptic therapy depends on the assessed risk for recurrence, in conjunction with a neurologist consultation.
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June 12, 2024
Written by Carmen Wolfe
In the setting of pediatric trauma, patients with a seatbelt sign are at greater risk of blunt cardiovascular injury if they have an injury severity score greater than 15, c-spine fracture, basilar skull fracture, or “other motorized” (i.e. ATV but not MVC) mechanism of injury.
BCVI is a pain in the neck!
Blunt cerebrovascular injury (BCVI), indicating injury to the carotid or vertebral arteries during blunt trauma, is tricky. Though initial presentations may be asymptomatic, serious complications such as stroke and even death can ensue, making screening for this injury an important consideration in the Emergency Department. Despite evidence suggesting that an isolated seatbelt sign does not predict BCVI, it is still used in some guidelines as an indicator to screen for BCVI. Who among this population is at risk and truly needs a scan?
Investigators conducted a retrospective analysis of all pediatric trauma patients who had a cervical CTA over a twelve year period (n=375). 23% of these patients had a seatbelt sign documented. A univariate analysis evaluated factors in this specific population associated with BCVI, and found significant association with Injury Severity Score > 15, presence of cervical spine fracture or basilar skull fractures, and a motorized mechanism of injury (i.e. a side-by-side ATV as opposed to a traditional MVC).
How will this change my practice?
Previous data suggests that presence of a seatbelt sign shouldn’t equate to automatic scanning in the pediatric patient. This study helps me better risk stratify patients with a seatbelt sign and ensure that I order a cervical CTA when a patient presents with these high risk features.
Source
Risk Factors for Blunt Cerebrovascular Injury in a Cohort of Pediatric Patients With Cervical Seat Belt Sign. Pediatr Emerg Care. 2024;40(5):359-363.
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June 17, 2024
Written by Amanda Mathews
This secondary analysis of the DOSE VF trial found that DSED (dual sequence external defibrillation) was the superior strategy for obtaining ROSC and functional neurologic outcome regardless of whether the patient was in recurrent VF or shock-refractory VF after three standard defibrillation shocks.
Time for a re-DOSE
The original publication of the DOSE VF trial showed that alternative defibrillation strategies of DSED and vector change (anterior-posterior pad placement) defibrillation demonstrated a survival benefit for patients compared to standard defibrillation for recurrent VF. There was no attempt to distinguish outcomes between recurrent VF (absence of VF for at least 5 seconds followed by spontaneous recurrence) and shock-refractory VF (continuous VF after first 3 shocks). There are studies showing that patients with shock-refractory VF have high mortality (97%) when treated with standard defibrillation only.
Researchers performed a secondary analysis of the original DOSE VF trial. 405 patients were in the original trial and after exclusions 345 were included in the secondary analysis. 60 patients (17%) were deemed to be in shock-refractory VF and 285 (83%) were deemed to be in recurrent VF. Patients characterized as being in recurrent VF had higher rates of survival to hospital discharge compared to shock-refractory VF.
DSED was found to be superior to standard defibrillation for survival overall and specifically for the shock-refractory group; no patient in shock refractory VF survived to hospital discharge using standard defibrillation. DSED was also superior to standard defibrillation for ROSC and neurologic survival for both sub-groups. Vector change defibrillation was not found to be superior to standard defibrillation overall or in either of the subgroups for survival.
How will this change my practice?
The DOSE VF trial was practice changing and gave me a new tool in my toolbox when treating a patient in what appears to be refractory VF. This secondary analysis further confirms that DSED is the superior strategy to terminate VF and obtain good neurologic outcomes for patients after three standard defibrillation shocks regardless of whether they are in recurrent or shock refractory VF.
Source
The impact of alternate defibrillation strategies on shock-refractory and recurrent ventricular fibrillation: A secondary analysis of the DOSE VF cluster randomized controlled trial. Resuscitation. 2024 May;198:110186. doi: 10.1016/j.resuscitation.2024.110186. Epub 2024 Mar 24. PMID: 38522736.
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Abstract Penetrating trauma of the aortic arch is relatively uncommon, even at busy trauma centers. Such an injury is challenging, especially in a “crashing” patient in whom emergency surgery is undertaken. When this scenario is coupled with an aortic arch abnormality, it may be infinitely more difficult to deal with, and the injury may prove non-salvageable. Bovine aortic arch abnormality occurs in approximately 25% of patients in our setting, according to existing literature. Hence, penetrating injury of a bovine aortic arch would be extremely rare. We present a patient who sustained a stab wound to a bovine arch, which proved non-salvageable because proximal and distal vascular control could not be provided without rendering the brain anoxic. We provide an overview of the bovine arch abnormality and a brief review of the management of aortic arch injuries.
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IntroductionPenetrating trauma of the thoracic aorta is infrequent, almost always life-threatening, and carries a mortality rate as high as 92.3% [1]. Although endovascular techniques are increasingly used, operative intervention is often undertaken. The surgical principle of proximal and distal vascular control poses a challenge during emergency surgery on the aortic arch, but there are maneuvers that may be used to address this issue. However, when an injury to a bovine aortic arch (BAA) anomaly (Figure 1) occurs, it may be impossible to safely achieve proximal and distal vascular control without occluding both common carotid arteries and compromising cerebral perfusion. We present a patient who sustained an un-survivable penetrating injury of the aortic arch due to the presence of a BAA.
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Case presentationA 20-year-old male sustained an isolated zone 1 penetrating neck injury just to the right of the midline. The patient was initially taken to a local clinic by friends, where the wound was sutured and two liters of intravenous crystalloid were infused. He was referred by the clinic to our tertiary facility, arriving five hours later. During transit, he was hemodynamically stable, with blood pressure (BP) 123/58, heart rate (HR) 100, oxygen saturation (SpO2) 99% on room air, and temperature 37°C.
In our Emergency Department, examination and initial management followed standard Advanced Trauma Life Support® principles. The patient’s airway was patent and self-maintained, and lung fields were clear on auscultation. Heart rate ranged between 90 and 105 beats per minute, with BP 117/50 on the left arm and 100/58 on the right, giving a brachial–brachial index of 0.86. Both radial pulses were palpable and equal with 99% SpO2 on both hands. There was a three-centimeter supraclavicular stab wound at the right sternoclavicular junction. A non-pulsatile, non-expanding hematoma was beneath the wound, with no audible bruit. Extended focused assessment with sonography for trauma showed no evidence of hemothorax, pneumothorax, or pericardial fluid. A venous blood gas test result included pH 7.33, Base Excess 1.5 mEq/L, lactate 3.5 mmol/L, and hemoglobin 8.3 g/dL.
The patient went for an emergency computerized tomography with angiography (CTA) (Figures 2 and 3). As the CTA was nearing completion, the patient’s wound started bleeding profusely. Attempts at Foley’s catheter balloon tamponade failed to control the bleeding. External digital compression of the wound was maintained and the patient was taken immediately to the operating theater. There was no opportunity to review the CTA. Rapid sequence induction, emergency intubation, and resuscitation with permissive hypotension were administered while preparing for an emergency median sternotomy. Emergency thoracic surgery in our institution is undertaken by General and Trauma Surgeons in the main theater suites as we neither have hybrid theater capacity nor a cardiothoracic surgery service, and hence no access to cardiopulmonary bypass (CPB).
After splitting the sternum and opening the mediastinum, hemorrhage was controlled with direct pressure using a gauze swab while dissection was carried down to the point of bleeding, which then was digitally controlled. It was found that the patient had a congenital variation of the great vessels, a BAA. There was a near-total transection of the origin of the “bovine trunk” at the level of the aorta (Figure 4). Proximal and distal vascular control is imperative when repairing such an injury. A Satinsky clamp was applied to the aorta without occluding the arch. While it was technically possible to apply vascular clamps distally on the arch vessels to control back bleeding, this was not a feasible option in this patient. Due to this anatomical anomaly, obtaining distal vascular control would have meant occluding both common carotid arteries and the right subclavian artery. This would leave the brain with perfusion only from the left vertebral artery arising from the left subclavian artery. In this situation, the combination of the BAA and the location and severity of the injury rendered it a non-survivable scenario. The decision was therefore made to abandon the procedure, and the patient died on the operating table.
Figure 1(A) Normal aortic arch compared with (B) bovine arch abnormality. BCT—brachiocephalic trunk; RCCA—right common carotid artery; LCCA—left common carotid artery.Figure 2CT angiogram—coronal view. Pseudoaneurysm arising from the common “bovine trunk.”Figure 3CT angiogram—3D reconstruction. Pseudoaneurysm arising from the common “bovine trunk.”Figure 4Bovine arch injury—operative view. Satinsky clamp on aortic arch, proximal and distal vascular control not physiologically feasible.3. DiscussionThe aortic arch and its branches are responsible for blood supply to the head, neck, and upper limbs. The typical pattern consists of three main branches—from right to left, these are the brachiocephalic trunk which gives rise to the right subclavian artery and right common carotid artery, the left common carotid artery, and the left subclavian artery. There are a number of congenital variations in aortic arch branching patterns—one being the BAA. In this variation, the aortic arch has only two branches: a common trunk giving rise to both the brachiocephalic trunk and left common carotid artery, with the left subclavian artery arising as the second branch (Figure 1). The BAA is the most common aortic arch variant within African and South American populations, with a prevalence of 26.8% and 24.2%, respectively, and is more prevalent than previously assumed [2]. Although generally asymptomatic, the BAA is known to pose a high risk for vascular complications such as cerebrovascular events and other problems after endovascular procedures [3]. There is limited literature available that relates specifically to the risks of BAA injuries in trauma; however, existing literature on aortic arch injuries describes varied mechanisms of injury, management strategies, and outcomes.
An autopsy study conducted in Greece showed the overall prevalence of thoracic aortic injuries was relatively low and a blunt mechanism was the predominant cause of injury [4]. These authors found that traumatic aortic injury was responsible for 12.7% of all injury-related fatalities and penetrating trauma was responsible for only 13.6% of those deaths. They also reported that the aortic arch and the ascending aorta were the most common sites of thoracic aortic injury following penetrating wounds, while the isthmus was most commonly involved in blunt injuries [4].
Other studies describe the successful management of thoracic aortic arch injuries. One such example describes a patient who sustained a through and through injury to the thoracic aorta by an airgun which was successfully repaired with the aid of deep hypothermic circulatory arrest (DHCA) as well as retrograde cerebral perfusion achieved with CPB. The advantages of DHCA and CPB include rapid aortic exposure, allowing for protection of cerebral perfusion [5]. The patient in our case report was potentially salvageable if CPB and DHCA had been available, but there would be a high risk of cerebrovascular brain damage. Unfortunately, our patient could not be transferred to a unit with these facilities because of his acute decompensation and need for emergency surgery.
In a case report by Ariaka et al., a patient presented with a ballpoint pen impaled in the neck with an aortic arch injury. The pen had a tamponading effect and allowed for isolation of the injury using a side-biting Satinsky clamp with subsequent primary repair [6]. In the current case report, it was not a problem applying a Satinsky clamp to the aortic arch for proximal control, but this was not physiologically feasible.
The mainstay of treatment for aortic arch injuries following penetrating trauma has traditionally been operative, but on rare occasions, these injuries have been managed conservatively. Conservative management is dependent on the site and severity of the injury and the hemodynamic status of the patient and demands a setting in which patients can be appropriately monitored and surveyed both during admission and at subsequent follow-ups after discharge [7].
This current case report highlights the potential challenges represented by anatomical variations of the aortic arch in a decompensating (“crashing”) trauma patient in whom preoperative CTA could not be reviewed and the anomaly only discovered at the time of surgical intervention. A practical takeaway from this case is that basic maneuvers such as Foley catheter balloon tamponade [8], digital compression, and permissive hypotension [9] can be used as a bridge to definitive intervention when faced with active bleeding.
Cordova et al. [10] describes graft repair of a traumatic innominate artery pseudoaneurysm in the setting of a bovine arch, but this injury was situated above the bifurcation of the bovine trunk and therefore cross-clamping was feasible. The emphasis in the current case report is that no form of cross-clamping was feasible without inducing immediate global brain ischemia. The injury of the bovine trunk was at its take-off from the aortic arch, and the transection was near-total. Hence, with no landing zone for a stent proximally, endovascular management would not have been feasible in this case either. Volpe et al. describe successful stenting of the innominate artery in the setting of a bovine arch but again the innominate artery distal to the bifurcation of the bovine trunk was involved, not the bovine trunk itself [11].
Gott et al. described a heparin-bonded shunt for off-pump use in excluding part of the aortic arch [12], and since then there have been a number of reports on the successful use of this technique and modifications thereof in treatment of aortic arch injuries [13]. A modification of this shunt described by Gelsomino et al., which has the ability to provide cerebral perfusion, may have offered a chance of survival to our patient, had it been available [14].
Although some aortic arch injuries may be survivable, overall mortality rate remains high. BAA anomalies are found in only a portion of the population—with injuries to such arches being extremely rare. Due to the associated implications of such a unique injury, BAA injuries, particularly those involving the bovine trunk, can be expected to be uniformly fatal in acutely decompensating patients who cannot undergo preoperative imaging and who are treated at units without the availability of a modified Gott shunt and without the capacity to perform DHCA and CPB.
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ABSTRACT:
BACKGROUND Among critically ill adults undergoing tracheal intubation, hypoxemia increases the risk of cardiac arrest and death. The effect of preoxygenation with noninvasive ventilation, as compared with preoxygenation with an oxygen mask, on the incidence of hypoxemia during tracheal intubation is uncertain. METHODS In a multicenter, randomized trial conducted at 24 emergency departments and intensive care units in the United States, we randomly assigned critically ill adults (age, ≥18 years) undergoing tracheal intubation to receive preoxygenation with either noninvasive ventilation or an oxygen mask. The primary outcome was hypoxemia during intubation, defined by an oxygen saturation of less than 85% during the interval between induction of anesthesia and 2 minutes after tracheal intubation. RESULTS Among the 1301 patients enrolled, hypoxemia occurred in 57 of 624 patients (9.1%) in the noninvasive-ventilation group and in 118 of 637 patients (18.5%) in the oxygen-mask group (difference, −9.4 percentage points; 95% confidence interval [CI], −13.2 to −5.6; P<0.001). Cardiac arrest occurred in 1 patient (0.2%) in the noninvasive-ventilation group and in 7 patients (1.1%) in the oxygen-mask group (difference, −0.9 percentage points; 95% CI, −1.8 to −0.1). Aspiration occurred in 6 patients (0.9%) in the noninvasive-ventilation group and in 9 patients (1.4%) in the oxygen-mask group (difference, −0.4 percentage points; 95% CI, −1.6 to 0.7). CONCLUSIONS Among critically ill adults undergoing tracheal intubation, preoxygenation with noninvasive ventilation resulted in a lower incidence of hypoxemia during intubation than preoxygenation with an oxygen mask. (Funded by the U.S. Department of Defense; PREOXI ClinicalTrials.gov number, NCT05267652.)
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ABSTRACT:
This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed
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James F Holmes, Kenneth Yen, Irma T Ugalde, Paul Ishimine, Pradip P Chaudhari, Nisa Atigapramoj, Mohamed Badawy, Kevan A McCarten-Gibbs, Donovan Nielsen, Allyson C Sage, Grant Tatro, Jeffrey S Upperman, P David Adelson, Daniel J Tancredi, Nathan Kuppermann
Summary BackgroundCervical spine injuries in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionising radiation. The aim of this study was to derive and validate a paediatric clinical prediction rule that can be incorporated into an algorithm to guide radiographic screening for cervical spine injury among children in the emergency department.MethodsIn this prospective observational cohort study, we screened children aged 0–17 years presenting with known or suspected blunt trauma at 18 specialised children’s emergency departments in hospitals in the USA affiliated with the Pediatric Emergency Care Applied Research Network (PECARN). Injured children were eligible for enrolment into derivation or validation cohorts by fulfilling one of the following criteria: transported from the scene of injury to the emergency department by emergency medical services; evaluated by a trauma team; and undergone neck imaging for concern for cervical spine injury either at or before arriving at the PECARN-affiliated emergency department. Children presenting with solely penetrating trauma were excluded. Before viewing an enrolled child’s neck imaging results, the attending emergency department clinician completed a clinical examination and prospectively documented cervical spine injury risk factors in an electronic questionnaire. Cervical spine injuries were determined by imaging reports and telephone follow-up with guardians within 21–28 days of the emergency room encounter, and cervical spine injury was confirmed by a paediatric neurosurgeon. Factors associated with a high risk of cervical spine injury (>10%) were identified by bivariable Poisson regression with robust error estimates, and factors associated with non-negligible risk were identified by classification and regression tree (CART) analysis. Variables were combined in the cervical spine injury prediction rule. The primary outcome of interest was cervical spine injury within 28 days of initial trauma warranting inpatient observation or surgical intervention. Rule performance measures were calculated for both derivation and validation cohorts. A clinical care algorithm for determining which risk factors warrant radiographic screening for cervical spine injury after blunt trauma was applied to the study population to estimate the potential effect on reducing CT and x-ray use in the paediatric emergency department. This study is registered with ClinicalTrials.gov, NCT05049330.FindingsNine emergency departments participated in the derivation cohort, and nine participated in the validation cohort. In total, 22 430 children presenting with known or suspected blunt trauma were enrolled (11 857 children in the derivation cohort; 10 573 in the validation cohort). 433 (1·9%) of the total population had confirmed cervical spine injuries. The following factors were associated with a high risk of cervical spine injury: altered mental status (Glasgow Coma Scale [GCS] score of 3–8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness); abnormal airway, breathing, or circulation findings; and focal neurological deficits including paresthesia, numbness, or weakness. Of 928 in the derivation cohort presenting with at least one of these risk factors, 118 (12·7%) had cervical spine injury (risk ratio 8·9 [95% CI 7·1–11·2]). The following factors were associated with non-negligible risk of cervical spine injury by CART analysis: neck pain; altered mental status (GCS score of 9–14; verbal or pain on the AVPU; or other signs of altered mental status); substantial head injury; substantial torso injury; and midline neck tenderness. The high-risk and CART-derived factors combined and applied to the validation cohort performed with 94·3% (95% CI 90·7–97·9) sensitivity, 60·4% (59·4–61·3) specificity, and 99·9% (99·8–100·0) negative predictive value. Had the algorithm been applied to all participants to guide the use of imaging, we estimated the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%) of 22 430 children without increasing the number of children getting plain x-rays.InterpretationIncorporated into a clinical algorithm, the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the emergency department and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community emergency departments.FundingThe Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Health Resources and Services Administration of the US Department of Health and Human Services in the Maternal and Child Health Bureau under the Emergency Medical Services for Children programme.The post PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study first appeared on האיגוד הישראלי לרפואה דחופה.
Cervical Spine Injuries are fortunately rare in children. this episode is all about learning when to suspect them, how to immobilize the C-spine properly, and which imaging test to choose. It was inspired by a hot-off-the-presses publication from the Pediatric Emergency Care Applied Research Network (PECARN) focused on clinical decision rules for cervical spine imaging in children.
Maybe there’s a funky music video that will teach you how to clear the C-spine?The post VIDEO: Clear Cervical Spine Injuries first appeared on האיגוד הישראלי לרפואה דחופה.
June 4, 2024
Written by Michael Stocker
Data supporting pediatric cardiac arrest guidelines are limited. This study found increases in the longest pause in chest compressions (CC) during pediatric in-hospital cardiac arrest (pIHCA) were inversely associated with survival and ROSC.
When kids arrest, stay on the chest
This 27-hospital observational study sought to characterize the relationship between prolonged pauses in CC and outcomes of pIHCA. 562 pIHCA cases with at least 1 minute of defibrillator recorded external CCs on patients ages 37 weeks to 17 years were included. The majority of events (80.8%) took place in an intensive or cardiac intensive care setting. The primary exposure was the longest CC pause, and the primary outcome was neurologically favorable survival. Causal diagrams identified confounders, and adjustments were made for factors such as age, location within the hospital, and average CC depth. CC pauses were analyzed by increasing 5-second increments. As the duration of the longest CC pause increased, every 5-second increment represented a 3% decrease in the relative risk of neurologically favorable survival (aRR 0.97; 95%CI 0.95-0.99, p=0.02), as well as decreased relative risk of survival to hospital discharge (aRR 0.98; 95%CI 0.96-0.99, p=0.01) and ROSC (aRR 0.93; 95%CI 0.91-0.94). Secondary exposures, such as any CC pause >10 or 20 seconds or number of prolonged pauses per 2 minutes were inversely associated with chance of ROSC but not survival outcomes. Relying on defibrillator data presents limitations, as this cannot account for cases in which pads were never placed nor data on CC prior to pad placement.
How will this change my practice?
While I do not practice inpatient primarily, this study reaffirms my focus on high-quality CPR and the role of limiting interruptions in improving outcomes regardless of the patient’s age. Though few things are more distressing than coding kids, we cannot let that detract from executing the basics.
Source
Association Between Chest Compression Pause Duration and Survival After Pediatric In-Hospital Cardiac Arrest. Circulation. 2024 May 7;149(19):1493-1500. doi: 10.1161/CIRCULATIONAHA.123.066882. Epub 2024 Apr 2. PMID: 38563137; PMCID: PMC11073898.
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June 6, 2024
Written by Shannon Markus
Physician gestalt significantly outperformed existing sepsis screening tools (SIRS, qSOFA, SOFA, and MEWS) in identifying sepsis early in critically ill, undifferentiated patients’ ED courses.
Not gonna be replaced by AI anytime soon…
The authors evaluated how physician gestalt compared to existing screening tools for the suspicion of sepsis. They included undifferentiated, non-trauma patients seen only in their designated resuscitation areas deemed to be clinically unstable (determined by EMS or nurse triage) and who were rapidly assessed. Emergency physicians were asked, “What is the likelihood that this patient has sepsis?” and completed a visual analog scale (VAS), rating their suspicion at 15 minutes; 0 = no infection, 100 = infection. VAS cutoff of >50% was compared to sepsis screening tool scores at their respective thresholds.
For the 275 patients with a sepsis diagnosis at hospital discharge, initial VAS significantly outperformed all tools. Authors included a very interesting table summarizing cases considered “misses” (initial VAS 0) who ultimately had a sepsis diagnosis, and suggested there may be a role for screening tools to be applied after initial assessment to curtail the number of “misses”.
They excluded patients seen in regular ED treatment areas, who presumably had longer times to initial physician evaluation and workup, which limits the generalizability of this study. As ideal as their process for rapid assessment of these sick patients seems, immediate physician assessment in a dedicated resuscitation bay could be limited by bed and resource availability, by reliance on accurate nursing or EMS triage, or by physician availability.
How will this change my practice?
This article further highlights the weaknesses of sepsis screening tools and reinforces the value of physicians laying eyes on sick, undifferentiated patients as quickly as possible to assess need for emergent interventions and promote early diagnosis of critical conditions. This affirms my practice of heading to the bedside quickly when there is any concern for sepsis or other critical condition and decreases my reliance on scoring systems and lab values not available early in a patient’s course.
Source
Early Physician Gestalt Versus Usual Screening Tools for the Prediction of Sepsis in Critically Ill Emergency Patients. Ann Emerg Med. 2024 Mar 25:S0196-0644(24)00099-4. doi: 10.1016/j.annemergmed.2024.02.009. Epub ahead of print. PMID: 38530675.
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May 30, 2024
Written byAaron Lacy
In a large retrospective review of patients with out-of-hospital-cardiac-arrest (OHCA) there was a very small, and probably clinically insignificant, association with favorable neurological outcome and survival in those who underwent early as opposed to late advanced airway management.
ABC, BAC, CBA? When to do the airway?
This study found a statistically significant difference in favorable neurologic outcome (Risk ratio 0.997, 95%CI 0.995-0.999) and 1-month survival (RR 0.990, 95%CI 0.986-0.994) when comparing early (<10 minutes) to late (>10 minutes) advanced airway management (ETI, SGA) in OHCA patients. 21,446 patients were included in the early advanced airway management group, with 19,655 in the late category.
While other studies have looked at timing andtype of advanced airways in OHCA patients, this study is unique as they did an exceptional job focusing on reducing resuscitation time bias (the idea that those who are down longer get more intervention, introducing bias). While they found statistically significant differences in their planned primary and secondary analysis, they correctly point out that the differences are so small it is unlikely to be clinically significant. This is consistent with other studies which have looked attiming of intubation in cardiac arrest.
How will this change my practice?
Every situation is unique, so it is difficult to make blanket recommendations. However, I favor advising placement of a supraglottic airway when most feasible in the prehospital setting when managing OHCA, so the focus can be on other more proven interventions (high quality CPR, early defibrillation, etc.). This is consistent with recent prehospital airway management guidelines. This article supports my current practice, so is unlikely to change my opinions unless new evidence comes to light.
Source
Early versus late advanced airway management for adult patients with out-of-hospital cardiac arrest: A time-dependent propensity score matched analysis. Acad Emerg Med. 2024 Apr 8. Epub ahead of print. DOI: 10.111/acem.14907
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James F Holmes 1, Kenneth Yen 2, Irma T Ugalde 3, Paul Ishimine 4, Pradip P Chaudhari 5, Nisa Atigapramoj 6, Mohamed Badawy 2, Kevan A McCarten-Gibbs 6, Donovan Nielsen 7, Allyson C Sage 7, Grant Tatro 8, Jeffrey S Upperman 9, P David Adelson 10, Daniel J Tancredi 11, Nathan Kuppermann 12Affiliations expand PMID: 38609287 * DOI: 10.1016/S2352-4642(24)00029-4 Abstract Background:* The intra-abdominal injury and traumatic brain injury prediction rules derived by the Pediatric Emergency Care Applied Research Network (PECARN) were designed to reduce inappropriate use of CT in children with abdominal and head trauma, respectively. We aimed to validate these prediction rules for children presenting to emergency departments with blunt abdominal or minor head trauma.
Methods: For this prospective validation study, we enrolled children and adolescents younger than 18 years presenting to six emergency departments in Sacramento (CA), Dallas (TX), Houston (TX), San Diego (CA), Los Angeles (CA), and Oakland (CA), USA between Dec 27, 2016, and Sept 1, 2021. We excluded patients who were pregnant or had pre-existing neurological disorders preventing examination, penetrating trauma, injuries more than 24 h before arrival, CT or MRI before transfer, or high suspicion of non-accidental trauma. Children presenting with blunt abdominal trauma were enrolled into an abdominal trauma cohort, and children with minor head trauma were enrolled into one of two age-segregated minor head trauma cohorts (younger than 2 years vs aged 2 years and older). Enrolled children were clinically examined in the emergency department, and CT scans were obtained at the attending clinician’s discretion. All enrolled children were evaluated against the variables of the pertinent PECARN prediction rule before CT results were seen. The primary outcome of interest in the abdominal trauma cohort was intra-abdominal injury undergoing acute intervention (therapeutic laparotomy, angiographic embolisation, blood transfusion, intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries, or death from intra-abdominal injury). In the age-segregated minor head trauma cohorts, the primary outcome of interest was clinically important traumatic brain injury (neurosurgery, intubation for >24 h for traumatic brain injury, or hospital admission ≥2 nights for ongoing symptoms and CT-confirmed traumatic brain injury; or death from traumatic brain injury).
Findings: 7542 children with blunt abdominal trauma and 19 999 children with minor head trauma were enrolled. The intra-abdominal injury rule had a sensitivity of 100·0% (95% CI 98·0-100·0; correct test for 145 of 145 patients with intra-abdominal injury undergoing acute intervention) and a negative predictive value (NPV) of 100·0% (95% CI 99·9-100·0; correct test for 3488 of 3488 patients without intra-abdominal injuries undergoing acute intervention). The traumatic brain injury rule for children younger than 2 years had a sensitivity of 100·0% (93·1-100·0; 42 of 42) for clinically important traumatic brain injuries and an NPV of 100·0%; 99·9-100·0; 2940 of 2940), whereas the traumatic brain injury rule for children aged 2 years and older had a sensitivity of 98·8% (95·8-99·9; 168 of 170) and an NPV of 100·0% (99·9-100·0; 6015 of 6017). The two children who were misclassified by the traumatic brain injury rule were admitted to hospital for observation but did not need neurosurgery.
Interpretation: The PECARN intra-abdominal injury and traumatic brain injury rules were validated with a high degree of accuracy. Their implementation in paediatric emergency departments can therefore be considered a safe strategy to minimise inappropriate CT use in children needing high-quality care for abdominal or head trauma.
Funding: The Eunice Kennedy Shriver National Institute of Child Health and Human Development.
Copyright © 2024 Elsevier Ltd. All rights reserved.
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May 20, 2024
Written by Ketan Patel
This review article illustrates the evidence-based “no-zone” approach in managing penetrating neck injuries, with a reliance on clinical symptoms as well as multidetector computed tomographic angiography (MDCTA) to mitigate unnecessary invasive tests and negative explorations.
Beyond the zone
While selective operative management (versus mandatory exploration) of neck injuries significantly reduced the negative exploration rates in neck injuries, there remained an appreciable negative operative rate and an inconsistent correlation between surface anatomy and internal injuries. A push toward reliance on physical exam, followed by the advent and wide adoption of MDCTA, however, has modernized the approach.
In neck injuries, the initial evaluation should focus on hemorrhage control and avoiding airway compromise. Subsequent triage focuses on stratifying patients into a high (hard signs), intermediate (soft signs), and low-risk (no signs) groups. Patients with hard signs should undergo operative management, given the likelihood of significant injuries. Those with no signs approach zero in terms of likelihood of clinically significant injuries, and observation is the mainstay.
For patients with soft signs, MDCTA is the gold standard test. This approach results in a sensitivity of 90-100% for vascular injuries, with a specificity of 98-100%. In terms of aerodigestive injuries, the sensitivity and specificity range from 92-100% and 90-100%, respectively. For indeterminate MDCTA, consider catheter-based angiography for vascular concerns, as it may be both diagnostic and therapeutic. For aerodigestive concerns, esophagoscopy, contrast-based swallow studies, bronchoscopy and direct laryngoscopy may be needed.
The above modern approach minimizes invasive procedures and alleviates unnecessary care burdens associated with prior approaches to penetrating neck injuries.
How will this change my practice?
While working at a level 1 trauma center, the paradigm shift in management of penetrating neck injuries is noticeable. This article forges the utility of MDCTA as the pivotal tool in diagnosing penetrating neck trauma, when paired with the physical exam, and subsequently guiding care and interventions.
Source
Diagnostic Approach to Penetrating Neck Trauma: What You Need to Know. J Trauma Acute Care Surg. 2024 Mar 25. doi: 10.1097/TA.0000000000004292. Epub ahead of print. PMID: 38523116
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May 22, 2024
Written by Chris Thom
This was a network meta-analysis of 13 randomized controlled trials comparing 5 different central venous catheterization (CVC) approaches. The supraclavicular subclavian (SupraSCV) demonstrated superior first-attempt success, while artery puncture was similar for all five locations.
Aim for the supraclavicular pocket
This network meta-analysis included 13 RCTs encompassing 4,418 participants. The trials were varied in their comparators, with five trials comparing SupraSCV to InfraSCV, three trials comparing proximal axillary vein (ProxiAV) to distal axillary vein (DistalAV), three trial comparing ProxiAV to internal jugular (IJ), one trial comparing InfraSCV to IJ, and one comparing SupraSCV to IJ. The meta-analysis methodology then sought to compare the common endpoints of first-attempt success, artery puncture, line failure, pneumothorax, hemothorax, and hematoma between the five anatomical sites.
Compared to the IJ site, SupraSCV increased first-attempt success (risk ratio, RR of 1.22; 95%CI 1.06-1.40). Conversely, DistalAV location reduced the first-attempt success (RR of 0.72, 95%CI 0.59-0.87). In indirect comparisons, the SupraSCV had a higher first-attempt success than all other approaches. The additional endpoints evaluated did not show any statistical differences other than a reduction in hematoma formation when using the SupraSCV approach, though the authors note this metric featured low confidence evidence.
How will this change my practice?
Ultrasound guided central lines are here to stay and the evidence continues to mount that they are superior to landmark for subclavian lines. Site selection within the subclavian region can include the SupraSCV, InfraSCV, DistalAV, and ProxiAV. This study adds to the evidence that the SupraSCV might be the best initial location to scout with your ultrasound probe and perhaps should be a focus of our educational efforts for ultrasound guided central lines.
Source
Ultrasound-guided central venous catheterization around the neck: Systematic review and network meta-analysis. Am J Emerg Med. 2024;78:206-214.
The post What’s the Best Target in the Neck for US Guided Central Access first appeared on האיגוד הישראלי לרפואה דחופה.
May 2, 2024
Written by Doug Wallace
This medical news article interview highlights the risk of biased data leading to inherently biased medical AI models. The ethics of machine learning in general and approaches to minimize bias are also touched on.
Biased Input = Biased Output
In an interview discussing the ethics of AI use in medicine, Dr. Marzyeh Ghassemi of MIT’s Department of Electrical Engineering and Computer Science breaks down how input of biased data can lead to bias in AI model output. She expressly highlights minority groups and biologic females as being at higher risk for machine learning bias, given bias in existing data sets. The importance of an ethical approach to designing AI models is emphasized. Of further note, the interesting concept of “automation bias” is defined along with the risk of algorithmic over-reliance being present even if clinicians are aware of the potential for erroneous output in early studies.
How will this change my practice?
This article is unlikely to change my (current) practice, but poses well thought out concerns about the risk of bias in AI systems and clinicians as we enter the inevitable age of AI models in medicine. We owe it to our patients to support efforts to maintain high quality and unbiased medical AI content generation going forward.
Source
AI Developers Should Understand the Risks of Deploying Their Clinical Tools, MIT Expert Says. JAMA. 2024 Feb 27;331(8):629-631. doi: 10.1001/jama.2023.22981. PMID: 38324320.
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May 3, 2024
Written by Clark Strunk
A significant minority of code STEMI patients have an initial normal computer ECG interpretation. Consequently, emergency physicians must remain vigilant to identify signs of OMI regardless of the initial computer ECG interpretation.
When the computer says the ECG is not bad, the patient could still need the cath lab…
This was a multicenter, retrospective cohort study from 2016 to 2022 evaluating the initial computer ECG interpretation of all 536 patients who went emergently to the cath lab from the emergency department as a Code STEMI. Out of the 536 patients, 394 patients were found to have culprit lesions, 16 (4.1%) of which had an initial ECG labeled as normal by the computer, 6 of which were identified in real time by the emergency physician. This leads the authors to conclude the importance of emergency provider triage ECG interpretation despite a normal interpretation by the computer. This study provides an alternate perspective regarding the necessity of reviewing ECGs that the computer has identified as normal, as multiple recent studies have advocated that this may not be necessary. However, many of these studies reviewed only normal ECGs in small patient populations who were relatively low risk, over a more abbreviated period of time, with suboptimal outcome measures1-3.
How will this change my practice?
The number of patients with an occlusion MI who would benefit from emergent coronary angiography who have an initial ECG interpreted by the computer as normal is relatively small but significant. Thus, I will continue to prioritize timely ECG interpretation, independent of the computer interpretation, despite the many distractions in the emergency department. Patients benefit from clinicians trained in advanced ECG interpretation to identify OMI, which can easily be missed by the conventional computer algorithm.
Source
Emergency department Code STEMI patients with initial electrocardiogram labeled “normal” by computer interpretation: A 7-year retrospective review. Acad Emerg Med. 2024 Mar;31(3):296-300. doi: 10.1111/acem.14795. Epub 2023 Sep 17. PMID: 37620163.
The post Emergent Cath Lab Activations with “Normal” Computer ECG Interpretations first appeared on האיגוד הישראלי לרפואה דחופה.
Kevin Chu,1 Anne- Maree Kelly ,2,3 Win Sen Kuan,4 Frances B Kinnear,5,6 Gerben Keijzers,7 Daniel Horner ,8 Said Laribi,9 Alejandro Cardozo,10 Mehmet Akif Karamercan,11 Sharon Klim,2 Tissa Wijeratne,12 Sinan Kamona,13,14 Colin A Graham,15 Richard Body ,16,17 Tom Roberts ,18,19 HEAD and HEAD- Colombia study groups
Abstract Objectives Only a small proportion of patients presenting to an ED with headache have a serious cause. The SNNOOP10 criteria, which incorporates red and orange flags for serious causes, has been proposed but not well studied. This project aims to compare the proportion of patients with 10 commonly accepted red flag criteria (singly and in combination) between patients with and without a diagnosis of serious secondary headache in a large, multinational cohort of ED patients presenting with headache.
Methods Secondary analysis of data obtained in the HEAD and HEAD-Colombia studies. The outcome of interest was serious secondary headache. The predictive performance of 10 red flag criteria from the SNNOOP10 criteria list was estimated individually and in combination.
Results 5293 patients were included, of whom 6.1% (95% CI 5.5% to 6.8%) had a defined serious cause identified. New neurological deficit, history of neoplasm, older age (>50 years) and recent head trauma (2–7 days prior) were independent predictors of a serious secondary headache diagnosis. After adjusting for other predictors, sudden onset, onset during exertion, pregnancy and immune suppression were not associated with a serious headache diagnosis. The combined sensitivity of the red flag criteria overall was 96.5% (95% CI 93.2% to 98.3%) but specificity was low, 5.1% (95% CI 4.3% to 6.0%). Positive predictive value was 9.3% (95% CI 8.2% to 10.5%) with negative predictive value of 93.5% (95% CI 87.6% to 96.8%).
Conclusion The sensitivity and specificity of the red flag criteria in this study were lower than previously reported. Regarding clinical practice, this suggests that red flag criteria may be useful to identify patients at higher risk of a serious secondary headache cause, but their low specificity could result in increased rates of CT scanning.
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April 23, 2024
Written by Laura Murphy
In patients with anterior circulation large-vessel occlusion (LVO) stroke presenting to thrombectomy capable stroke centers, the benefit of intravascular thrombolysis in the setting of endovascular thrombectomy appears to be time-dependent.
The earlier, the better…This study included a total of 2,313 patients with anterior circulation large vessel occlusion from the IRIS meta-analysis, which included 6 randomized trials comparing IVT plus thrombectomy vs thrombectomy alone (January 2017 and July 2021, 190 sites, 15 countries). Primary outcome analysis tested the association between allocated treatment (IVT + thrombectomy vs thrombectomy alone) and disability at 90 days using modified Rankin Scale (mRS) score range.
Prior to this study, no randomized trial has demonstrated a benefit of IVT in patients directly admitted to thrombectomy-capable stroke centers undergoing thrombectomy, and the results of the IRIS meta-analysis did not establish non-inferiority of endovascular treatment alone compared with IVT + thrombectomy (i.e. don’t thrombolyze if thrombectomy is immediately available). This study hypothesized that there is a benefit of IVT + thrombectomy if IVT is administered early.
The benefit of IVT plus thrombectomy decreased with longer times from symptom onset to expected administration of IVT: adjusted common OR for 1-step mRS shift toward improvement was 1.49 (95%CI 1.13 to 1.96) at 1 hour, 1.25 (95%CI 1.04 to 1.49) at 2 hours and 1.04 (95%CI 0.88 to 1.23) at 3 hours. After 2 hours and 20 minutes, the benefit associated with IVT plus thrombectomy was not statistically significant. For every hour of delay, there was a significant reduction in association of IVT + thrombectomy with better outcomes.
One study limitation is that patients were only included if presenting to thrombectomy-capable stroke centers, and the use of admission imaging to exclude patients with likely irreversible infarcts may have influenced the magnitude of observed associations with treatment time, which may not be generalizable to all patients. In addition, almost all patients were treated with alteplase (rather than tenecteplase, which is now more widely being adopted). However, the results are likely clinically meaningful and may help to stratify which patients undergoing thrombectomy are most likely to benefit from IVT.
Finally, early recanalization (absence of treatable occlusion on first angiography or successful reperfusion), occurred more often in patients allocated to IVT + thrombectomy (4.0% vs 1.7% for thrombectomy alone), but the association was stronger in patients treated later from symptom onset, though absolute differences were noted to be small. This unexpected finding runs contrary to the classic concept of infarct progression that has been used to explain time dependency in IVT vs placebo trials.
How will this change my practice?
This study demonstrates that the effect of IVT in patients undergoing thrombectomy is most beneficial when administered early; this can be used as part of the decision-making discussion with both patients and consultants about administration of IV thrombolysis in anterior LVO patients who are eligible for thrombectomy. I will be on the lookout for additional studies that look at this clinical question and any guideline changes.
SourceTime to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke: A Meta-Analysis. JAMA. 2024 Mar 5;331(9):764-777. doi: 10.1001/jama.2024.0589. PMID: 38324409; PMCID: PMC10851137.
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April 26, 2024
Written by Caitlin Nicholson
In patients with ACS and concern for STEMI/NSTEMI requiring urgent intervention, randomization to the contrast volume reduction (CVR) group reduced the rate of acute kidney injury (AKI) and sustained kidney damage.
Continued controversy between contrast and kidneys…The REMEDIAL IV trial (REnal Insufficiency Following Contrast MEDIA Administration Trial IV) was a well designed, randomized, single-blind trial aiming to identify whether a reduction in contrast media (CM) volume reduced AKI rate. The trial randomized 550 patients with STEMI or high-risk NSTEMI undergoing urgent invasive therapy to either a CM reduction group (276) or a control group (274). Patients in the CM reduction group were administered a significantly lower volume of CM via the DyeVert CM diversion system (95 +/- 30mL vs 160 +/- 23mL; p<0.001). Patients randomized to the CVR group were shown to have a significant reduction in AKI (16% vs 24.3%; RR: 0.66; p = 0.018) as well as sustained kidney damage (6.1% vs 13.8%; p = 0.003).
There are a few important things to note about this trial. First, the use of the DyeVert CM diversion system did not result in any prolongation of time to revascularization. Also, the reduction in AKI did not correlate with a reduction in mortality.
How will this change my practice?
Contrast-associated AKI continues to be a controversial topic, with quite a few studies previously covered here on Journal Feed. While this interesting trial does support CM minimization in patients undergoing emergency invasive procedures, it will not be changing my practice at this time. In the emergency department setting, the use of contrast in critically ill patients is a matter of risk vs benefit on a case by case basis. In most patients, I think it is reasonable to continue to follow the guidelines outlined by the American College of Radiology and the National Kidney Foundation in the 2020 Consensus Statement.
Editor’s note: I covered this study, not because I care about this device, but because there is precious little RCT data related to contrast-associated nephropathy. This adds some and supports ACR recommendations to use the lowest amount possible in high risk patients. ~Clay Smith
Source
Kidney Injury After Minimal Radiographic Contrast Administration in Patients With Acute Coronary Syndromes. J Am Coll Cardiol. 2024;83(11):1059-1069. doi:10.1016/j.jacc.2024.01.016
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שלום רב, במסגרת מחקר בביה”ס לבריאות הציבור, בפקולטה לרפואה באוניברסיטה העברית, אנחנו בוחנים את תהליכי קבלת ההחלטות הרפואיות במלר”ד. כחלק מן המחקר אנו מעבירים שאלון “דלפי” בקרב רופאים העובדים במלר”ד, זאת כדי להגיע להסכמות רחבות ככל הניתן על הגורמים הלא-קליניים המשפיעים על קבלת ההחלטות במלר”ד. אנחנו פונים אליכם כמי שמבינים לעומק את העבודה והדינמיקה הייחודית של המלר”ד.
במחקר זה, בהתאם לשיטת דלפי, נקיים שני סבבי שאלונים. הסבב הראשון, הנוכחי, נועד לבחון עמדות לגבי מספר היגדים ולאפשר לכם להוסיף תשובות פתוחות נוספות ולהעיר. בשבועות הקרובים, לאחר איסוף נתונים וניתוח של הסבב הראשון, ישלח אליכם במידת הצורך שאלון הסבב השני. בגלל ההבנה כי זמנכם יקר – השאלון הוא קצר, ואמור לקחת לא יותר מ-5-7 דקות לכל סבב.
חשוב להדגיש כי ההשתתפות במחקר היא לבחירתכם בלבד וכי נתונה לכם הזכות לא להשתתף בו ולהפסיק את מילוי השאלון בכל נקודה בה תבחרו. המידע עליכם יגיע רק לצוות המחקר וישמר בסודיות.
הנתונים אנונימיים – ללא שם או פרטים מזהים, ומשמשים למחקר בלבד, אין תשובות נכונות או לא נכונות, תודה על שיתוף הפעולה.
ד”ר עופר קובו ofermkobo@gmail.com
איתי יצחקי itay.itzhaki@mail.huji.ac.il
ד”ר שולי ברמלי גרינברג shuli.brammli@mail.huji.ac.il
כניסה לשאלוןThe post מחקר: תהליכי קבלת ההחלטות הרפואיות במלר”ד first appeared on האיגוד הישראלי לרפואה דחופה.
Dustin G. Mark, MD1,2,3; Brandon H. Horton, MPH3; Mary E. Reed, DrPH3; et alfor the Kaiser Permanente CREST Network InvestigatorsAuthor Affiliations Article InformationJAMA Netw Open. 2024;7(4):e247373. doi:10.1001/jamanetworkopen.2024.7373Key PointsQuestion Has the diagnostic evaluation of headache in the emergency department recently changed?
Findings In a cohort study of 21 emergency departments and 198 109 emergency encounters between 2015 and 2021, computed tomography cerebral angiography use increased 6-fold relative to lumbar puncture, with a 33% increase in the detection of unruptured intracranial aneurysms and no significant change in missed diagnoses of subarachnoid hemorrhage or bacterial meningitis.
Meaning These findings suggest emergency physicians are increasingly using computed tomography cerebral angiography and less often using lumbar puncture for headache evaluations, which appears safe in the short-term but has uncertain long-term consequences.
Abstract Importance Subarachnoid hemorrhage is typically diagnosed by noncontrast head computed tomography (CT); lumbar puncture is recommended if computed tomography is nondiagnostic, although CT cerebral angiography has been promoted as an alternative to lumbar puncture in this diagnostic pathway. The outcomes of this debate in practice have not been studied.
Objective To determine whether CT cerebral angiography use has increased in lieu of lumbar puncture among emergency department (ED) patients with headache, with an increase in unruptured intracranial aneurysm detection.
Design, Setting, and Participants This retrospective cohort study took place in 21 community EDs of an integrated health care system in Northern California between 2015 and 2021. Participants were adult (aged >17 years) health plan members with a chief concern of headache. Exclusions were prior diagnoses of subarachnoid hemorrhage, unruptured intracranial aneurysm, cerebral arteriovenous malformation, or cerebrospinal fluid shunt. Data were analyzed from October to November 2023.
Exposures CT cerebral angiography and/or lumbar puncture during the ED encounter.
Main Outcomes and Measures Primary and secondary outcomes were 14-day and 90-day unruptured intracranial aneurysm detection, respectively. Safety outcomes were missed diagnoses of subarachnoid hemorrhage or bacterial meningitis. The annual incidence of unruptured intracranial aneurysm detection was normalized to the incidence of subarachnoid hemorrhage (UIA:SAH ratio). Average annualized percentage changes were quantified using joinpoint regression analysis.
Results Among 198 109 included ED encounters, the mean (SD) age was 47.5 (18.4) years; 140 001 patients (70.7%) were female; 29 035 (14.7%) were Black or African American, 59 896 (30.2%) were Hispanic or Latino, and 75 602 (38.2%) were White. Per year, CT cerebral angiography use increased (18.8%; 95% CI, 17.7% to 20.3%) and lumbar punctures decreased (−11.1%; 95% CI, −12.0% to −10.4%), with a corresponding increase in the 14-day UIA:SAH ratio (3.5%; 95% CI, 0.9% to 7.4%). Overall, computed tomography cerebral angiography use increased 6-fold relative to lumbar puncture, with a 33% increase in the detection of UIA. Results were similar at 90 days and robust to sensitivity analyses. Subarachnoid hemorrhage (1004 cases) and bacterial meningitis (118 cases) were misdiagnosed in 5% and 18% of cases, respectively, with no annual trends (P = .34; z1003 = .95 and P = .74; z117 = −.34, respectively).
Conclusions and Relevance In this cohort study of ED patients with headache, increases in CT cerebral angiography use were associated with fewer lumbar punctures and higher detection of unruptured intracranial aneurysms, with no significant change in missed diagnoses of subarachnoid hemorrhage or bacterial meningitis. While this shift in diagnostic strategy appeared safe in the short-term, the long-term consequences remain unclear.
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April 16, 2024
Written by Michael Stocker
Kids frequently present with abnormal vital signs but seldom require prehospital life-saving interventions (LSI). Based on the occurrence of LSI, age-group vital sign ranges were adjusted to better identify critically ill kids. Abnormal respiratory status (RR, SpO2) was strongly associated with prehospital LSI.
The kids aren’t alright
This retrospective cross-sectional analysis of the National Emergency Services Information System (NEMSIS) database sought to establish outcomes-based pediatric vital sign ranges. After exclusions for age, missing data, and BLS response, 987,515 patients under 18 years-old encountered on scene by ALS or critical care response were included. The primary exposure was first recorded vital signs (HR, RR, SBP, SpO2) and the outcome of interest was LSI such as respiratory interventions (e.g. intubation), resuscitative procedures (e.g. CPR), and medication administration (e.g. norepinephrine). 42,609 (4.3%) encounters involved at least one LSI performed by EMS. Using age-based distribution models, vital signs were weighted by assigning z-scores. From these models, higher sensitivity and higher specificity ranges were generated with cut point analysis. In the higher specificity models, low RR (OR 5.83, 95%CI 5.55-6.13) and high RR (OR 2.97, 95%CI 2.87-3.08) were most associated with LSI, whereas in higher sensitivity models it was high RR (OR 2.13, 95%CI 2.06-2.20) and low SpO2 (OR 1.69, 95%CI 1.65-1.73). The high specificity ranges identify kids most likely to receive critical intervention, while high sensitivity ranges may help identify kids who can be transported by BLS or maybe not at all. Limitations include the use of occurrence of an intervention, as opposed to necessity, as the primary outcome.
From cited articleHow will this change my practice?
The ranges themselves are intriguing and potentially useful to hone EMS protocols. While my own practice is primarily in-hospital (~20% in a pediatric ED) abnormal RR will further raise my suspicion of badness in a potentially sick kid.
Editor’s note: Alarming vital sign ranges by age are helpful but impractical to memorize in detail. These data can be used to train AI systems to give us early warning of possible deterioration in the prehospital setting, ED, and in-hospital. ~Clay Smith
Source
Establishing outcome-driven vital signs ranges for children in the prehospital setting. Acad Emerg Med. 2024 Mar;31(3):230-238. doi: 10.1111/acem.14837. Epub 2023 Nov 30. PMID: 37943118.
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Stephanie B. Kiser, MD, MPH1; J. David Sterns, MD, MPH2; Po Ying Lai, MS3; et alNora K. Horick, MS3; Kerri Palamara, MD4Author Affiliations Article InformationJAMA Netw Open. 2024;7(4):e245645. doi:10.1001/jamanetworkopen.2024.5645Key Points Question Does coaching by professionally trained physician peers reduce burnout and improve well-being, workplace satisfaction, and engagement for physicians?
Findings In this randomized clinical trial of 138 physicians, participants who received 3 months of coaching by professionally trained physician peers had a statistically significant reduction in interpersonal disengagement and burnout, with improvement in professional fulfillment and work engagement.
Meaning These findings show that physician peer coaching is an effective strategy for reducing burnout and improving well-being.
AbstractImportance Physician burnout is problematic despite existing interventions. More evidence-based approaches are needed.
Objective To explore the effect of individualized coaching by professionally trained peers on burnout and well-being in physicians.
Design, Setting, and Participants This randomized clinical trial involved Mass General Physician Organization physicians who volunteered for coaching from August 5 through December 1, 2021. The data analysis was performed from February through October 2022.
Interventions Participants were randomized to 6 coaching sessions facilitated by a peer coach over 3 months or a control condition using standard institutional resources for burnout and wellness.
Main Outcomes and Measures The primary outcome was burnout as measured by the Stanford Professional Fulfillment Index. Secondary outcomes included professional fulfillment, effect of work on personal relationships, quality of life, work engagement, and self-valuation. Analysis was performed on a modified intention-to-treat basis.
Results Of 138 physicians enrolled, 67 were randomly allocated to the coaching intervention and 71 to the control group. Most participants were aged 31 to 60 years (128 [93.0%]), women (109 [79.0%]), married (108 [78.3%]), and in their early to mid career (mean [SD], 12.0 [9.7] years in practice); 39 (28.3%) were Asian, 3 (<0.1%) were Black, 9 (<0.1%) were Hispanic, 93 were (67.4%) White, and 6 (<0.1%) were of other race or ethnicity. In the intervention group, 52 participants underwent coaching and were included in the analysis. Statistically significant improvements in burnout, interpersonal disengagement, professional fulfillment, and work engagement were observed after 3 months of coaching compared with no intervention. Mean scores for interpersonal disengagement decreased by 30.1% in the intervention group and increased by 4.1% in the control group (absolute difference, −0.94 poimys [95% CI, −1.48 to −0.41 points; P = .001), while mean scores for overall burnout decreased by 21.6% in the intervention group and increased by 2.5% in the control group (absolute difference, −0.79 points; 95% CI, −1.27 to −0.32 points; P = .001). Professional fulfillment increased by 10.7% in the intervention group compared with no change in the control group (absolute difference, 0.59 points; 95% CI, 0.01-1.16 points; P = .046). Work engagement increased by 6.3% in the intervention group and decreased by 2.2% in the control group (absolute difference, 0.33 points; 95% CI, 0.02-0.65 points; P = .04). Self-valuation increased in both groups, but not significantly.
Conclusions and Relevance The findings of this hospital-sponsored program show that individualized coaching by professionally trained peers is an effective strategy for reducing physician burnout and interpersonal disengagement while improving their professional fulfillment and work engagement.
Trial Registration ClinicalTrials.gov Identifier: NCT05036993
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April 15, 2024
Written by Amanda Mathews
Low and high extremes of prehospital vital signs were associated with higher rates of hospitalization and in-hospital mortality; however, there was not statistically significant improvement in their model when using age adjusted vital signs.
What were those vitals again?
Researchers used a national database of EMS encounters within the United States to derive centiles of vital signs for adults; an additional database was used to validate this sample. Sets of vital signs were both age adjusted, and non-age adjusted to determine if different cutoffs would prove more reliable in predicting in hospital outcomes. They extracted heart rate (HR), respiratory rate (RR), and systolic blood pressure (SBP) for the patient encounters. When there were multiple sets of vital signs obtained during an encounter, they selected the first set documented. Vital signs that had a high chance of being erroneous or not compatible with life were excluded (ex. RR >120 or <1). All EMS encounters with a documented age >18 years that were transferred via a BLS or ALS crew were included. The data set (from 2018) was 13+ million encounters of which 2.5 million had in-hospital data later available.
In-hospital mortality was greatest among patients at the low and high extremes of centiles for all three vital signs, with hypotension being a particularly strong indicator of in hospital mortality (14.3% for patients below the 1st centile). Risk of hospitalization was also higher among patients at the extremes of centiles. Age adjusted vital signs had slightly increased accuracy for HR and RR but lower accuracy for SBP when looking at both in-hospital mortality and risk of hospitalization. Here is a table of vital sign extremes by age.
From cited articleHow will this change my practice?
It can be easy to miss an in-person EMS report on a busy shift and too often triage notes don’t tell the whole story for these patients. I will pay extra attention to the initial vital signs being reported by our pre-hospital colleagues as it may help me determine a patient’s clinical trajectory early in the encounter.
Editor’s note: This is helpful info, but it’s not something we memorize. Rather, we use these data to train AI systems to alert us for age-specific abnormal vitals in the prehospital setting, in the ED, and to flag abnormal discharge vitals. ~Clay Smith
Source
Correlation of vital sign centiles with in-hospital outcomes among adults encountered by emergency medical services. Acad Emerg Med. 2024 Mar;31(3):210-219. doi: 10.1111/acem.14821. Epub 2023 Nov 3. PMID: 37845192.
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April 12, 2024
Written by Laura Murphy
This systematic review was conducted to answer the clinical question: Is there a superior parenteral medication or combination of medications for acute management of adult out-of-hospital or emergency department patients with severe agitation? These recommendations do not apply to pediatric, elderly (>65 years), pregnant, or out-of-hospital patients. For these groups, additional studies are needed given unique risk profiles.
When “You need to calm down” won’t work…
Patients presenting with severe agitation have high morbidity and mortality. Verbal deescalation and oral or sublingual medications are, of course, preferable initial approaches. However, when these are ineffective, parenteral medications are indicated to treat agitation in order to calm the patient and create a safe environment for patients and staff to allow safe and prompt evaluation and treatment of serious underlying medical problem. Obviously, treatment of underlying medical problem leading to agitation is of paramount importance. Literature on this topic is fairly heterogeneous, and more studies are needed to compare specific medications and to standardize dosing.
The current body of evidence suggests that the most effective combination of parenteral medications is droperidol and midazolam. Studies demonstrate that droperidol is likely the superior antipsychotic, though this is not always available. Atypical antipsychotics, such as olanzapine, appear to have a more favorable profile than other traditional antipsychotics such as haloperidol. When it comes to benzodiazepines, midazolam has a more rapid onset than lorazepam. While time to sedation is similar for midazolam, droperidol, and olanzapine, antipsychotics are preferred if a single agent is to be used, as benzodiazepines have more adverse effects and require more rescue medication administration.
Ketamine likely provides faster and more reliable management of agitation, though there are concerns surrounding risk of laryngospasm, hypersalivation, respiratory and hemodynamic compromise, and emergence phenomena. Unfortunately, due to lack of high-quality studies of ketamine for treatment of agitation, it is difficult to develop formal recommendations surrounding use of this medication for severe agitation. However, it remains a viable option for treatment of agitation in the ED, particularly when safety of the patient and staff call for more rapid and effective treatment of agitation. Initiation of monitoring for hemodynamic respiratory compromise is recommended as soon as the situation safely allows.
How will this change my practice?
Unfortunately, droperidol is not readily available at the main hospital where I work; I am still reaching for a combination of antipsychotic and benzodiazepine as first-line treatment, so that is unlikely to change. I will continue to advocate for availability of droperidol and look out for additional studies surrounding safety and efficacy of ketamine use for severe agitation.
Source
Clinical Policy: Critical Issues in the Evaluation and Management of Adult Out-of-Hospital or Emergency Department Patients Presenting With Severe Agitation: Approved by the ACEP Board of Directors, October 6, 2023. Ann Emerg Med. 2024 Jan;83(1):e1-e30. doi: 10.1016/j.annemergmed.2023.09.010. PMID: 38105109.
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April 10, 2024
Written by Jason Lesnick
This external validation compared the 2023 Duke-International Society for Cardiovascular Infectious Diseases Diagnostic (ISCVID) Criteria against various other criteria for diagnosing infective endocarditis (IE) and found the 2023 Duke-ISCVID Criteria had the best test characteristics. Tomorrow, we’ll dive into the new criteria.
The 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis: Updating the Modified Duke Criteria
Duke…still making noise even after March Madness!
These authors analyzed data from 595 consecutive adult patients with suspected or confirmed IE referred to the IE team of Amsterdam University Medical Center from Oct 2016-Mar 2021. An international expert panel independently reviewed case summaries and assigned a final diagnosis of “IE” or “Not IE” which was used as the reference standard and compared to the “Definite” Duke-ISCVID classification. They also compared the 2023 Duke-ISCVID to the 2000 Modified Duke Criteria and the 2015 and 2023 European Society of Cardiology (ESC) Criteria.
For each criteria set they used the definitions for “Definite”, “Possible” and “Rejected” IE and their definitions of Major and Minor Criteria. For each case, two classifications were made – one with all available data including results from surgery and post-mortem examination, and another using only the clinical data available before surgery or death. If two experts disagreed, a third adjudicator ruled on the diagnosis; kappa was 0.72, and 88% of all cases had both adjudicators agree on the diagnosis. Notably, an expert adjudication panel was used previously in other studies validating other prior version of the Duke Criteria.
The data showed 67% (399) of patients were adjudicated as IE; 19% (111) had prosthetic valve IE, and 48 (8%) had cardiac implantable electronic device IE. The 2023 Duke-ISCVID Criteria were more sensitive (84.2%) than both the Modified Duke and 2015 ESC Criteria (74.9% and 80%, respectively; p < 0.001). The Duke-ISCVID Criteria were similarly sensitive but more specific than the 2023 ESC Criteria (94% vs 82%, p <0.001).
Sensitivity and specificity were compared to the reference standard provided by the adjudication panel where “Definite IE” was selected as a positive test while both “Possible IE” and “Rejected IE” constituted a negative test. The authors also calculated the same measures for Clinical Criteria only (excluding surgery and pathology findings).
The authors found sensitivity of the 2023 Duke-ISCVID Criteria to be 84.2% (95%CI 80.3-87.7) and specificity 93.9% (95%CI 89.6-96.8) when including surgery and pathology information, while without these sensitivity dropped to 79% (95%CI 74.6-82.3) and specificity was unchanged.
A sensitivity analysis was performed looking at if “definite” and “possible” were classified as positive tests, and the 2023 Duke-ISCVID Criteria in that case had 99% sensitivity but specificity dropped to 21%.
How will this change my practice?
I tend to agree with the authors who concluded that the 2023 Duke-ISCVID Criteria should supplant other criteria and be the preferred tool for attempting to diagnose IE. Based on this study, when considering the diagnosis of IE I will reference the 2023 Duke-ISCVID Criteria when discussing this with the admitting team. I also find it useful to know that if a patient is classified as “rejected” the NPV was found to be 98% in this study.
Source
External Validation of the 2023 Duke – International Society for Cardiovascular Infectious Diseases Diagnostic Criteria for Infective Endocarditis. Clin Infect Dis. Published online February 8, 2024. doi:10.1093/cid/ciae033. PMID: 38330166.
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April 3, 2024
Written by Ketan Patel and Charles Worth
This review article discusses four randomized clinical trials (RCT) focusing on interventions for out-of-hospital-cardiac-arrest (OHCA) that were published in 2023, all of which showed negligible impact on survival for the interventions studied.
Minimal gains in OHCA care (and tortured acronyms)
- INCEPTION Trial – Early Initiation of Extracorporeal Life Support in Refractory OHCA
See separate Journal Feed dedicated to this study: INCEPTION. This multicenter randomized controlled trial comparing ECPR vs conventional CPR for refractory cardiac arrest showed no improvement in neurologically intact survival at 30 days. - TAME Trial – Targeted Therapeutic Mild Hypercapnia after Resuscitated Cardiac Arrest
See separate Journal Feed dedicated to this study: TAME. In this OHCA patient population, targeted mild hypercapnia showed no significant favorable neurological outcomes at 6 months compared to normocapnia. - ARREST Trial – A Randomized tRial of Expedited transfer to a cardiac arrest center for non-ST elevation OHCA
This was covered by JournalFeed in the Top Picks video series by Dr. Alblaihed. This RCT tested if transport of resuscitated OHCA patients without ST elevation after ROSC to a cardiac center would improve outcomes vs. transfer to the nearest emergency department. This was conducted in London at 35 hospitals, including 862 randomized patients. The time to arrive at the cardiac center was similar to the nearest emergency department (84min vs. 77min). Key findings were that the 30-day all-cause mortality was the same (63% vs 63%) as was the 3-month all-cause mortality (65% vs 64%) as well as survival with favorable neurologic outcomes (30% vs. 31%). - STEROHCA Trial – STERoid for Out-of-Hospital Cardiac Arrest
This RCT conducted in Denmark tested if administration of high-dose methylprednisolone (250mg IV bolus) to OHCA patients with ROSC could reduce inflammatory markers and reduce secondary neurological injury. 158 randomized patients were included. Baseline IL-6 values were similar, though the intervention group saw a reduction at 24 hours (2.1pg/mL vs. 29.8pg/mL, p < 0.0001), at 48 hours (5.7pg/mL vs. 10.1pg/mL), but not at 72 hours. This also did not lead to other improved brain injury biomarkers.
How will this change my practice?
Based on these RCTs in patients presenting with OHCA, ECPR, mild hypercapnia, and transport to a cardiac arrest center were not associated with improved outcomes and, therefore, will not be changing my practice at this time.
Peer Reviewed by Dr. Ketan Patel
Source
Top cardiac arrest randomised trials of 2023. Resuscitation. 2024 Mar;196:110133. doi: 10.1016/j.resuscitation.2024.110133. Epub 2024 Feb 3.
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April 5, 2024
Written by Alex Clark
In this systematic review and meta-analysis to evaluate the use of a bougie versus non-bougie approach (ie. stylet) in intubations of adult patients, a bougie-first approach significantly increased the rate of first-attempt success compared to controls. But what does this say about your intubation strategy?
Allow me to introduce…the bougie!
This well-done systematic review and meta-analysis pooled 18 studies (including 12 RCTs) and a total of 9,151 patients with 4,897 of those in the bougie-first cohort. Most intubations occurred in the out-of-hospital, ED, or ICU setting (n = 8,070 patients, 9 studies). Most studies (61.1%) used DL, the remainder used standard geometry VL. Patient demographics were similar across groups. It is very important to note that the authors declare an overall low certainty for their pooled studies with no studies at low risk of bias.
A bougie-first approach significantly increased the rate of first-attempt success: RR 1.11 (95%CI 1.06 to 1.17), with nearly identical findings in the out-of-hospital, ED, and ICU combined subgroups. This effect was amplified in difficult airways: RR 1.6 (1.4 to 1.84). However, statistical significance was lost in the subgroup of three RCTs involving emergency intubations: RR 1.05 (0.91 to 1.21). Additional pre-planned secondary outcomes suggested there was no increase in hypoxemia, esophageal intubation, or rate of post-procedural cardiac arrest with bougie-first. There was an increase in intubation time with the bougie (~13s increase) and small but greater risk of intubation-related oral injuries.
Overall, the authors suggest that the bougie increases first-attempt success in adult intubations and probably should be used first and NOT as a rescue device. Limitations include low certainty evidence and high risk of bias, high-levels of heterogeneity, no data on operator experience, and a lack of patient-centered outcomes.
How will this change my practice?
I must admit my own bias… I grew up in a home that preached “bougie-left-turn” for every intubation. However, this report is a reminder that airway trials are difficult, and bias is inevitable. The low-level of evidence presented in this meta-analysis just does not yet support the authors’ full recommendation for a bougie-first approach. The bougie remains a powerful instrument, among many other airway adjuncts, in the armamentarium of the emergency physician.
Editor’s note: I thought that since 11 of the 18 studies used DL, this may have made bougie use look better. However, there was still better first-pass success in both DL and VL subgroups. ~Clay Smith
Source
Effect of Bougie Use on First-Attempt Success in Tracheal Intubations: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2024 Feb;83(2):132-144. doi: 10.1016/j.annemergmed.2023.08.484. Epub 2023 Sep 19.
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April 8, 2024
Written by Laura Murphy
The goal of invasive management in the cardiac catheterization laboratory (CCL) is to identify and treat culprit coronary lesion or additional resuscitative measures (such as mechanical circulatory support (MCS) or interventions for massive pulmonary embolism). This is a scientific statement from the American Heart Association (AHA) which provides an update on the role of CCL in the management of resuscitated patients or those with ongoing cardiac arrest.
Activate or not?
Coronary artery disease may account for up to 70% of sudden cardiac arrest cases, though the proportion of ischemic cause of OHCA is decreasing. Assessment of patients resuscitated from OHCA should focus on identifying likelihood of acute ischemic trigger to guide decision about urgent invasive angiography. Post-ROSC ECG is an important component of this1. Benefits of invasive therapies should be balanced with potential consequences of anoxic encephalopathy, particularly for patients with one or more of the following risk factors for poor neurologic outcome2.
So Who Benefits from the Cath Lab?
- OHCA with STE on ECG: >80% of these patients have acute coronary occlusion. There are no RCTs directly studying the role of emergent cardiac catheterization in patients with OHCA and STE; there is little question about benefit of emergency reperfusion in this population. Outcomes in comatose patients are overall much worse than awake patients, likely due to death from anoxic brain injury or multiorgan failure. Benefit is questionable for patients with signs suggesting poor neurological outcome, but more information is needed to determine patients in whom coronary reperfusion is not beneficial or harmful. As such, coronary reperfusion continues to have a critical role in this subset of patients, and guidelines provide a Class 1 Recommendation for emergency angiography and reperfusion.
- OHCA without STE on ECG: Up to 1/3 of these patients may have an acute coronary occlusion, but recent studies have collectively failed to demonstrate a benefit to emergency angiography compared to delayed or no angiography. However, in patients with high degree of suspicion for coronary occlusion (e.g. history of chest pain, marked ST depressions, posterior MI), or who have cardiogenic shock or electrical instability, early invasive strategy may still be beneficial. For these patients, the guidelines provide a Class 2a recommendation for proceeding with emergency angiography.
- Cardiac arrest with cardiogenic shock (CS): Data in this group of patients with OHCA are lacking, and rates of anoxic encephalopathy and irreversible end-organ injury are higher. Patients with more favorable prognostic features may benefit from coronary reperfusion as well as initiation of mechanical circulatory support (MCS) such as intra-aortic balloon pump (IABP), Impella or TandemHeart, or VA-ECMO.
- Cardiac arrest with massive PE: While fibrinolytic therapy remains the standard of care for patients with massive PE with OHCA, catheter-directed lysis or mechanical thrombectomy, with or without VA-ECMO in the CCL, can be considered in patients with contraindications to fibrinolytics or with treatment failure. As such, AHA provides a Class 2a Recommendation for proceeding with treatment of confirmed PE and OHCA in the CCL.
- Cardiac Arrest with Ongoing CPR: Increased use of mechanical compression devices may have benefit in the CCL setting; while AHA assigns Class 3 Recommendation to routine use of these devices, they assign a Class 2b Recommendation for use in situations such as CCL where it is otherwise challenging to provide high quality CPR.
- ECPR: Several trials which have demonstrated survival benefit compared to conventional CPR, leading to a Class 2a Recommendation for ECPR for select patients with cardiac arrest if cause of arrest is deemed to be potentially reversible. However, successful implementation of ECPR requires experienced as well as highly resourced and integrated systems. While there is promising data from regional systems, but it is challenging to replicate these systems nationwide.
In general, best practices focus on minimizing potential for procedure-related complications include radial access (unless plan for MCS), PCI of culprit lesions only, minimization of IV contrast use, and use of IV P2Y12 agents if concern for poor oral absorption to avoid in-stent thrombosis.
How will this change my practice?
This statement highlights the importance of post-ROSC ECG as well as other clinical factors to determine who may benefit from activation of CCL for diagnostic, therapeutic and resuscitative support after OHCA. In patients without STE on post-ROSC ECG, I will be discussing patients with high clinical suspicion of ischemic event or with cardiogenic shock or electrical instability with cardiology for consideration of emergent catheterization. The same goes for patients with OHCA secondary to massive pulmonary embolism.
Source
Cardiac Catheterization Laboratory Management of the Comatose Adult Patient With an Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation. 2024 Jan 30;149(5):e274-e295. doi: 10.1161/CIR.0000000000001199. Epub 2023 Dec 19. PMID: 38112086.
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April 1, 2024
Written by Clark Strunk
The use of radiopaque markers (ROM) in penetrating trauma is based on expert opinion and historical clinical practice; however, there is no high-quality evidence to support their routine use in clinical practice.
Quick! Grab the paperclips!
This article provides commentary on the use of ROM in penetrating trauma. The authors first review the historical context of this practice where it may have had some utility in certain practice settings with limited access to advanced imaging modalities. They also discuss the multiple factors that affect the trajectory of ballistics such as the type, size, velocity, and potential for ricochet. These factors can lead the bullet to deviate from its anticipated course and can lead to injury to structures that might not be on the suspected path between the ROMs. Furthermore, ROM can cause artifact and degrade the quality of certain imaging studies. Finally, the authors conclude that the use of ROM in penetrating trauma is not evidence based and has become medical dogma.
How will this change my practice?
In my current practice environment, the use of ROM is routine, and I do not see that changing anytime soon. Although I do not believe that there is significant harm when utilizing ROM in the assessment of patients with penetrating trauma, I also don’t think they provide useful diagnostic information. Consequently, if ROM are readily available and will not impede the clinical evaluation and treatment of a patient with penetrating trauma, I will likely continue to use them; however, if there is a paperclip shortage at my hospital, I don’t believe there will be a decline in the care patients receive.
Source
The use of radiopaque markers is medical dogma. Acad Emerg Med. 2024 Feb;31(2):193-194. doi: 10.1111/acem.14858. Epub 2024 Feb 6.
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September 8, 2023 / Critical Care, EMS, Trauma Written by Michael Stocker Blast injuries combine common polytrauma mechanisms – blunt, penetrating, burns – with the unique pathophysiology of blast wave injuries, and mass casualty scenarios. While rare, these patients are resource-intensive, prone to delayed yet rapid clinical deterioration, and carry high morbidity and mortality. Close only counts in horseshoes […]
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Behnood Bikdeli, MD, MS, reviewing Kirchhof P et al. N Engl J Med 2023 Aug 25 Edoxaban did not benefit older adults at risk for stroke who did not have AF on surface ECG and led to excess major bleeding events. Atrial high-rate episodes (AHREs) represent a potentially heterogenous group of atrial arrhythmias detected by implantable cardiac devices. […]
The post NEJM: Should Patients with Atrial High-Rate Episodes Without Atrial Fibrillation Receive Anticoagulation? first appeared on האיגוד הישראלי לרפואה דחופה.
פרסום זה חשוב מאדSections
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- Introduction
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- Scope of Practice
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- Training and Proficiency
- 4.Hospital Credentialing and Privileging
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- Specialty Certification
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- Quality and Ultrasound Management
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- Value and Reimbursement
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- Clinical Ultrasound Leadership in Health Care Systems
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- Future Issues
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- Conclusion
Tables
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- Emergency Medicine Ultrasound Definitions
Figures
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- ACEP 2023 Emergency Ultrasound Scope of Practice
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- Pathways for Clinical Ultrasound Training, Credentialing, and Incorporation of New Applications
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- Clinical Ultrasound Workflow
Appendices
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- Evidence for Core Emergency Ultrasound Applications
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- Evidence for Advanced Emergency Ultrasound Applications
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- Emergency Ultrasound Learning Objectives
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- Recommendations for Emergency Medicine Residency EUS Education Program
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- Recommendations for EUS Course
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- Ultrasound in UME—Medical School Rotation and Curriculum
Section 1—IntroductionClinical ultrasound (CUS) has become an integral aspect of emergency care in the United States for over 2 decades. Since the last update of these guidelines in 2016, the role of ultrasound has expanded throughout clinical medicine. The wide breadth of recognized CUS applications offers both diagnostic and therapeutic benefits to patients around the world. Benefits of bedside imaging with ultrasound include its relatively low cost, lack of ionizing radiation, portability, and ease of use. Data have demonstrated that CUS can improve diagnostic accuracy in numerous common clinical presentations, including dyspnea,1 abdominal pain,2 and joint dislocations.3 Ultrasound guidance has also been incorporated into bedside procedures, improving success and decreasing inadvertent complications.4, 5, 6
Emergency physicians have been leaders in innovation and education in the CUS space both nationally and internationally. This has led to increased integration and improved standardization at the undergraduate, postgraduate, and continuing medical education levels. Emergency medicine leaders have also leveraged their extensive knowledge and teaching to educate other specialties seeking to enhance their ultrasound training and expertise. Specifically, CUS curricula in undergraduate medical education are growing exponentially because of the leadership and advocacy of emergency physicians, integrating CUS into the education of the next generation of clinicians. In fact, CUS in emergency medicine residency training has been codified in the Model of the Clinical Practice of Emergency Medicine, a joint policy collaboration between 7 organizations. Moreover, CUS fellowship has advanced, with fellowships now eligible for accreditation by the Emergency Ultrasound Fellowship Accreditation Council (EUFAC) and fellowship graduates being recognized with certification as a focused practice designation by American Board of Emergency Medicine (ABEM). Leaders in CUS have created the foundation of a subspecialty of ultrasonography that provides the expertise for establishing clinical practice, educating across the educational spectrum, and researching a wide range of applications. The CUS leaders have also become instrumental in bringing health care systems into the future through championing and often running system-wide programs. As CUS continues to evolve and access to ultrasound machines becomes increasingly widespread, it is critical to understand the current field and provide national guidelines to inform education and practice. This guideline update is intended to provide a framework for new and established programs using CUS.
Section 2—Scope of PracticeClinical ultrasound is the medical use of ultrasound technology for the bedside clinical evaluation of acute or critical medical conditions.7 It is used for diagnosis of any emergency condition, such as the resuscitation of the critically ill patient, during guidance of procedures, and monitoring of certain pathologic states. The CUS examinations are typically performed and interpreted by emergency physicians or those under the supervision of emergency physicians in the setting of the emergency department or a non-ED emergency setting hospital unit (out-of-hospital, battlefield, space, urgent care, clinic, remote, or other settings). It may be performed as a single examination, repeated serially based on clinical need or patient deterioration or used for monitoring of physiologic or pathologic changes.
In this document, CUS refers to ultrasound performed by emergency physicians or clinicians in the emergency setting, whereas point-of-care ultrasound (POCUS) refers to a multidisciplinary field of ultrasound use by clinicians at the point-of-care.8 Table 1 summarizes relevant ultrasound definitions in CUS.
Table 1. Emergency medicine ultrasound definitions.
| Advanced Emergency Medicine Ultrasonography (AEMUS) | Ultrasound by emergency physicians with advanced training. This term is used by the American Board of Emergency Medicine Focused Practice Designation. | | Focused Practice Designation (FPD) | A pathway created by the American Board of Medicine Specialties to recognize advanced training. The pathway is specialty-specific and applies to advanced knowledge in an area. The American Board of Emergency Medicine offers an FPD in AEMUS. | | Point-of-Care Ultrasound (POCUS) | Ultrasound performed by clinicians at the patient’s bedside that answers a specific clinical question. There are many somewhat synonymous terms for ultrasound performed by emergency physicians at the patient’s bedside. | | Emergency Ultrasound | Ultrasound performed and interpreted by the clinician as an emergency procedure and directly integrated into the care of the patient. There are many somewhat synonymous terms for ultrasound performed by emergency physicians at the patient’s bedside. | | Educational Ultrasound | Ultrasound performed on a patient, volunteer, or in simulation that is not intended to provide information to further the clinical care of that individual. | | Consultative Ultrasound | Ultrasound performed by nonemergency medicine specialists at the request of an emergency physician. This ultrasound is generally distinct from emergency ultrasound in its scope (less narrow) and purpose (diagnostic question that can wait for a consultant). | | Resuscitative Ultrasound | Ultrasound use directly related to cardiac resuscitation (ACLS), general medical resuscitation (eg, sepsis), or resuscitation from unknown causes. | | Diagnostic Ultrasound | Ultrasound use in a diagnostic imaging capacity. Some diagnostic ultrasounds are performed in series to monitor physiologic changes. | | Sign- or Symptom-Based Ultrasound | Ultrasound used in a clinical pathway based on the patient’s symptoms or signs (eg, shortness of breath). | | Therapeutic Ultrasound | Ultrasound use as part of therapy for patient care. | | Ultrasound-Guided Procedure | Ultrasound to guide a procedure in real time. | | Ultrasound-Assisted Procedure | Ultrasound used to assist with a procedure that is not performed in real time (eg, preprocedural identification). | | Limited Ultrasound | Ultrasound imaging of an organ or organ system that is not comprehensive. This term is used to represent a level of US for coding and billing. Limited ultrasounds are sometimes confused with incomplete ultrasound where a complete set of needed images are not recorded or performed. |
Other medical specialties may wish to use this document if they perform CUS in the manner described above. However, guidelines that apply to ultrasound examinations or procedures performed by consultants, especially consultative imaging in ultrasound laboratories or departments or in alternative settings, may not be applicable to emergency physicians.
Emergency ultrasound (EUS) is an emergency medicine procedure and should not be considered in conflict with exclusive “imaging” contracts that may be in place with consultative ultrasound practices. In addition, EUS should be reimbursed as a separate billable procedure.9 (See Section 7—Value and Reimbursement.)
The CUS is a separate entity distinct from the physical examination that adds anatomic, functional, and physiologic information to the care of the acutely ill patient.10 It provides clinically significant data not obtainable by inspection, palpation, auscultation, or other components of the physical examination.11 The ultrasound used in this clinical context is also not equivalent to use in the training of medical students and other clinicians in training looking to improve their understanding of anatomic and physiologic relationships of organ systems.
The CUS can be classified into the following functional clinical categories: 1.Resuscitative: ultrasound use directly related to an acute resuscitation * 2.Diagnostic: ultrasound used in an emergency diagnostic imaging capacity * 3.Symptom or sign-based: ultrasound used in a clinical pathway based on the patient’s symptom or sign (eg, shortness of breath) * 4.Procedure guidance: ultrasound used as an aid to guide a procedure * 5.Therapeutic and Monitoring*: ultrasound use in therapeutics or in physiological monitoring
Within these broad functional categories of use, 15 core emergency ultrasound applications have been identified as Aorta, Bowel, Cardiac/Hemodynamic assessment, Deep Venous Thrombosis (DVT), Hepatobiliary, Musculoskeletal (MSK), Ocular, Pregnancy, Procedural Guidance, Skin and Soft-tissue, Testicular, Thoracic/Airway, Trauma, Ultrasound-Guided Nerve Blocks, and Urinary Tract. Evidence for these core applications may be found in Appendix 1. The criteria for a core application are widespread use, significant evidence base, uniqueness in diagnosis or decisionmaking, importance in primary emergency diagnosis and patient care, or technological advance.
Alternatively, symptom and sign-based ultrasound pathways, such as Shock or Dyspnea, may be considered an integrated application based on the skills required in the pathway. In such pathways, applications may be mixed and used in a format and order that maximizes medical decisionmaking, outcomes, efficiency, and patient safety tailored to the setting, resources, and patient characteristics. See Figure 1.
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Figure 1. The ACEP 2023 Emergency Ultrasound Guidelines scope of practice.
Emergency physicians should have a basic education in ultrasound physics, knobology, instrumentation procedural guidance, and Focused Assessment with Sonography in Trauma (FAST) as part of emergency medicine practice. It is not mandatory that every clinician performing EUS examinations use or be an expert in each core application, but it is understood that each core application is incorporated into common EUS practice nationwide. The descriptions of these examinations may be found in the American College of Emergency Physicians (ACEP) policy, Emergency Ultrasound Imaging Criteria Compendium.12 Many other ultrasound applications or advanced uses of these applications may be used by emergency physicians. Their noninclusion as a core application does not diminish their importance in practice nor imply that emergency physicians are unable to use them in patient care.
Each EUS application represents a clinical bedside skill that can be of great advantage in a variety of emergency patient care settings. In classifying an emergency ultrasound, a single application may appear in more than one category and clinical setting. For example, focused cardiac ultrasound may be used to identify a pericardial effusion in the diagnosis of an enlarged heart on a chest radiograph. The focused cardiac ultrasound may be used in a cardiac resuscitation setting to differentiate true pulseless electrical activity from profound hypovolemia. The focused cardiac US can be used to monitor the heart during resuscitation in response to fluids or medications. If the patient is in cardiac tamponade, the cardiac ultrasound can also be used to guide a pericardiocentesis. In addition, the same focused cardiac study can be combined with one or more additional emergency ultrasound types, such as the focused abdominal, the focused aortic, or the focused chest/thoracic ultrasound, into a clinical algorithm for an undifferentiated hypotensive patient. See Figure 1.
Ultrasound guidance provides added safety to a wide variety of procedures ranging from vascular access (eg, central venous access) to drainage procedures (eg, thoracentesis pericardiocentesis, paracentesis, arthrocentesis) to localization procedures like ultrasound-guided nerve blocks. These procedures may provide additional benefits by increasing patient safety and helping alleviate acute pain.
Other ultrasound applications are performed by emergency physicians and may be integrated depending on the setting, training, and needs of that particular ED or emergency medicine group.
Other Settings or PopulationsPediatricsClinical ultrasound is a particularly advantageous diagnostic tool in the management of pediatric patients in whom radiation exposure is a significant concern. The CUS applications, such as musculoskeletal evaluation for certain fractures (rib, forearm, skull) and lung for pneumonia, may be more advantageous in children than in adults because of smaller patient size and density.13 Ultrasound can be associated with increased procedural success and patient safety and decreased length of stay.14,15 Whereas most ultrasound modalities in the pediatric arena are the same as in adult patients (the Extended Focused Assessment with Sonography in Trauma [EFAST] examination, procedural guidance), other modalities are unique to the pediatric population, such as in suspected pyloric stenosis and intussusception, or in the child with hip pain or a limp).16, 17, 18 Mostly recently, EUS has been formally incorporated into Pediatric Emergency Medicine fellowship training.19,20
Critical CareThe CUS core applications are being integrated into cardiopulmonary resuscitations and noninvasive hemodynamic monitoring in critical care scenarios.21,22 Dual-trained physicians in emergency medicine and critical care are leading the application, education, and research of ultrasound for critically ill patients and have significant leadership in advancing ultrasound concepts in multidisciplinary critical care practice. Advanced cardiopulmonary ultrasound applications are being integrated into critical care practice.
PrehospitalThere is increasing evidence that CUS has an increasing role in out-of-hospital emergency care.23,24 Challenges to the widespread implementation of out-of-hospital ultrasound include significant training and equipment requirements and the need for oversight and quality assurance. Studies focusing on patient outcomes need to be conducted to further define the role of out-of-hospital CUS and to identify settings where the benefit to the patient justifies the investment of resources necessary to implement such a program.25
International arena including field, remote, rural, global public health, and disaster situationsUltrasound has become the primary initial imaging modality in disaster care.26, 27, 28, 29, 30 Ultrasound can direct and optimize patient care in natural disasters such as tsunami, hurricane, famine, or man-made disasters such as battlefield or refugee camps. Ultrasound allows for imaging in remote locations such as rural areas, developing countries, or small villages, which often do not have other imaging options (eg, radiograph, computed tomography [CT], magnetic resonance imaging [MRI]), unreliable electrical supplies, and less experienced clinicians. Ultrasound in outer space is often the only imaging modality for space exploration and missions.31,32 Ultrasound has also been used in remote settings such as international exploration, mountain base camps, and cruise ships.23 The increasing portability of ultrasound machines and the development of handheld devices with improving image resolution has expanded the use of emergent imaging in such settings.
Military and TacticalThe military has embraced the use of ultrasound technology in austere battlefield environments.33,34 It is now routine for combat support hospitals and forward surgical teams to deploy with next generation portable ultrasonography equipment. Clinical ultrasonography is often used to inform decisions on the mobilization of casualities to higher echelons of care and justify the use of limited resources. Within the last decade, emergency physicians at academic military medical centers have expanded ultrasonography training to clinical personnel who practice in close proximity to the point of injury, such as combat medics, special operations forces, physician assistants, and nurse practitioners.35 The overarching goal of these training programs is to create a generation of competent clinical sonologists capable of practicing “good medicine in bad places.” The military is pursuing telemedicine-enabled ultrasound applications, automated ultrasound interpretation capabilities, and extension of clinical ultrasonography in additional areas of operation, such as critical care air evacuation platforms.36
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August 30, 2023 / Infectious Disease, PediatricsWritten by Clay Smith
Is taking a croupy child outdoors in the cold air a myth or evidence-based practice? Turns out, the RCT shows it actually works!
Not much cold outside air right now…but the concept makes sense
Dexamethasone and nebulized racemic epinephrine are the core treatments for croup. Mist doesn’t hurt but also doesn’t help. What about cool air?
This was an unblinded RCT, with 118 children with at least mild croup. Westley Croup Scores (WCS) were obtained at baseline, and they received dexamethasone. They were randomized to wait in a monitored outdoor area <10°C (<50°F) or an indoor room temperature environment for 30 minutes. WCS decreased by ≥2 points in 29/59 (49.2%) in the outdoor group and 14/59 (23.7%) in the room temperature group: risk difference 25.4% (95%CI 7.0-43.9), p = 0.007). The effect was more pronounced in patients with moderate symptoms (WCS 3-5).
The trial is at risk of expectation bias, being unblinded. Maybe they really wanted cool air to work and subconsciously rated those children as more improved. Also, patients had to thread the needle of severity – not too sick to need immediate racemic epi but not too mild to be unable to show a 2-point benefit. The setting was wintertime in Switzerland. This clearly wouldn’t work during a Nashville summer! It is also a big ask for families to wait outside when it’s cold. However, taking a child outdoors into cool air is simple, and for many places in the world, achievable in the right season of the year. Since croup is more common when it’s colder outdoors, that works out well. Overall, with a NNT = 4, this is a pretty cool intervention.
How will this change my practice?
I see this trial impacting pediatricians who take calls during the night and are trying to help parents avoid an ED visit. I also see it as a key talking point in our discharge instructions for mild recurrences at home. For warmer parts of the world, holding a freezer door open for 30 minutes is probably not feasible. One idea would be to jump in a car, turn the AC all the way down, and place the child in front of the cold air vent, which would expose them to air <10°C.
Source
Outdoor Cold Air Versus Room Temperature Exposure for Croup Symptoms: A Randomized Controlled Trial. Pediatrics. 2023 Aug 1;e2023061365. doi: 10.1542/peds.2023-061365. Online ahead of print.
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Hannah Smyth , Deirdre Breslin, Lorcán Mullany, Vinny Ramiah, Roisin Riches,
Rico Laguna, Paula Morgan, Colm Byrne
- Correspondence to Dr Hannah Smyth, Mater Misericordiae University Hospital, Dublin, D07 R2WY, Ireland; hmsmyth@tcd.ie Abstract Background Increasing numbers of older patients are presenting to the ED following trauma. These patients require multidisciplinary care that the traditional trauma model fails to provide. A Silver Trauma Review Clinic (STRC) was developed in conjunction with the geriatric ED and multidisciplinary services to improve the post-discharge care of patients with non-operative traumatic injuries.
We aimed to assess the STRC by reviewing the journey and outcomes of patients who attended the clinic.
Methods A retrospective review of electronic chart data was performed on all patients who attended the clinic over the initial 1-year period. Data were collected on patient demographics, medical history, medications, timelines, trauma assessments and further investigations, fracture types, occult injuries, geriatric assessments (Comprehensive Geriatric Assessment, Clinical Frailty Scale, bone health, falls, Orthostatic Hypotension (OH), cognitive screening, mobility), number of reviews and discharge destination.
Results 137 patients were reviewed with a median age of 80 years (IQR 74–86) and 69% were female. The median Clinical Frailty Scale was 3 with a median time from the patient’s initial ED presentation to clinic of 15 days (IQR 9.75–21) and median time from initial review to discharge 20 days (IQR 1–35). 71% of presentations were as a result of falls under 2 m. Tertiary survey in the STRC identified previously unrecognised injuries in 24 patients (18%). In total, 56 patients were reviewed with vertebral fractures. 87% of these patients (n=49) were further investigated with a CT or MRI and 95% of patients (n=53) were referred for physiotherapy. Patients attending the STRC had a comprehensive geriatric assessment with abnormal Mini-Cog assessments found in 29%, a new diagnosis of osteoporosis in 43% and orthostatic hypotension diagnosed in 13% of patients. 61% were discharged to primary care and 19% linked into a specialist geriatric clinic.
Conclusion The STRC is a novel approach allowing timely, patient-focused, comprehensive and collaborative trauma care of older patients following non-operative injuries.
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August 29, 2023 / Venous Thromboembolism Written by Samuel G. Rouleau Structured surveillance without anticoagulation of patients with isolated subsegmental pulmonary embolism (ssPE) rarely occurs in community practice. After applying CHEST guidelines, ~5% of patients with isolated subsegmental PE are eligible for surveillance. Small PE? Fat chance…of surveillance without anticoagulation Pulmonary emboli confined to the subsegmental […]
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Michael Dan Arvig ,1,2,3 Annmarie Touborg Lassen ,3,4,5 Peter Haulund Gæde,6,7 Stefan Wernblad Gärtner,1,8 Casper Falster ,9,10 Inge Raadal Skov,9,10 Henrik Ømark Petersen,4,11 Stefan Posth,3,4 Christian B Laursen9,10 Abstract Background Serial point-of-care ultrasound (PoCUS) can potentially improve acute patient care through treatment adjusted to the dynamic ultrasound findings. The objective was […]
The post BMJ: Impact of serial cardiopulmonary point- of- care ultrasound exams first appeared on האיגוד הישראלי לרפואה דחופה.
Sarah R Martin ,1,2,3 Isaac Hung,2,4 Theodore W Heyming,3,5 Michelle A Fortier,2,6,7 Zeev N Kain1,2,7,8 Correspondence to Dr Zeev N Kain, Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, USA; zkain@uci.edu Abstract Background Children experience significant anxiety in the paediatric ED. Although research from preoperative and primary care samples indicates […]
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August 25, 2023 / Imaging, Neurosurgery, Trauma Written by Laura Murphy ACEP has issued an updated Clinical Policy to provide evidence-based guidelines for management of adult patients presenting to the ED with mild traumatic brain injury based on systematic review of available literature. (Head) bang for the buck Traumatic brain injury leads to significant number of hospitalizations and causes […]
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Adam R. Schertz, MD, MS1,2; Kristin M. Lenoir, MPH3; Alain G. Bertoni, MD, MPH1,3; et alBeverly J. Levine, PhD4; Morgana Mongraw-Chaffin, PhD5; Karl W. Thomas, MD1,2 Author Affiliations Article Information JAMA Netw Open. 2023;6(8):e2329729. doi:10.1001/jamanetworkopen.2023.29729 Key Points Question Does the Sepsis Prediction Model (SPM) outperform other sepsis prediction scores with respect to validity and timeliness? Findings This cohort study of 60 507 adult admissions found that although balanced […]
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David J. Cohen, MD, MSc, reviewing Thiele H et al. N Engl J Med 2023 Aug 26 A major randomized trial showed no mortality difference with extracorporeal membrane oxygenation versus supportive care alone. Despite great strides in managing acute myocardial infarction (AMI), 30-day mortality rates remain at 40% to 50% when cardiogenic shock complicates AMI (AMI-CS). Several percutaneous […]
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August 21, 2023 / Airway, Critical Care, Pharmacy/Pharmacology Written by Joshua Campbell There is no association between the weight-based drug dose of etomidate or ketamine and post-intubation hypotension. Does sedative dose matter? Experts have long recommended reducing the dose of sedative used during RSI in hemodynamically unstable patients to reduce the risk of worsening post-intubation hypotension, despite little data […]
The post Does Low Dose Ketamine or Etomidate Prevent Post-Induction Hypotension in Unstable Patients? first appeared on האיגוד הישראלי לרפואה דחופה.
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices.However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences fromapplication of the information in this book and make no warranty, expressed or implied, with respect to the currency,completeness, or accuracy […]
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Richard AF Pellatt FACEM, MBChB, BA (Hons), Katherine Isoardi FACEM, GradDipClinTox, BMed, Gerben Keijzers MSc (Biomed Health Sci), MBBS, FACEM, PhD Abstract Patients frequently present to the ED with drug overdose and reduced conscious level leading to coma. There is considerable practice variation around which patients require […]
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Peter Freeman MBChB, FRCEM, FACEM Abstract I propose a methodology to compare individual emergency physician (EP) work patterns. This is intended to generate discussion within the specialty. A work pattern graph shows individual EP productivity and, assuming the EPs case selection is similar, can be used to compare group […]
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SAEM · Suicidal Ideation is Insensitive to Suicide Risk after ED Discharge Abstract Objectives: We describe the Columbia-Suicide Severity Rating Scale (C-SSRS)–Clinical Practice Screener’s ability to predict suicide and emergency department (ED) visits for self-harm in the year following an ED encounter.Methods: Screening data from adult patients’ first ED encounter during a […]
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Paul I. Musey Jr. MD, MSc, Fernanda Bellolio MD, MS, Suneel Upadhye MD, MSc, Anna Marie Chang MD, MSCE, Deborah B. Diercks MD, MSc, Michael Gottlieb MD, Erik P. Hess MD, MSc, Michael C. Kontos MD, Bryn E. Mumma MD, MAS, Marc A. Probst MD, MS, John H. Stahl, Jason P. Stopyra MD, Jeffrey A. Kline MD, Christopher R. Carpenter MD, MSc Abstract […]
The post Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department first appeared on האיגוד הישראלי לרפואה דחופה.
Sanjana Salwi, MD1 Author Affiliations Article Information JAMA Neurol. 2023;80(8):773-774. doi:10.1001/jamaneurol.2023.1423 The mother’s eyes are clamped shut. Her nails dig into her husband’s forearm. The room is silent except for the quiet creaking of the conference room chair as she rocks back and forth. There is no way to soften the blow. So, I speak directly. […]
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August 15, 2023 / Pediatrics, Trauma Written by Millie Cossé A reduction in both 24-hour and in-hospital mortality was seen among children who received a transfusion after traumatic injury in the prehospital setting compared to those who were transfused in the emergency department. They’re not bleeding salt water This retrospective cohort study examined 559 patients age 0 to […]
The post Does Prehospital Transfusion of Pediatric Trauma Patients Save Lives? first appeared on האיגוד הישראלי לרפואה דחופה.
August 9, 2023 / Endocrine Written by Jason Lesnick Thyroid storm is a high-risk, low-prevalence disease that mimics multiple other emergent diagnoses due to its most common features being fever, altered mental status, and cardiovascular dysfunction. There’s a storm brewing in your patient’s neck Thyroid storm (TS) is a life-threatening condition defined as exaggerated signs and symptoms […]
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Endotracheal intubation — a potentially lifesaving procedure that is used for the care of many critically ill patients — demands precision, speed, and skill. It involves the placement of a tube into the trachea to protect the airways while ensuring adequate oxygenation and ventilation for patients who are in respiratory distress or are unable to […]
The post NEJM: EDITORIAL Video Laryngoscopy for Intubation — Time for a New Paradigm? first appeared on האיגוד הישראלי לרפואה דחופה.
CIRCULATION: TAKE-HOME MESSAGE This time-stratified case–crossover study investigated the impact of extreme temperature events and fine particulate matter (PM2.5) on myocardial infarction (MI)–related mortality. Of 202,678 MI-related deaths from 2015 to 2020, heat waves were associated with a higher risk of MI-related mortality (OR, 1.18–1.74) compared with cold spells (OR, 1.04–1.12). Exposure to PM2.5 also increased […]
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August 2, 2023 / Critical Care, Imaging, Resuscitation Written by Clay Smith A full-body CT protocol in resuscitated adults with out of hospital cardiac arrest (OHCA) more often – and more quickly – found the cause of arrest than standard of care CT but did not improve neurologically intact survival. R2, fire up the scanner…or not Yesterday we covered a retrospective […]
The post CT FIRST – Full Body CT Post-OHCA – Does CT Help? first appeared on האיגוד הישראלי לרפואה דחופה.
Written by Clark Strunk Computed tomography (CT) after out-of-hospital cardiac arrest (OHCA) often identifies clinically important pathology such as the etiology of the arrest, traumatic injuries from resuscitation, and consequences from inadequate perfusion. One, two, CT for you… OHCA is a relatively common and important presentation to the emergency department, and identification of the etiology […]
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TAKE-HOME MESSAGE The RAPID study is a large-scale multicentre, randomised, placebo-controlled, event-driven trial conducted in North America and Europe that assessed the effectiveness and safety of etripamil — a fast-acting L-type calcium-channel blocker — for terminating atrioventricular nodal–dependent paroxysmal supraventricular tachycardia (PSVT) events. The study involved using a self-administered etripamil nasal spray in a non-healthcare […]
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July 28, 2023 / Cardiology Written by Jason Lesnick A recalibrated HEART score ≤ 3 utilizing hs-cTnT ruled out MACE (adjudicated type 1 MI, unplanned coronary revascularization, and all cause death) at 30 days at a sensitivity of 98.5% and NPV of 99.7% with the ability to discharge 46.5% of patients in this cohort. Don’t break my […]
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Geoffrey C. Cloud, MB, BS1; Jeff D. Williamson, MD2; Le Thi Phuong Thao, PhD3; et alCammie Tran, MPH3; Charles B. Eaton, MD4; Rory Wolfe, PhD3; Mark R. Nelson, PhD5; Christopher M. Reid, PhD3,6; Anne B. Newman, MD7; Jessica Lockery, PhD3; Sharyn M. Fitzgerald, PhD3; Anne M. Murray, MD8; Raj C. Shah, MD9; Robyn L. Woods, PhD3; Geoffrey A. Donnan, MD10; John J. McNeil, PhD3 Author Affiliations Article Information JAMA Netw Open. 2023;6(7):e2325803. doi:10.1001/jamanetworkopen.2023.25803 visual abstract icon Visual Abstract Key Points Question In a primary prevention setting, does long-term, daily low-dose aspirin treatment affect the incidence of stroke or intracerebral bleeding? Findings This secondary […]
The post Low-Dose Aspirin and the Risk of Stroke and Intracerebral Bleeding in Healthy Older People Secondary Analysis of a Randomized Clinical Trial first appeared on האיגוד הישראלי לרפואה דחופה.
van Baarle FLF, van de Weerdt EK, van der Velden WJFM, Ruiterkamp RA, Tuinman PR, Ypma PF, van den Bergh WM, Demandt AMP, Kerver ED, Jansen AJG, Westerweel PE, Arbous SM, Determann RM, van Mook WNKA, Koeman M, Mäkelburg ABU, van Lienden KP, Binnekade JM, Biemond BJ, Vlaar APJ. Abstract […]
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July 26, 2023 / Technology Written by Doug Wallace Verified physician answers to patient questions on a public social media forum were compared to Chatbot answers to the same questions by rating the quality and empathy of responses. Guess who won? ChatGPT vs Physicians: FIGHT! Artificial Intelligence (AI) utilization is on the rise in health care settings, […]
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Youngran Kim, PhD1; Trudy Millard Krause, DrPH1; Scott D. Lane, PhD2 Key Points Question Did trends and seasonal patterns of suicidality among children and adolescents change after the onset of the COVID-19 pandemic in March 2020? Findings This cross-sectional study of 73 123 emergency department (ED) visits and hospitalizations for suicidality found that the incidence of ED visits and hospitalizations increased from 2016 to 2021, […]
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Richard J. Fantus, MD1; Robert E. Brannigan, MD2; Andrew M. Davis, MD, MPH3 Guideline titles Priapism in People With and Without Sickle Cell Disease: Acute Diagnosis and Treatment Release dates November 2021 and July 2022 Developer and funding source American Urological Association (AUA) and Sexual Medicine Society of North America (SMSNA) Target population Males, including those with hematologic and oncologic disorders (eg, sickle cell disease [SCD]; chronic […]
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Brennan Carne MBChB, Aditya Raina BSc, MBChB, Roshit Bothara BSc, MBChB, BMedSc (Hons), DCH, Andrew McCombie PhD, Dominic Fleischer MBChB, FACEM, Laura R Joyce MBChB, FACEM, MMedEd, BMedSc (Hons), CCPU Abstract Objective To identify factors associated with death secondary to haemorrhage following major trauma. Methods A retrospective case–control study was conducted on data from adult major […]
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Sandra L Peake BMBS, BSc (Hons), FCICM, PhD, Anthony Delaney MBBS, MSc, PhD, FACEM, FCICM, Mark Finnis MBBS, MBiostat, FCICM … See all authors Abstract Objective Optimal resuscitation of sepsis-induced hypotension is uncertain, particularly the role of restrictive fluid strategies, leading to variability in usual practice. The objective of this study is to […]
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Robert Smyth, M.D., Christopher Kabrhel, .D., M.P.H., and Timothy Morris, M.D. Case Vignette A Woman with a Pulmonary Embolism Robert Smyth, M.D. A 33-year-old woman presents to her local rural health center with acute-onset dyspnea and chest pain. She has no relevant medical history and takes a combined oral contraceptive for birth control. On examination, she has […]
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July 17, 2023 / Trauma Written by Michelle Skuba Gray This large multi-center retrospective cohort study found no difference in overall risk-adjusted mortality for severely injured trauma patients treated by a surgeon versus non-surgeon trauma team leader (TTL). Interchangeable, to a point This study advocates that EM physicians are equally capable as surgeons to be TTL for […]
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Abstract BACKGROUND Whether prehospital administration of tranexamic acid increases the likelihood of survival with a favorable functional outcome among patients with major trauma and suspected trauma-induced coagulopathy who are being treated in advanced trauma systems is uncertain. METHODS We randomly assigned adults with major trauma who […]
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TAKE-HOME MESSAGE In this study, a risk-stratification score was developed for the prediction of major arrhythmic events (MAE) — defined as sudden cardiac arrest, sudden cardiac death, sustained ventricular tachycardia, ventricular fibrillation, or appropriate ICD therapy — in patients with Brugada syndrome (BrS). The Predicting Arrhythmic Event (PAT) score was constructed on the basis of […]
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Journal of the American College of Cardiology TAKE-HOME MESSAGE This large database analysis of American and Canadian patients sought to evaluate the risk of ventricular arrhythmia associated with the use of over-the-counter opioids, specifically loperamide and mitragynine (kratom, an over-the-counter herbal supplement commonly used for opioid withdrawal). The […]
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July 14, 2023 / Airway, Pediatrics Written by Vivian Lei Emergency intubation in children has similar procedural success rates when directly or indirectly lifting the epiglottis. When indirectly lifting the epiglottis, engagement of the median glossoepiglottic fold is associated with better visualization and success. The view is better with VL Kids are less tolerant of prolonged and multiple intubation attempts […]
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July 13, 2023 / Imaging, Surgery Written by Vivian Lei This ACEP clinical policy covers issues in the evaluating and managing ED patients with suspected appendicitis including clinical prediction rules, comparative imaging modalities, and need for IV contrast in CT imaging. Still a hot topic: appendicitis This ACEP clinical policy was updated recently for ED patients with acute […]
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Leanne Greene ,1 Rachel Lane,1 Maria Crotty,1 Craig Whitehead,1 Elizabeth Potter,1 Petra Bierer,2 Kate Laver בעברית : אשפוז בית Abstract Background High emergency department (ED) usage by older individuals for non-emergencies is a global concern. ED avoidance initiatives have proven effective in addressing this issue. […]
The post Evaluating a new emergency department avoidance service for older people: patient and relative experiences first appeared on האיגוד הישראלי לרפואה דחופה.
Prekker ME, Driver BE, Trent SA, Resnick-Ault D, Seitz KP, Russell DW, Gaillard JP, Latimer AJ, Ghamande SA, Gibbs KW, Vonderhaar DJ, Whitson MR, Barnes CR, Walco JP, Douglas IS, Krishnamoorthy V, Dagan A, Bastman JJ, Lloyd BD, Gandotra S, Goranson JK, Mitchell SH, White HD, Palakshappa JA, Espinera A, Page DB, Joffe A, Hansen […]
The post NEJM: Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults first appeared on האיגוד הישראלי לרפואה דחופה.
Nuala Quinn MBChB, FRCPI, Grantley Ward B-BMed, MD, Cyril Ong FRCR, FRANZCR, David Krieser MBBS, FRACP, Robert Melvin MBBS, FACEM … See all authors First published: 23 November 2022 https://doi.org/10.1111/1742-6723.14141 Abstract Objective Life-threatening thoracic trauma requires emergency pleural decompression and thoracostomy and chest drain insertion are core trauma procedures. Reliably determining a safe […]
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Raeed Deen MD, MMedStats, Calyb Austin MD, Andrew Bullen MBBS, FRACS First published: 22 March 2023 https://doi-org.ezproxy.bgu.ac.il/10.1111/1742-6723.14202 Abstract Young adults who present to the ED with neck pain following non-penetrating, seemingly trivial trauma to the neck, are at risk of neck artery dissection and subsequent stroke. Sport-related neck injury is the chief cause. […]
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Arthur James, MD, PhD1; Anatole Harrois, MD, PhD2; Paer-Selim Abback, MD3; et alJean Denis Moyer, MD4; Caroline Jeantrelle, MD5; Jean-Luc Hanouz, MD, PhD4,6; Mathieu Boutonnet, MD7,8; Thomas Geeraerts, MD, PhD9; Anne Godier, MD, PhD10; Julien Pottecher, MD, PhD11; Delphine Garrigue-Huet, MD12; Jean Cotte, MD13; Jean Pasqueron, MD14; Arnaud Foucrier, MD5,15; Tobias Gauss, MD16; Mathieu Raux, MD, PhD17; for the French Observatory for Major Trauma (TraumaBase) Author Affiliations Article Information JAMA Netw Open. 2023;6(6):e2320960. doi:10.1001/jamanetworkopen.2023.20960 Key Points Question What is the severity of injuries associated with electric scooters (e-scooters) compared with motorbikes or bicycles? Findings In this cohort study of 5233 patients referred in […]
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Brit Long, MD*; Michael Gottlieb, MD Peritonsillar abscess is defined as a collection of pus between the palatine tonsil capsule and the pharyngeal muscles. It most often affects the superior pole of the tonsil and, after that, the middle and inferior poles. The condition may be preceded by pharyngitis or tonsillitis, or it may occur without a […]
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Qiuzhe Chen ,1 Chris G Maher,1 Eileen Rogan,2 Gustavo Machado Abstract Background Disparate care in the ED for minority populations with low back pain is a long-standing issue reported in the USA. Our objective was to compare care delivery […]
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Stig Walravens, MD1,2; Albina Zharkova, MD, PhD3; Anja De Weggheleire, MD, MPH1; et alMarie Burton, MPH4; Jean-Clément Cabrol, MD4; James S. Lee, MD, MSc1,5 Author Affiliations Article Information JAMA Netw Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 Key Points Question How can medical evacuation trains be implemented in a war zone and what type of patients can be expected? Findings This case series describes medical evacuation by train during the 2022 Ukraine conflict using […]
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Joseph El Dahdah, MD Joseph Kassab, MD 1 Michel Chedid El Helou, MD 1 Andrew Gaballa, MD Stephen Sayles III, MD Michael P. Phelan, MD Published:June 17, 2023DOI:https://doi.org/10.1016/j.annemergmed.2023.04.027 Introduction Currently, the physician-patient relationship is becoming a triad, with patients relying more on online symptom research. In November 2022, Chat Generative Pretrained Transformer (ChatGPT), […]
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עלייה דרמטית במספר הפניות למרכזים לרפואה דחופה בישראל ללא עלייה הולמת במספר התקנים – והתוצאה היא מצוקה ועומסים בלתי נתפסים. שבוע רפואה דחופה בישראל, הוא הזדמנות להוקיר תודה לאנשים בחוד החנית של הצלת החיים, ולדרוש גיוס כוח אדם איכותי ד”ר צחי סלוצקי|אתמול | 20:17 ליל יום ראשון, 3 לפנות בוקר. שקט שורר ברחבי בית […]
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Chinedu Ulrich Ebenebe1, Kristina Schriever1, Sofia Apostolidou1, Monika Wolf1, Jochen Herrmann2, Dominique Singer1 Philipp Deindl1 Correspondence to Dr Chinedu Ulrich Ebenebe, Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; c.ebenebe@uke.de Abstract Background Endotracheal tube (ETT) malposition is frequent in paediatric intubation. The current recommendations for ETT insertion depths are based […]
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Guideline title ESICM Guidelines on Acute Respiratory Distress Syndrome: Definition, Phenotyping and Respiratory Support Strategies Release date June 16, 2023 Developer European Society of Intensive Care Medicine (ESICM) Target population Adult patients with or at risk for acute respiratory distress syndrome (ARDS) Major recommendations For nonintubated patients with acute hypoxemic respiratory failure not due to […]
The post JAMA: Caring for Patients With Acute Respiratory Distress Syndrome, 2023 Practice Guidelines first appeared on האיגוד הישראלי לרפואה דחופה.
Glenn Eastwood, Ph.D., Alistair D. Nichol, Ph.D., Carol Hodgson, Ph.D., Rachael L. Parke, Ph.D., Shay McGuinness, M.B., Ch.B., Niklas Nielsen, Ph.D., Stephen Bernard, M.D., Markus B. Skrifvars, Ph.D., Dion Stub, Ph.D., Fabio S. Taccone, Ph.D., John Archer, Ph.D., Demetrios Kutsogiannis, M.D., Abstract BACKGROUND Guidelines recommend normocapnia for adults with coma who are resuscitated after out-of-hospital cardiac arrest. However, mild hypercapnia increases cerebral blood flow and may […]
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Abdulrhman Alghamdi PhD a b, Mark Hann PhD c, Edward Carlton MB ChB, PhD d, Jamie G. Cooper MB ChB e f, Eloïse Cook PhD g, Angela Foulkes h, Aloysius N. Siriwardena MBBS, PhD i, John Phillips j, Alexander Thompson PhD c, Steve Bell MSc k, Kim Kirby PhD l, Andy Rosser MSc m, Richard Body MBChB, PhD g n o Study objective Chest pain is one of the most common reasons for emergency ambulance calls. Patients are routinely transported to the hospital to prevent acute myocardial infarction (AMI). We evaluated the diagnostic accuracy of clinical pathways in the out-of-hospital environment. The Troponin-only Manchester Acute Coronary Syndromes decision aid and History, ECG, Age, […]
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Khand, Aleem U.; Backus, Barbra; Campbell, Michael; … Mumma, Bryn E. Study objective We examined the diagnostic performance of a recalibrated History, Electrocardiogram, Age, Risk factors, Troponin (HEART), and Thrombolysis in Myocardial Infarction (TIMI) score in patients with suspected acute cardiac syndrome (ACS). Recalibration of troponin thresholds was performed, including shifting from the 99th percentile […]
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Sadiya S. Khan, MD, MSc1,2; Wendy S. Post, MD3; Xiuqing Guo, PhD4; et alJingyi Tan, MA4; Fang Zhu, MSc, MPH5; Daniel Bos, MD, PhD5,6; Bahar Sedaghati-Khayat, MSc7; Jeroen van Rooij, PhD7; Aaron Aday, MD, MS8; Norrina B. Allen, PhD2; Maxime M. Bos, PhD5; André G. Uitterlinden, PhD5,7; Matthew J. Budoff, MD9; Donald M. Lloyd-Jones, MD, ScM1,2; Jonathan D. Mosley, MD, PhD8,10; Jerome I. Rotter, MD4; Philip Greenland, MD1,2,11; Maryam Kavousi, MD, PhD5 Author Affiliations Article Information JAMA. 2023;329(20):1768-1777. doi:10.1001/jama.2023.7575 Key Points Question Does discrimination change when either a coronary artery calcium score or a polygenic […]
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Dimitrios Doudesis, Kuan Ken Lee, Jasper Boeddinghaus, Anda Bularga, Amy V. Ferry, Chris Tuck, Matthew T. H. Lowry, Pedro Lopez-Ayala, Thomas Nestelberger, Luca Koechlin, Miguel O. Bernabeu, Lis Neubeck, Atul Anand, Karen Schulz, Fred S. Apple, William Parsonage, Jaimi H. Greenslade, Louise Cullen, John W. Pickering, Martin P. Than, Alasdair Gray, Christian Mueller, Nicholas L. Mills & CoDE-ACS Investigators Abstract […]
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Low CJW, Ramanathan K, Ling RR, Ho MJC, Chen Y, Lorusso R, MacLaren G, Shekar K, Brodie D. Abstract Background: Although outcomes of patients after cardiac arrest remain poor, studies have suggested that extracorporeal cardiopulmonary resuscitation (ECPR) might improve survival and neurological outcomes. We aimed to investigate any potential benefits of […]
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June 7, 2023 / Pain/Sedation/Procedure, Pulmonary/Allergy, Surgery Written by Megan Hilbert Primary spontaneous pneumothorax (PSP) may be most cost-effectively managed by observation alone in the appropriate patient population. Why does this matter? The British Thoracic Society guidelines currently indicate placement of pleural drain for symptomatic pneumothorax greater than 2cm in size on chest X-ray. This paper demonstrated that observation […]
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Michael Jarvis Boyle1, Margaret Lin-Martore2, Sally Graglia1
Correspondence to Dr Michael Jarvis Boyle, Emergency Medicine, University of California San Francisco, San Francisco, CA 94143-0203, USA; michael.boyle@ucsf.edu
Case presentationA 15-year-old boy presents to the ED with 1 day of periumbilical non-radiating abdominal pain. The pain, described as a stinging sensation, started gradually 1 day prior to presentation after eating lunch and increased to an intensity of 8 out of 10 at its worst over the day. The patient reports that the pain has since improved to 4 out of 10. He does not have fevers, chills, anorexia, nausea, emesis, urinary symptoms, stool changes, testicular pain or swelling, and prior abdominal surgery. The patient has no significant medical or surgical history, takes no medications and has no allergies.
He is afebrile with other triage vital signs notable for a BP of 135/77 mm Hg, low-grade tachycardia with an HR of 101 beats/min, a normal RR of 18 breaths/min and a normal oxygen saturation of 100% on room air. On physical examination, he is a well-appearing adolescent boy lying in bed in no acute distress. He is breathing comfortably, and his cardiovascular examination reveals strong radial pulses with a regular rate and rhythm, and warm extremities. He has normal bowel sounds. On palpation, his abdomen is soft and flat, but he has tenderness at McBurney’s point. There is voluntary guarding, but no rigidity or rebound tenderness. Deep palpation in the left lower quadrant reproduces his pain in the right lower quadrant (RLQ) (Rovsing’s sign). On further evaluation, he has no inguinal hernia, and his testicles are neither swollen nor tender. He has no costovertebral angle tenderness. His skin is warm and dry.
A complete blood count reveals no leucocytosis, and a comprehensive metabolic panel including liver function tests is without abnormalities. Inflammatory markers are not obtained. His urine has no occult blood, leucocyte esterase or nitrites.
What are the indications for evaluation of the appendix with point-of-care ultrasound (POCUS)?History and physical examination alone are often insufficient to rule in or rule out paediatric appendicitis, so imaging including POCUS is often necessary.1 POCUS of the appendix should be considered when there is undifferentiated abdominal pain and especially if there is clinical suspicion for appendicitis, such as the presence of RLQ or periumbilical abdominal pain, nausea and vomiting, or fever, with abdominal tenderness to palpation. Both the American College of Radiology Appropriateness Criteria and the American College of Emergency Physicians clinical policy statement recommend an ultrasound (US) of the RLQ as the initial study of choice in suspected paediatric appendicitis.2 3 Although these policies refer to a radiology-performed US, POCUS in the hands of a provider comfortable with proper technique has been shown to be fast and accurate when compared with a radiology-performed study, and has the potential to shorten ED length of stay.4 5 Therefore, POCUS is worth considering as the initial imaging modality in any paediatric patient with the appropriate characteristics in whom appendicitis is suspected.
Which transducer is best suited for performing POCUS of the appendix?To maximise resolution, the highest possible frequency should be used to visualise the appendix. In most patients, a high-frequency linear transducer (mean frequency 5 MHz or greater) can often penetrate deep enough to visualise the appendix, whereas in larger patients, a deeper-penetrating low-frequency curvilinear transducer (mean frequency between 4 MHz and 6 MHz) may be necessary.6
What views should be obtained when assessing the appendix?There are four views necessary to accurately diagnose appendicitis and to minimise false positives: (1) a view of the tip of the appendix in the long orientation to identify it as a blind-ended tube; (2) a view of the appendix in a transverse orientation to identify it as a circular structure in cross section measuring at least 6 mm in diameter as measured from the most superficial to the deepest wall; (3) an online supplemental video 2 of the appendix, ideally in the transverse orientation, with compression to demonstrate that it is non-compressible and not peristalsing; and (4) online supplemental video 1 tracing the appendix in its entirety from its base, where it joins the cecum to its to tip in either transverse or long in order to provide the full context to adequately convince a viewer that the structure is the appendix. An additional helpful view is in the transverse plane with colour Doppler applied to demonstrate that the identified structure is not a vessel and to assess for wall hyperaemia. Assessing for hyperaemia, we found that a pattern of exaggerated colour Doppler flow in the appendiceal wall indicative of increased blood flow is not mandatory but can provide further evidence of inflammation. In order to assess for hyperaemia, the operator must use colour Doppler or power Doppler at a setting to detect low-flow velocities (eg, scale up to 10 cm/s) with the colour gain increased enough such that normal tissue exhibits rare, scattered colour.7
Supplementary video[emermed-2022-212433supp002.mov]Supplementary video[emermed-2022-212433supp001.mov]How do you interpret POCUS of the appendix?The typical appearance of the normal appendix is an oval or circle in the transverse plane with a maximal diameter of 6 mm,8 and a blind-ending tubular structure in the longitudinal plane. A normal appendix should be compressible. It can be differentiated from small bowel by the lack of peristalsis and its blind end, from large bowel by its small calibre, and from iliac vessels by their pulsatility and their flow seen with colour Doppler.
The diagnosis of appendicitis is made by identifying a non-compressible, non-peristalsing, blind-ended, tubular structure measuring greater than 6 mm in diameter (measured from outer edge to outer edge at its widest point along its length) (figure 1). Secondary signs of appendicitis can also be visualised, including hyperaemia, periappendiceal or pericecal fluid, free fluid, phlegmon, pericecal inflammatory fat changes and an appendicolith.9–11 Hyperaemia in the wall of the appendix can be visualised with colour or power Doppler.9 10 As an inflamed bowel wall becomes more oedematous, the distinct layers of the wall become apparent, with hyperechoic layers separated by anechoic layers of oedema, which can help to differentiate an inflamed appendix from other small bowel or iliac vessels.9 10 Occasionally, an appendicolith can be visualised, which appears as a hyperechoic interface with sonographic shadowing within the appendix similar to the appearance of a gallstone.10
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- Download powerpoint Figure 1Point-of-care ultrasound of the right lower quadrant using a high-frequency linear transducer reveals a tubular, blind-ended, fluid-filled structure in the longitudinal plane.
What is the interpretation of this patient’s US?The visualised appendix is a tubular, blind-ended structure (figure 1), 8.4 mm in diameter with multiple layers of oedematous bowel wall visible (figure 2), and is non-compressible and non-peristalsing (not shown). The first online supplemental video 1 traces the appendix from the tip to its origin at the cecum (note the surrounding inflammatory fat stranding). Finally, the image in figure 3 confirms with colour Doppler that it is not a vascular structure. This US is diagnostic for appendicitis.
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Download powerpoint Figure 2The appendix in the transverse plane measuring 8.4 mm in diameter (measurement in top left corner). Multiple layers of the oedematous bowel wall are visible as alternating hyperechoic and anechoic rings.
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What is the evidence for using appendix POCUS in clinical practice?POCUS is accurate, rapidly performed at the bedside (less than 10 min4), can shorten ED length of stay5 and can reduce patient exposure to the ionising radiation used in CT.4 5 Multiple single-centre studies have demonstrated that emergency physician-performed POCUS is specific for ruling in appendicitis and has test characteristics similar to that of radiology-performed US.12–14 Reported POCUS test characteristics for appendicitis range from sensitivities of 60%–96% and specificities of 68%–97%.4–6 9 10 15 In two studies that directly compared POCUS to radiology-performed US, the test characteristics were similar.4 5 In the case of an equivocal study, multiple studies have validated the efficacy of following an indeterminate POCUS with a radiology-performed US or CT to increase accuracy and minimise false negatives.4 5 16
POCUS offers several advantages over a radiology-performed US. One study demonstrated the use of POCUS first rather than radiology-performed US or CT reduced ED length of stay by 46% and 68%, respectively.5 In many facilities, radiology-performed US may not be available during specific hours or may not be present at all. Radiology-performed imaging may also require transfer of a sick patient out of the ED or even to another facility. When compared with radiology-performed US and CT, POCUS may be more affordable for the patient and spares the patient the ionising radiation of CT.17 Given the high specificity of POCUS for appendicitis, the benefits of early identification and the aforementioned logistical factors likely outweigh the additional time it requires.4 5 12–14 18
What are some expert tips when performing POCUS of the appendix?Finding the appendix is the most challenging aspect of this study. There are three general approaches: (1) placing the transducer on the point of maximal tenderness, (2) using anatomical landmarks (figure 4) and (3) the sweeping Sivitz method (figure 5). The anatomical approach used at our institution begins with scanning low in the RLQ in the axial plane near the inguinal ligament until the iliac vessels are identified. Moving superiorly, one can identify the cecum as the first area of air shadowing. The appendix can often be found by systematically searching around in the area of the cecum, especially at the point of maximal tenderness, with graded compression, a technique where increasingly firmer pressure is applied with each patient exhalation such that intervening bowel is pushed aside.2 6 9 Vascular structures, typically the iliac vessels, can mimic the appendix in the transverse plane, so colour Doppler is useful to differentiate the two.
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Download powerpoint Figure 4The anatomical method to find the appendix begins with finding the iliac vessels at the inguinal ligament and moving superiorly to identify the cecum. The appendix can often be found medial to the cecum overlying the iliac vessels. Note that graded compression is used throughout the study to displace the bowel.
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- Download powerpoint Figure 5The Sivitz method begins with the probe transverse at the umbilicus. The operator then moves the probe laterally to the lateral border of the ascending colon (1), inferiorly to the end of the cecum (2), medially across the psoas and iliac vessels (3), then up and down along the medial edge of the cecum (4). If unsuccessful, the operator can place the probe in a sagittal orientation over the cecum and move medially across the psoas (not shown). The Anterior Superior Iliac Spine (ASIS) and inguinal ligament are included for anatomical reference. Note that graded compression is used throughout the study to displace the bowel.
Sivitz et al also recommend the following standardised protocol12: ‘With the probe initially in the transverse position at the level of the umbilicus and using compression, move laterally to identify the lateral border of the ascending colon. Move down the lateral border to the end of the cecum. Move medially across the psoas and iliac vessels. Move down and up the border of the cecum’. Then, ‘with the probe in a sagittal position, identify the end of the cecum in the long axis and move medially across the psoas’. The cecum appears as air shadowing (a hyperechoic line close to the probe with shadowing behind it), whereas small bowel is often fluid-filled, mobile and can be seen peristalsing.
Alternatively, one can simply find the iliacs in the transverse plane in the RLQ and follow them superiorly and inferiorly looking for a blind-ended tubular sac draped over them.
What are some pitfalls of performing appendix US?The most significant pitfalls are the inability to locate the appendix, mistaking the small bowel for a dilated appendix, mistaking vascular structures for the appendix (mitigated by the use of colour Doppler), difficulty displacing bowel gas by graded compression, and prematurely excluding perforated appendicitis when the appendix cannot be visualised.
Inability to locate the appendixEven with the use of the aforementioned protocols, visualising the appendix can be challenging. In fact, non-visualisation of the appendix may be the most probable outcome. Multiple studies have documented non-visualisation rates from 29% to as great as 54% to 73% in larger studies, even when US technicians acquire the images.11 12 15 19–21 Several factors make identification of the appendix difficult, including the sonographic shadowing from surrounding bowel gas, the absence of clear delineation between distinct loops of bowel, and the multiple possible orientations of the appendix (eg, retrocecal). Given these difficulties, an extended search may be necessary, so adequate analgesia is essential to allow the patient to tolerate the study without premature termination. Increased body mass index may also influence visualisation of the appendix. While some studies have argued that increased body mass index increases the rate of indeterminate US studies, other studies have found no such effect.12 21 22 Fortunately, there is some evidence that in the right clinical context, a study without a visualised appendix that also has no secondary signs of appendiceal inflammation has a high negative predictive value.11 19 21 23 Importantly, however, non-visualisation may also signify appendiceal perforation. As previously mentioned, if there is concern for appendicitis, an equivocal study should be followed by a radiology-performed US or cross-sectional imaging.
Mistaking the small intestine for the appendixA common cause of false-positive POCUS of the appendix is the misidentification of the small bowel as a dilated appendix. For this reason, it is essential that the appendix be thoroughly visualised in the long axis and confirmed to have a blind end. Additionally, the small bowel can often exhibit peristalsis, which will not be present in the appendix.
Case conclusionThe patient was diagnosed with acute appendicitis by POCUS, which significantly accelerated his disposition since no US technicians were in-house at the time of his presentation. Surgery was consulted and the patient was admitted within an hour of the initial POCUS in the late evening with a plan for appendectomy the following morning. The patient was made nil per os and given antibiotics and pain control. Since the patient was stable early in the course of his illness and could not be scheduled for surgery until the following day, the surgical team opted to corroborate the POCUS findings with an attending radiologist interpretation prior to operating, necessitating a radiology-performed US. The radiology-performed US corroborated the diagnosis with findings of a dilated appendix 10 mm in diameter, with associated hyperaemia and recruited periappendiceal fat. No appendicolith was visualised. Later that afternoon, the patient had an unremarkable laparoscopic appendectomy and was discharged home the next day.
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Stacy A. Trent MD, MPH a b, Brian E. Driver MD c, Matthew E. Prekker MD, MPH c d, Christopher R. Barnes MD e, Joseph M. Brewer MD g, Kevin C. Doerschug MD h, John P. Gaillard MD i, Kevin W. Gibbs MD j, Shekhar Ghamande MD k, Christopher G. Hughes MD l, David R. Janz MD, MSc o p, Akram Khan MD r, Steven H. Mitchell MD f, David B. Page MD s t, Todd W. Rice MD m, Derek W. Russell MD u, Wesley H. Self MD n, Lane M. Smith MD, PhD i, Susan Stempek PA v, Derek J. Vonderhaar MD q…Matthew W. Semler MD, MSc mStudy objectives Successful intubation on the first attempt has historically been defined as successful placement of an endotracheal tube (ETT) using a single laryngoscope insertion. More recent studies have defined successful placement of an ETT using a single laryngoscope insertion followed by a single ETT insertion. We sought to estimate the prevalence of first-attempt success using these 2 definitions and estimate their associations with the duration of intubation and serious complications.
MethodsWe performed a secondary analysis of data from 2 multicenter randomized trials of critically ill adults being intubated in the emergency department or ICU. We calculated the percent difference in successful intubations on the first attempt, median difference in the duration of intubation, and percent difference in the development of serious complications by definition.
ResultsThe study population included 1,863 patients. Successful intubation on the first attempt decreased by 4.9% (95% confidence interval 2.5% to 7.3%) when defined as 1 laryngoscope insertion followed by 1 ETT insertion (81.2%) compared with when defined as only 1 laryngoscope insertion (86.0%). When successful intubation with 1 laryngoscope and 1 ETT insertion was compared with 1 laryngoscope and multiple ETT insertions, the median duration of intubation decreased by 35.0 seconds (95% confidence interval 8.9 to 61.1 seconds).
ConclusionDefining successful intubation on the first attempt as placement of an ETT in the trachea using 1 laryngoscope and 1 ETT insertion identifies attempts with the shortest apneic time.
The post Defining Successful Intubation on the First Attempt Using Both Laryngoscope and Endotracheal Tube Insertions: A Secondary Analysis of Clinical Trial Data first appeared on האיגוד הישראלי לרפואה דחופה.
EM Board Bombs · 178. Eye Irrigation and tide pod challenge (yes, its back!)Things are so crazy on TikTok now they are running out of challenges. time to recycle old ones? Enter the Tide pod challenge. Let’s talk eye irrigation and this critically tested vision emergency.
Want to experience the greatest in board studying? Check out our interactive question bank podcast- the FIRST of its kind here: emrapidbombs.supercast.com.
Cite this podcast as: Briggs, Blake. Episode 178. Eye Irrigation and tide pod challenge (yes, its back!). www.emboardbombs.com/podcasts/178-e…e-yes-its-back. May 30th, 2023. Accessed [date]
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Floor L.F. van Baarle, M.D., Emma K. van de Weerdt, M.D., Ph.D., Walter J.F.M. van der Velden, M.D., Ph.D., Roelof A. Ruiterkamp, M.Sc., Pieter R. Tuinman, M.D., Ph.D., Paula F. Ypma, M.D., Ph.D.,
Walter M. van den Bergh, M.D., Ph.D., Astrid M.P. Demandt, M.D., Emile D. Kerver, M.D., A.J. Gerard Jansen, M.D., Ph.D., Peter E. Westerweel, M.D., Ph.D., Sesmu M. Arbous, M.D., Ph.D.,
Abstract BACKGROUNDTransfusion guidelines regarding platelet-count thresholds before the placement of a central venous catheter (CVC) offer conflicting recommendations because of a lack of good-quality evidence. The routine use of ultrasound guidance has decreased CVC-related bleeding complications.
METHODSIn a multicenter, randomized, controlled, noninferiority trial, we randomly assigned patients with severe thrombocytopenia (platelet count, 10,000 to 50,000 per cubic millimeter) who were being treated on the hematology ward or in the intensive care unit to receive either one unit of prophylactic platelet transfusion or no platelet transfusion before ultrasound-guided CVC placement. The primary outcome was catheter-related bleeding of grade 2 to 4; a key secondary outcome was grade 3 or 4 bleeding. The noninferiority margin was an upper boundary of the 90% confidence interval of 3.5 for the relative risk.
RESULTSWe included 373 episodes of CVC placement involving 338 patients in the per-protocol primary analysis. Catheter-related bleeding of grade 2 to 4 occurred in 9 of 188 patients (4.8%) in the transfusion group and in 22 of 185 patients (11.9%) in the no-transfusion group (relative risk, 2.45; 90% confidence interval [CI], 1.27 to 4.70). Catheter-related bleeding of grade 3 or 4 occurred in 4 of 188 patients (2.1%) in the transfusion group and in 9 of 185 patients (4.9%) in the no-transfusion group (relative risk, 2.43; 95% CI, 0.75 to 7.93). A total of 15 adverse events were observed; of these events, 13 (all grade 3 catheter-related bleeding [4 in the transfusion group and 9 in the no-transfusion group]) were categorized as serious. The net savings of withholding prophylactic platelet transfusion before CVC placement was $410 per catheter placement.
CONCLUSIONSThe withholding of prophylactic platelet transfusion before CVC placement in patients with a platelet count of 10,000 to 50,000 per cubic millimeter did not meet the predefined margin for noninferiority and resulted in more CVC-related bleeding events than prophylactic platelet transfusion. (Funded by ZonMw; PACER Dutch Trial Register number, NL5534. opens in new tab.)
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May 29, 2023 / Venous ThromboembolismWritten by Chris Thom
In a retrospective cohort of patients with acute pulmonary embolism (PE) and a low pulmonary embolism severity index (PESI) score, increased heart rate and bilateral PE were factors associated with physicians’ decision for hospitalization.
Why does this matter?
In the US, approximately half of DVTs are discharged from the emergency department (ED), while less than 10% of PEs receive outpatient management.1-4 Although high-risk PE is associated with considerable mortality, the majority of patients with acute PE are hemodynamically stable and have low 30-day mortality rates.5,6 It is estimated that approximately 30-50% of low-risk PEs may be safe for discharge.1,7-10 The pulmonary embolism severity index (PESI) is a clinical decision rule that seeks to aid in identifying individuals with low risk PE.11,12 Despite the growing body of clinical trial and real-world evidence to suggest outpatient treatment of low-risk PE is both safe and efficacious, many of these patients are still admitted.
A decision on hospitalization is often more than the PESI score….
This was a retrospective cohort of patients from 21 community EDs in California from January 2019 to February 2020. The authors previously performed a pragmatic trial of clinical decision support (CDS) embedded in the electronic health record to provide physicians with risk-based recommendations on PE management. In the current study, the authors performed a retrospective analysis four years following the CDS intervention. They evaluated low-risk patients with acute PE (PESI ≤ 85) for factors associated with the disposition decision.
461 low-risk patients were identified, 265 were admitted and 196 discharged. Heart rate > 110 had an odds ratio (OR) for admission of 3.11 (95%CI 1.07 to 9.57) and heart rate 90-109 had an OR of 2.03 (95%CI 1.18 to 3.50). Presence of bilateral PEs (as opposed to unilateral PE) had an OR of 1.92 for hospitalization (95%CI 1.13 to 3.27). The authors noted that 90% (37/41) of patients with RV dilatation by CT criteria were hospitalized.
In short, heart rate ≥90 and bilateral PEs had the biggest influence on the decision to admit patients who otherwise had low-risk PE based on PESI score.
Source
Bilateral Emboli and Highest Heart Rate Predict Hospitalization of Emergency Department Patients With Acute, Low-Risk Pulmonary Embolism [published online ahead of print, 2023 Apr 5]. Ann Emerg Med. 2023;S0196-0644(23)00123-3.
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ACEP Frontline · Tactical EMS And Care In The Warm Zone – Dr. Brian SpringerIn further efforts to get people the life saving care they need as soon as possible, we chat about tactical EMS/medicine. We focus on some of the realities with steps towards better preparedness and training.The post PODCAST: Tactical EMS And Care In The Warm Zone – Dr. Brian Springer first appeared on האיגוד הישראלי לרפואה דחופה.
May 29, 2023
Contributor: Travis Barlock MD
Educational Pearls:
- Three categories of pressors: inopressors, pure vasoconstrictors, and inodilators
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Inopressors:
- Epinephrine – nonselective beta- and alpha-adrenergic agonism, leading to increased cardiac contractility, chronotropy (increased heart rate), and peripheral vasoconstriction. Dose 0.1mcg/kg/min.
- Levophed (norepinephrine) – more vasoconstriction peripherally than inotropy; useful in most cases of shock. Dose 0.1mcg/kg/min.
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Peripheral vasoconstrictors:
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Phenylephrine – pure alpha agonist; useful in atrial fibrillation because it avoids cardiac beta receptor activation and also in post-intubation hypotension to counteract the RSI medications. Start at 1mcg/kg/min and increase as needed.
- Vasopressin – No effect on cardiac contractility. Fixed dose of 0.4 units/min.
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Inodilators are useful in cardiogenic shock but often not started in the ED since patients mostly have undifferentiated shock
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Dobutamine – start at 2.5mcg/kg/min.
- Milrinone – 0.125mcg/kg/min.
References
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Ellender TJ, Skinner JC. The Use of Vasopressors and Inotropes in the Emergency Medical Treatment of Shock. Emerg Med Clin North Am. 2008;26(3):759-786. doi:https://doi.org/10.1016/j.emc.2008.04.001
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Hollenberg SM. Vasoactive drugs in circulatory shock. Am J Respir Crit Care Med. 2011;183(7):847-855. doi:10.1164/rccm.201006-0972CI
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Lampard JG, Lang E. Vasopressors for hypotensive shock. Ann Emerg Med. 2013;61(3):351-352. doi:10.1016/j.annemergmed.2012.08.028
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
The post Podcast : Critical Care Medications – Vasopressors first appeared on האיגוד הישראלי לרפואה דחופה.
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Keita Shibahashi, Taichi Kato, Mayu Hikone, Kazuhiro Sugiyama FULL PDF
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Tertiary Emergency Medical Center, Metropolitan Bokutoh Hospital, Sumida-ku, Japan
- Correspondence to Dr Keita Shibahashi, Tertiary Emergy Medical Center, Metropolitan Bokutoh Hospital, Sumida-ku, 130-8575, Japan; kshibahashi@yahoo.co.jp AbstractBackground Whether and how bystander cardiopulmonary resuscitation (CPR) modifies the cardiac rhythm after out-of-hospital cardiac arrest (OHCA) over time remains unclear. We investigated the association between bystander CPR and the likelihood of ventricular fibrillation (VF) or ventricular tachycardia (VT) as the first documented cardiac rhythm.
Methods We identified individuals with witnessed OHCA of cardiac origin from a nationwide population-based OHCA registry in Japan between 1 January 2005 and 31 December 2019. The first documented cardiac rhythm was compared between patients who received bystander CPR and those who did not, using a 1:2 propensity score-matched analysis.
Results Of 309 900 patients with witnessed OHCA of cardiac origin, 71 887 (23.2%) received bystander CPR. Propensity score matching paired 71 882 patients who received bystander CPR with 143 764 who did not. The likelihood of detecting a VF/VT rhythm was significantly higher among patients who received bystander CPR than among those who did not (OR 1.66; 95% CI 1.63 to 1.69; p<0.001). Comparing the two groups at each time point, the difference in the proportions of patients with VF/VT rhythms peaked at 15–20 min but was insignificant at 30 min postcollapse (15 min after collapse; 20.9% vs 13.9%; p<0.001). The likelihood of a pulseless electrical activity rhythm was significantly lower in patients who received bystander CPR during the first 25 min postcollapse (15 min after collapse; 26.2% vs 31.5%; p<0.001). The two groups had no significant difference in the likelihood of asystole (15 min after collapse; 51.0% vs 53.3%; p=0.078).
Conclusion Bystander CPR was associated with a higher VF/VT likelihood and a lower likelihood of pulseless electrical activity at first documented rhythm analysis. Our results support early CPR for OHCA and highlight the need for further research to understand whether and how CPR modifies the cardiac rhythm after arrest.
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May 25, 2023 / Pediatrics, ResuscitationWritten by Joel Schirding
Spoon FeedUsing a 1-handed technique in infants <1yr and 2-handed technique in children >1yr resulted in deeper compressions, closer to AHA guideline recommendations, but compliance with rate and depth were mediocre regardless of technique.
Why does this matter?
There have been few in-vivo pediatric studies on CPR technique with the current AHA recommendations being based on adult or mannequin studies.
They failed to eat their Wheaties…
This was a multicenter prospective observational cohort study in 3 tertiary children’s hospital EDs utilizing institutionally established videography and CPR feedback devices. Because the AHA gives providers the option to use various compression techniques (thumb-encircling chest, 2-fingers, 1-handed, and 2-handed) they hoped to see if one technique stood out as superior in meeting AHA recommendations. Disappointingly, compressors, on average, failed to achieve the recommended depth with all techniques. The 2-finger technique was utilized too infrequently to be statistically evaluated. The 1-handed technique in <1yr olds came the closest to guideline recommendations (1/3-1/2 of the chest’s AP diameter or 3.6-4.4cm), achieving on average 2.87cm. In children >1yr old, the 2-handed technique came the closest to recommendations (4.5-5.5cm), achieving an average depth of 3.96cm. Average compression rates with the various techniques were all close to recommendations across all ages. When total compliance to AHA PALS was evaluated, accounting for both rate and depth, the 1-handed technique in <1yr was the closest at 47% compliant. The 2-handed technique in the 1 to 5 yr old group was only 24% compliant, and 16% in 5 to 8 yr group, still outpacing the abysmal performance of the 1-handed technique in these older age groups.
Peer Reviewed by Dr. Ketan Patel
Source
The effect of hand position on chest compression quality during CPR in young children: Findings from the Videography in Pediatric Resuscitation (VIPER) collaborative. Resuscitation. 2023 Apr;185:109741. doi: 10.1016/j.resuscitation.2023.109741. Epub 2023 Feb 16.
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May 24, 2023 / TraumaWritten by Vivian Lei
Spoon Feed
Information gathered from post-mortem CT shows that fatal injury patterns in blunt trauma are similar for those who die prior to ED arrival vs. after arrival. The frequent identification of unevacuated pneumothorax and endotracheal tube misplacement suggests that mandatory surgical chest decompression and tube placement confirmation should always be performed on blunt trauma arrest patients.
Why does this matter?
While formal autopsy rates in trauma patients have declined, post-mortem computed tomography (PMCT) can provide insight into the primary cause of death and potentially intervenable injury patterns in blunt trauma patients.
Autopsy by CT
This was a single-center retrospective cohort review of blunt trauma decedents who died at or within 1 hour of ED arrival and then underwent PMCT. Over the 9 year study period, 80 patients were included for analysis with an average ISS of 42. Of these, 62 lost pulses pre-hospital (77.5%) and 18 lost pulses in the trauma bay (22.5%). The most common mortal injuries were traumatic brain injury (40%), cervical spine injury (22.5%), hemothorax (22.5%), and hemoperitoneum (22.5%). These injuries did not differ significantly for pre-hospital or in-hospital arrests. Presence of potentially mortal injuries, defined as injuries which could be addressed by prehospital providers or immediately in the trauma bay such as pneumothoraces, misplaced airway devices, or long bone fractures, also did not differ significantly with an overall rate of 57.5%. Airway device malpositioning was found in 13.7% of decedents, with esophageal intubation in 5% overall. The rate of moderate to large pneumothoraces was 36.6% overall with 18.8% that were found to be unevacuated.
PMCT is an interesting concept for guiding quality improvement in trauma resuscitation, and it appears this group at Indiana University has been performing them for some time. The study is limited by its potential for selection bias, with a relatively low sample size and limited power to detect differences between the dichotomized groups. Still, it provides a good reminder to always check the airway and surgically decompress the chest in agonal blunt trauma patients.
Source
Characterization of fatal blunt injuries using post-mortem computed tomography. J Trauma Acute Care Surg. 2023 Apr 17. doi: 10.1097/TA.0000000000004012. Online ahead of print.
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EM Board Bombs · 177. Wrist Fractures: Live from SAEM’23!Marlena and Iltifat are LIVE from SAEM’23. This is their recording from the conference. We cover all wrist fractures, what you need to know, how to manage, and why you almost never need to consult Orthopedics.
Want to experience the greatest in board studying? Check out our interactive question bank podcast- the FIRST of its kind here: emrapidbombs.supercast.com.
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Contributor: Aaron Lessen, MD
Educational Pearls:
What is thrombolysis?
- Thrombolysis is performed by administration of a medication that promotes the body’s natural ability to break up clots. These medications include Alteplase (tPA) and Tenecteplase (TNK).
- The main side effect of using such an agent is bleeding which typically occurs at puncture sites but can also occur internally. However, an unusual side effect of thrombolytic agents, which occurs in about 1-5% of cases, is angioedema.
What is angioedema?
- Angioedema is a medical condition that causes swelling beneath the surface of the skin, typically in the face, lips, and throat (orolingual angioedema). Fluid leaks from blood vessels and accumulates in the deeper layers of the skin.
How are these two connected?
- The mechanism by which angioedema occurs after thrombolysis is not well understood, but it is likely connected to how tPA can increase levels of bradykinin and histamine.
- Swelling can appear suddenly but can also occur up to 24 hours after thrombolysis, and may last for a few hours or several days.
- In some cases, angioedema can affect the airways, leading to difficulty breathing.
What can be done?
- If this side effect occurs the provider can stop the medication or infusion and treat the patient with anti-histamines, steroids, epinephrine, and airway monitoring.
- Medications such as Berinert or Icatibant, typically used in hereditary angioedema or ACE-i-induced angioedema, can also be used but have limited evidence for their efficacy.
Fun fact
- tPA-related angioedema is about 4 times more likely in patients on ACE inhibitors. This is likely related to how ACE inhibitors also increase bradykinin and histamine in a patient’s body.
References
- Zhu A, Rajendram P, Tseng E, Coutts SB, Yu AYX. Alteplase or tenecteplase for thrombolysis in ischemic stroke: An illustrated review. Res Pract Thromb Haemost. 2022 Sep 20;6(6):e12795. doi: 10.1002/rth2.12795. PMID: 36186106; PMCID: PMC9487449.
- Pahs L, Droege C, Kneale H, Pancioli A. A Novel Approach to the Treatment of Orolingual Angioedema After Tissue Plasminogen Activator Administration. Ann Emerg Med. 2016 Sep;68(3):345-8. doi: 10.1016/j.annemergmed.2016.02.019. Epub 2016 May 10. PMID: 27174372.
- Burd M, McPheeters C, Scherrer LA. Orolingual Angioedema After Tissue Plasminogen Activator Administration in Patients Taking Angiotensin-Converting Enzyme Inhibitors. Adv Emerg Nurs J. 2019 Jul/Sep;41(3):204-214. doi: 10.1097/TME.0000000000000250. PMID: 31356244.
- Sczepanski M, Bozyk P. Institutional Incidence of Severe tPA-Induced Angioedema in Ischemic Cerebral Vascular Accidents. Crit Care Res Pract. 2018 Sep 27;2018:9360918. doi: 10.1155/2018/9360918. PMID: 30363665; PMCID: PMC6180929.
Summarized by Jeffrey Olson, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS1
The post PODCAST: Angioedema After Thrombolysis first appeared on האיגוד הישראלי לרפואה דחופה.
Melissa Suran, PhD, MSJ Article InformationAlthough semaglutide may not ring a bell, the drug has been popping up in news headlines and social media feeds since last year. That’s because the branded version called Ozempic has surged in popularity—and notoriety—for its off-label use as a weight-loss medication.
Here’s what to know about this in-demand drug.
What Is Semaglutide?
Semaglutide is a peptide sold by Novo Nordisk under the brand names Ozempic, Rybelsus, and Wegovy for long-term treatment of type 2 diabetes or obesity.
The drug belongs to the family of incretin glucagon-like peptide-1 (GLP-1) receptor agonists that have been used in type 2 diabetes treatment for almost 20 years. GLP-1 receptor agonists mimic the GLP-1 hormone, which increases insulin production when blood glucose levels are elevated. The GLP-1 hormone also slows gastric emptying—in turn prolonging the feeling of fullness after eating—and works as an appetite suppressant by targeting parts of the brain responsible for hunger and cravings.
What’s the Difference Between Brands?
The differences among these branded products are in the dosage, administration, and indication, explained Susan Yanovski, MD, the senior scientific advisor for clinical obesity research and codirector of the Office of Obesity Research at the National Institute of Diabetes and Digestive and Kidney Diseases.
The US Food and Drug Administration (FDA) approved Ozempic in 2017 to treat type 2 diabetes. Similar to other GLP-1 receptor agonists, it’s often added to improve glycemic control when patients have already tried metformin without much success. It’s available in doses of 0.5 mg to 2 mg and self-administered weekly with injectable pens.
In 2019, the FDA approved Rybelsus, a daily oral medication, to help control blood glucose in adults with type 2 diabetes. It’s available in 7-mg or 14-mg tablets.
Then, in 2021, Wegovy received FDA approval for chronic weight management for adults with obesity or those who are overweight with at least 1 weight-related condition, such as type 2 diabetes, high cholesterol, or hypertension. Last year, it was approved for adolescents aged 12 years or older.
Like Ozempic, Wegovy requires a weekly pen injection but at a higher dose of 2.4 mg. At that dose, semaglutide combined with a reduced-calorie diet and increased physical activity produced an average weight loss of about 15% at 68 weeks among clinical trial participants without type 2 diabetes, and those results were sustained at year 2 in a related trial.
There’s considerable overlap among all 3 products, Yanovski said in an interview with JAMA. For example, they’re all started at a low dose and then titrated up to limit adverse effects. Because the injectable forms of semaglutide contain the same medication, 1 mg of Ozempic is equivalent to 1 mg of Wegovy for managing weight.
Who Can Use Semaglutide Specifically for Weight Loss?
According to its indication, people without type 2 diabetes can be candidates for Wegovy if their body mass index is 30 or higher or if it’s 27 or higher and they also have a weight-related condition.
But even though Wegovy was specifically approved for this, Ozempic is better known as a weight-loss drug. “Ozempic appears to be getting more attention than Wegovy due to the name being put out more in the mainstream media and especially social media as a go-to medication for weight loss,” Peminda Cabandugama, MD, an endocrinologist and obesity medicine practitioner at the Cleveland Clinic, wrote in an email.
Prescribing Ozempic for weight loss is considered an off-label use. That said, “there’s nothing unethical about using the brand name Ozempic for someone with obesity,” Yanovski remarked. She pointed out, however, that it’s unavailable at the 2.4-mg dose shown to have the largest efficacy for weight loss.
People with uncontrolled type 2 diabetes may be ideal candidates for either injectable semaglutide product, noted Cabandugama, who is also the director of Digital Obesity at the Cleveland Clinic and a diplomate of the American Board of Obesity Medicine. Semaglutide helps bring down blood glucose levels without causing hypoglycemia, as long as it’s not used alongside insulin or oral antidiabetic medications such as sulfonylureas. Moreover, people with type 2 diabetes who are at high risk of heart disease may decrease their risk by using semaglutide. It’s unclear whether the same holds true for people without type 2 diabetes who use the drug strictly for weight loss, Yanovski said, but a cardiovascular outcomes trial is underway for this population.
What Are the Risks?
The most common adverse events are gastrointestinal issues, including nausea, vomiting, diarrhea, and constipation. Semaglutide may also heighten the risk of pancreatitis, kidney failure, and medullary thyroid carcinoma, especially among patients with a family history of this cancer. And Yanovski cautioned that gallbladder disease can develop when patients lose a lot of weight quickly with semaglutide or other means.
Media reports have linked the drug to facial aging. But it’s not the medication as much as its potent weight-loss effects that can cause what’s now known colloquially as “Ozempic face,” according to Fatima Stanford, MD, MPH, an obesity medicine physician–scientist at Massachusetts General Hospital.
“This term is a misnomer as it presumes that facial aging is specific to semaglutide,” Stanford wrote in an email. Instead, skin sagging is due to the loss of fat in the face, which is associated with any method of weight loss, she explained.
It may occur when weight-loss strategies become too aggressive. “When persons regain lost weight from stopping behavioral strategies or anti-obesity medication, they will likely regain fat in their face and elsewhere,” said Stanford, who is also an associate professor of medicine and pediatrics at Harvard Medical School.
Patients prescribed semaglutide can mitigate excess facial fat loss by monitoring their diets carefully, advised W. Scott Butsch, MD, MSc, the director of obesity medicine at the Cleveland Clinic’s Bariatric and Metabolic Institute.
“Many patients and providers alike think that the purpose of these obesity drugs is to limit the amount of food intake, so it makes sense to increase the dose as high as possible to maximize the weight loss,” he wrote in an email. “This misconception around how these drugs work can lead to an inappropriate amount of weight loss.”
An unintentionally restricted diet may not only lead to fat loss but also nutrient deficiencies.
Patients “should be aware of how much protein they are consuming, because with weight loss comes the loss of muscle as well in some individuals,” Butsch explained, adding that the appearance of facial aging may also stem from muscle loss in the face.
He underscored that only a small percentage of people who lose weight experience facial aging, and that this reversable effect should not overshadow the potential benefits of weight loss.
“All drugs have side effects, and semaglutide is no exception,” Yanovski said. She noted that the benefits of controlling blood glucose levels, as well as lowering blood pressure and reducing the risk of fatty liver disease, may offset semaglutide’s risks for people with obesity-related complications.
Patients who experience severe adverse events or don’t achieve adequate weight loss should discontinue the drug, she said: “For them, the risks outweigh the benefits.”
What About Compounded Versions?
Compounded versions of semaglutide, which are often advertised online as cheap alternatives, are gaining traction, according to news reports.
Yanovski said it can be difficult to gauge where the compounds were mixed or how they were manufactured. Often, when people obtain compounded semaglutide, especially online, “they get the drug in a multidose vial, and a vial of saline—in some cases without ever seeing a clinician who’s evaluating them—and just given instructions on how to mix this up and inject it,” Yanovski explained.
She also warned of opportunities for bacterial and fungal contamination when mixing the drug with saline and using a vial with needles rather than injectable pens. And there’s a risk of misdosing.
“It’s not semaglutide itself that might cause serious problems but the compounded versions or inappropriate administration,” she said, adding that sometimes, the drug is even mixed with vitamins without evidence of safety and effectiveness.
“That’s all a recipe for bad outcomes,” Yanovski cautioned.
How Long Does Semaglutide Keep the Weight Off?
A clinical trial published in JAMA and a follow-up study of a related trial found that semaglutide is only effective for weight loss for as long as it’s used. In the follow-up study, published last year, participants who had been randomized to receive 2.4 mg of semaglutide regained up to two-thirds of their weight within a year of stopping the drug when the trial ended.
That’s why semaglutide is approved for long-term weight management. Because obesity is a chronic disease, “semaglutide, like any other anti-obesity medication, should be prescribed with the expectation that it will be used long term, possibly lifelong,” endocrinologist Daniela Hurtado, MD, PhD, wrote in an email.
Obesity stems from genetic and environmental factors that result in the dysregulation of calories that are consumed and burned, explained Hurtado, an assistant professor at the Mayo Clinic Alix School of Medicine in Florida and a researcher at the Mayo Clinic Precision Medicine for Obesity Program. “Anti-obesity medications, like semaglutide, help regulate this system. If these medications are stopped, the system goes back to where it was, resulting in weight regain.”
It’s also important to note that semaglutide should not be prescribed in isolation but as an adjunct to dietary changes and exercise.
“In my experience, this is seen more with patients who have been put on the medication without being given proper comprehensive therapy that also involves provider-directed lifestyle instructions involving diet and exercise,” said Cabandugama, who is a spokesperson for The Obesity Society.
What About Other Weight-Loss Medications?
Beyond semaglutide, 4 other drugs and drug combinations are approved for chronic weight management in the US: liraglutide (Saxenda), orlistat (Alli and Xenical), naltrexone plus bupropion (Contrave), and phentermine plus topiramate (Qsymia).
Introduced in 1959, phentermine is the oldest FDA-approved prescription drug for obesity and, according to a 2019 government report, the most prescribed weight-loss medication in the US.
Used alone, phentermine’s indication is only for short-term use—typically less than 12 weeks, although Yanovski said it’s often prescribed off-label for longer periods. It remains popular because of its price, which can be less than $30 per month. In stark contrast, the list price of a single Ozempic pen that lasts about a month is almost $900, and a package of Wegovy for a comparable period costs upwards of $1300. Insurance companies often don’t cover weight-loss medications, and phentermine is one of the least expensive options.
“This is particularly important in populations [that are] at greater risk for diabetes or obesity yet have trouble affording the most effective drugs,” Yanovski said. However, phentermine isn’t as effective as semaglutide, even when combined with topiramate in Qsymia.
What’s Next in the Pipeline?
Some think Eli Lilly’s tirzepatide, approved as Mounjaro in 2022 for patients with type 2 diabetes, could be the next popular weight-loss medication. The drug had substantial weight-loss effects in a trial involving people with obesity who did not have type 2 diabetes. In fact, the average weight loss of around 20% approached what’s observed after some forms of bariatric surgery.
Tirzepatide is a GLP-1 receptor agonist, like semaglutide, combined with a glucose-dependent insulinotropic polypeptide, or GIP, analogue. Similar to semaglutide, tirzepatide mimics natural hormones that suppress hunger. “These 2 classes of medications give approximately 3 times the weight loss that you would see with medications like phentermine,” Cabandugama said.
There are no head-to-head studies comparing semaglutide and tirzepatide, but “tirzepatide seems to result in greater diabetes control improvement and greater weight loss,” Hurtado said.
The FDA is now evaluating tirzepatide for obesity treatment. However, none of these drugs work for everyone. And they’re no panacea for the obesity crisis.
“We need more research and policy changes to help people not develop obesity in the first place,” Yanovski said. “Anti-obesity medications aren’t a magic bullet.”
Back to topArticle InformationPublished Online: April 26, 2023. doi:10.1001/jama.2023.2438
Conflict of Interest Disclosures: Dr Butsch reported previously serving as a consultant for Novo Nordisk on education initiatives but has no current relationship with the company. Dr Cabandugama reported being a founding advisory board member of the Midwest Obesity Society, as well as a member of the Obesity Medicine Association Outreach Committee. Dr Stanford reported serving as an obesity consultant to Currax, Eli Lilly, Gelesis, Novo Nordisk, Pfizer, and Rhythm. No other disclosures were reported.
The post מעט פפופולריות As Ozempic’s Popularity Soars, Here’s What to Know About Semaglutide and Weight Loss first appeared on האיגוד הישראלי לרפואה דחופה.
Richard T. Griffey MD, MPH, Ryan M. Schneider MSN, ACNP-BC, CPPS, Margo Girardi MD, Julianne Yeary Pharm D, BCCCP, Craig McCammon Pharm D, BCCCP … See all authors First published: 12 February 2023AbstractBackgroundStudies using fast-acting subcutaneous (SQ) insulin analogs in diabetic ketoacidosis (DKA) have demonstrated efficacy, safety, and cost-effectiveness, allowing treatment of mild-to-moderate (MTM)-severity DKA patients in non–intensive care unit (ICU) settings. However, emergency department (ED)-based studies are few, with limited exploration of impacts on operational metrics.
MethodsWe implemented the SQuID (Subcutaneous Insulin in Diabetic Ketoacidosis) protocol for adults with MTM-severity DKA in an urban academic ED, collecting data from August 1, 2021, to February 28, 2022. We examined fidelity (frequency of required q2h glucose checks), safety (proportion of patients administered rescue dextrose for hypoglycemia), and ED length of stay (EDLOS) for the SQuID cohort compared to patients (non-ICU) treated with a traditional insulin infusion. We also examined ICU admission rate among MTM-severity DKA patients after introduction of SQuID to two historical control periods (pre-intervention and pre-COVID). We used Mann–Whitney U to test for differences in EDLOS distributions, bootstrapped (n = 1000) confidence intervals (CIs) for EDLOS median differences, and the two-sample z-test for differences in ICU admissions.
ResultsWe identified 177 MTM-severity DKA patients in the study period (78 SQuID, 99 traditional cohort) and 163 preintervention and 161 pre-COVID historical control patients. Fidelity to the SQuID pathway was good, with glucose checks exceeding the q2-h requirement. We found no difference in the proportion of rescue dextrose administration compared to the traditional pathway. We observed significant reductions in median EDLOS for the SQuID cohort compared to the traditional cohort during the study period (−3.0, 95% CI −8.5 to −1.4), the preintervention period (−1.4, 95% CI −3.1 to −0.1), and the pre-COVID control period (−3.6, 95% CI −7.5 to −1.8).
ConclusionsIn this single-center study at an academic ED, treatment of patients with MTM-severity DKA with a SQ insulin protocol was effective, demonstrated equivalent safety, and reduced ED length of stay.
The post The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics first appeared on האיגוד הישראלי לרפואה דחופה.
May 18, 2023 / GI, Pain/Sedation/ProcedureWritten by Gabby Leonard
Patients who are discharged from the emergency department after presenting with abdominal pain and receiving opioids have 57% greater odds of return within 30 days. This population is also at higher risk for adverse effects from these medications.
Why does this matter?
Abdominal pain is the most common presenting complaint to the ED. The opioid epidemic has been an ongoing crisis affecting hundreds of thousands of patients worldwide. This study evaluates return rates of patients discharged from the ED after presenting with abdominal pain and receiving either an opioid or acetaminophen/ibuprofen for pain management.
My favorite Painkillers…are in St. John
Opioid administration in the ED is likely connected to long-term opioid use disorder, with an estimated 10% contribution to long-term opioid use disorder. Patients who present with undifferentiated abdominal pain are often given opioid medication in the immediate setting for symptomatic relief. This study looked at 30-day return visit rate for patients treated with IV, oral or IM opioids compared to acetaminophen and/or NSAIDs.
Patients who received opioids in the acute setting had a 22% 30-day return rate for abdominal pain compared to 14.7% of patients who received acetaminophen and/or NSAIDs, OR 1.57 (95%CI 1.27 to 1.95).
It is important to remember that opioids can also cause detrimental side effects including nausea, constipation, and addiction. Additionally, there is a paucity of data surrounding opioid effectiveness in targeting nonspecific abdominal pain.
While there certainly is a place and time for opioid administration in the ED, it may be feasible to try symptomatic control with acetaminophen, NSAIDs, or other agents – such as dicyclomine, famotidine, and aluminum/magnesium hydroxide (Maalox) prior to opioid administration.
Editor’s note: Don’t forget to check out the JournalFeed podcast for the audio version of our spoon feeds! Including a harsh critical review of this article . ~Nick Zelt
Source
Return Rates for Opioid versus Nonopioid Management of Patients with Abdominal Pain in the Emergency Department. J Emerg Med. 2023 Apr;64(4):471-475. doi: 10.1016/j.jemermed.2023.01.008. Epub 2023 Mar 28.
The post Opioids For Abdominal Pain – Are We Influencing Rate Of Return? first appeared on האיגוד הישראלי לרפואה דחופה.
Alejandro A. Diaz, MD, MPH1,2; José L. Orejas, MD1,2; Scott Grumley, MD3; et alHrudaya P. Nath, MD3; Wei Wang, PhD2,4; Wojciech R. Dolliver, MD1; Andrew Yen, MD5; Seth J. Kligerman, MD5,6; Kathleen Jacobs, MD5; Padma P. Manapragada, MD3; Mostafa Abozeed, MD, MSc, PhD3; Muhammad Usman Aziz, MD3; Mohd Zahid, MD3; Asmaa N. Ahmed, MD, MBBCh, MSc3; Nina L. Terry, MD3; Ruben San José Estépar, MSc2,7; Victor Kim, MD8; Barry J. Make, MD9; MeiLan K. Han, MD10; Sushilkumar Sonavane, MD11; George R. Washko, MD, MSc1,2; Michael Cho, MD, MPH1,2,12; Raúl San José Estépar, PhD2,7Author Affiliations Article InformationJAMA. Published online May 21, 2023. doi:10.1001/jama.2023.2065 Key PointsQuestion Are mucus plugs that occlude airways identified on computed tomography scans in patients with chronic obstructive pulmonary disease (COPD) associated with increased all-cause mortality?Findings In this observational study that included 4363 patients with COPD, the presence of mucus plugs occluding medium- to large-sized airways (ie, approximately 2- to 10-mm lumen diameter) was significantly associated with higher risk of all-cause mortality (adjusted hazard ratio for mucus plugs affecting 1 to 2 vs 0 lung segments, 1.15; adjusted HR for mucus plugs affecting ≥3 vs 0 lung segments, 1.24).
Meaning Mucus plugs that occluded medium- to large-sized airways in patients with COPD were associated with increased all-cause mortality.
AbstractImportance Airway mucus plugs are common in patients with chronic obstructive pulmonary disease (COPD); however, the association of airway mucus plugging and mortality in patients with COPD is unknown.
Objective To determine whether airway mucus plugs identified on chest computed tomography (CT) were associated with increased all-cause mortality.
Design, Setting, and Participants Observational retrospective analysis of prospectively collected data of patients with a diagnosis of COPD in the Genetic Epidemiology of COPD cohort. Participants were non-Hispanic Black or White individuals, aged 45 to 80 years, who smoked at least 10 pack-years. Participants were enrolled at 21 centers across the US between November 2007 and April 2011 and were followed up through August 31, 2022.
Exposures Mucus plugs that completely occluded airways on chest CT scans, identified in medium- to large-sized airways (ie, approximately 2- to 10-mm lumen diameter) and categorized as affecting 0, 1 to 2, or 3 or more lung segments.
Main Outcomes and Measures The primary outcome was all-cause mortality, assessed with proportional hazard regression analysis. Models were adjusted for age, sex, race and ethnicity, body mass index, pack-years smoked, current smoking status, forced expiratory volume in the first second of expiration, and CT measures of emphysema and airway disease.
Results Among the 4483 participants with COPD, 4363 were included in the primary analysis (median age, 63 years [IQR, 57-70 years]; 44% were women). A total of 2585 (59.3%), 953 (21.8%), and 825 (18.9%) participants had mucus plugs in 0, 1 to 2, and 3 or more lung segments, respectively. During a median 9.5-year follow-up, 1769 participants (40.6%) died. The mortality rates were 34.0% (95% CI, 32.2%-35.8%), 46.7% (95% CI, 43.5%-49.9%), and 54.1% (95% CI, 50.7%-57.4%) in participants who had mucus plugs in 0, 1 to 2, and 3 or more lung segments, respectively. The presence of mucus plugs in 1 to 2 vs 0 and 3 or more vs 0 lung segments was associated with an adjusted hazard ratio of death of 1.15 (95% CI, 1.02-1.29) and 1.24 (95% CI, 1.10-1.41), respectively.
Conclusions and Relevance In participants with COPD, the presence of mucus plugs that obstructed medium- to large-sized airways was associated with higher all-cause mortality compared with patients without mucus plugging on chest CT scans.
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ACEP Frontline · Shake and Bake…Talking Seizures And LPs – Dr. Fontenette – ACEP22n this episode, we jump back to a couple of talks from ACEP22 with Dr. Rod Fontenette talking about seizure management and the evolution of LPs in EM. Two separate topics, though they segue just fine.The post PODCAST: Shake and Bake…Talking Seizures And LPs – Dr. Fontenette – ACEP22 first appeared on האיגוד הישראלי לרפואה דחופה.
Indications for LP:CNS infection, SAH, Guillian Barree, IIH
Contraindications for LP:Space occupying lesion with mass effect ; severe thrombocytopenia and coagulopathy; cellulitis over LP site or concern for epidural abscess ; traumatic injury to spine
Complications for LP:Post LP Headache, spinal hematoma, brainstem herniation
Technique for LP: Positioning is everything. Use US if necessary. Check for CSF early and often.
When to CT before LP?:AMS; focal neuro deficit; new onset seizures, known CNS lesions; immunosuppression; papilledema
The post PODCAST: Lumbar Punctures (Deep Dive R9 MW) first appeared on האיגוד הישראלי לרפואה דחופה.
Luke P. Dawson, MBBS, MPH1,2,3; Emily Nehme, MBiostats2,4; Ziad Nehme, PhD2,4,5; et alElla Zomer, PhD2; Jason Bloom, MBBS1,6; Shelley Cox, PhD2,4; David Anderson, MBChB4,5,7; Michael Stephenson, BHlthSci, GradDipHlthSci2,4,5; Jocasta Ball, PhD2; Jennifer Zhou, MBBS1; Jeffrey Lefkovits, MBBS2,3; Andrew J. Taylor, MBBS, PhD1,8; Mark Horrigan, MBBS9,10; Derek P. Chew, MBBS, MPH, PhD11; David Kaye, MBBS, PhD1,6; Louise Cullen, MBBS, PhD12; Cathrine Mihalopoulos, PhD2; Karen Smith, PhD2,4,5; Dion Stub, MBBS, PhD1,2,6Author Affiliations Article InformationJAMA Intern Med. 2023;183(3):203-211. doi:10.1001/jamainternmed.2022.6409 נקודות מפתחשאלה האם ריבוד סיכונים של פרמדיק ובדיקת טרופונין בנקודת טיפול יכולים להביא לחסכון בעלויות לטיפול בכאבי חזה חריפים ברמת האוכלוסייה?
ממצאים בהערכה כלכלית זו של 188,551 מטופלים שנכחו באמבולנס לכאבי חזה בויקטוריה, אוסטרליה, החיסכון השנתי בעלות של ריבוד סיכון טרום-אשפוזי ומדידות טרופונין היה 6.45 מיליון דולר ללא שימוש בשחרור טרום-אשפוז ו-42.84 עד 71.84 מיליון דולר אם נעשה שימוש בשחרור קדם-בית החולים. חולים בסיכון נמוך.
משמעות הממצאים מצביעים על כך שהערכת סיכונים טרום-אשפוזית ובדיקת טרופונין בנקודת הטיפול עשויות להיות כדאיות בהתבסס על חיסכון בעלויות בלבד, ויש לשקול השקעה על ידי שירותי הבריאות בתנאי שהבטיחות מאושרת במחקרים פרוספקטיביים.
אבסטרקטחשיבות בדיקת טרופונין קדם-אשפוזית וריבוד סיכון פרא-רפואי עשויות לשפר את היעילות של מסלולי טיפול בכאבי חזה בהשוואה לתהליכים קיימים עם תוצאות בריאותיות מקבילות, אך הקשר עם עלויות הטיפול הרפואי אינו ברור.
מטרה לנתח האם בדיקת טרופונין נקודתית טרום-אשפוזית וריבוד סיכון פרמדיק יכולים להביא לחיסכון בעלויות בהשוואה למסלולי טיפול קיימים בכאבי חזה.
עיצוב, הכנות ומשתתפים בהערכה כלכלית זו של מבוגרים עם כאבים חריפים בחזה ללא הגבהה של מקטע ST, נעשה שימוש בניתוח מזעור עלויות להערכת נוכחות של אמבולנס, חירום ובתי חולים מקושרים במדינת ויקטוריה, אוסטרליה, בין ה-1 בינואר, 2015 ו-30 ביוני 2019.
התערבויות ריבוד סיכון פרמדיק ובדיקת טרופונין נקודתית.
תוצאות ומדידות עיקריות התוצאה הוערכה ממוצעת עלויות שנתיות בכל המדינה עבור כאבים חריפים בחזה. בין ה-17 במאי ל-25 ביוני 2022, פותחו מודלים של עצי החלטה להערכת עלויות תחת 3 מסלולים: (1) טיפול קיים, (2) ריבוד סיכון פרמדיק ובדיקת טרופונין בנקודת טיפול ללא שחרור טרום-אשפוזי, או (3) טרום אשפוז. שחרור והפניה למחלקת חירום וירטואלית (ED) עבור חולים בסיכון נמוך. ההסתברויות למסלולים הפרה-אשפוזיים נגזרו מסקירת הספרות. ניתוח רגישות הסתברותי רב משתנים עם 50,000 משתנים במודל מונטה קרלו שימש להערכת עלויות ממוצעות והפרשי עלויות בין מסלולים.
תוצאות סך של 188,551 חולים שהגיעו באמבולנס לכאבים בחזה (ממוצע[SD] גיל, 61.9[18 .3] שנים; 50.5% נשים; 49.5% גברים; ילידי אוסטרליה, 2.0%) נכללו במודל. עלויות תשתית ואיוש משוערות שנתיות עבור מסלולי הטרופונין בנקודת הטיפול, בהנחה של אורך חיים של מכשיר של 5 שנים, היו 2.27 מיליון דולר עבור המסלול ללא שחרור טרום-אשפוז ו-4.60 מיליון דולר עבור המסלול עם שחרור קדם-אשפוז (כולל עלויות ED וירטואלי). במודל עץ ההחלטות, העלות השנתית הכוללת של שימוש בטרופונין בנקודת טיפול טרום-אשפוזית וריבוד סיכון פרמדיק הייתה נמוכה יותר בהשוואה לטיפול קיים, שניהם ללא שחרור טרום-אשפוז (חיסכון בעלויות, 6.45 מיליון דולר; רווח אי-ודאות של 95%. [UI], 0.59-16.52 מיליון דולר; נמוך ב-94.1% מהשתנות במודל) ועם שחרור לפני אשפוז (חיסכון בעלויות, 42.84 מיליון דולר; UI של 95%, 19.35-72.26 מיליון דולר; נמוך ב-100% מהשתנות במודל).
מסקנות ורלוונטיות טרופונין טרום-אשפוז נקודת טיפול וריבוד סיכון פרמדיק עבור חולים עם כאבים חריפים בחזה עשויים להביא לחיסכון משמעותי בעלויות. ממצאים אלה צריכים להילקח בחשבון על ידי קובעי מדיניות בהחלטות הנוגעות לתועלת הפוטנציאלית של ריבוד סיכון לכאבי חזה לפני אשפוז ומודלים של טרופונין נקודתית, בתנאי שהבטיחות מאושרת במחקרים פרוספקטיביים.
The post טיפול בכאבי חזה באמצעות טרופונין טרום-אשפוזי נקודתי טיפול והערכת סיכונים של הפרמדיק first appeared on האיגוד הישראלי לרפואה דחופה.
Hiram Shaish 1, Justin Ream 2, Chenchan Huang 3, Jonathan Troost 4, Sonia Gaur 5, Ryan Chung 6, Sooah Kim 3, Hanisha Patel 1, Jeffrey H Newhouse 1, Shokoufeh Khalatbari 4, Matthew S Davenport 7 8Affiliations expandAbstract Importance: Intravenous (IV) contrast medium is sometimes withheld due to risk of complication or lack of availability in patients undergoing computed tomography (CT) for abdominal pain. The risk from withholding contrast medium is understudied.
Objective: To determine the diagnostic accuracy of unenhanced abdominopelvic CT using contemporaneous contrast-enhanced CT as the reference standard in emergency department (ED) patients with acute abdominal pain.
Design, setting, and participants: This was an institutional review board-approved, multicenter retrospective diagnostic accuracy study of 201 consecutive adult ED patients who underwent dual-energy contrast-enhanced CT for the evaluation of acute abdominal pain from April 1, 2017, through April 22, 2017. Three blinded radiologists interpreted these scans to establish the reference standard by majority rule. IV and oral contrast media were then digitally subtracted using dual-energy techniques. Six different blinded radiologists from 3 institutions (3 specialist faculty and 3 residents) interpreted the resulting unenhanced CT examinations. Participants included a consecutive sample of ED patients with abdominal pain who underwent dual-energy CT.
Exposure: Contrast-enhanced and virtual unenhanced CT derived from dual-energy CT.
Main outcome: Diagnostic accuracy of unenhanced CT for primary (ie, principal cause[s] of pain) and actionable secondary (ie, incidental findings requiring management) diagnoses. The Gwet interrater agreement coefficient was calculated.
Results: There were 201 included patients (female, 108; male, 93) with a mean age of 50.1 (SD, 20.9) years and mean BMI of 25.5 (SD, 5.4). Overall accuracy of unenhanced CT was 70% (faculty, 68% to 74%; residents, 69% to 70%). Faculty had higher accuracy than residents for primary diagnoses (82% vs 76%; adjusted odds ratio [OR], 1.83; 95% CI, 1.26-2.67; P = .002) but lower accuracy for actionable secondary diagnoses (87% vs 90%; OR, 0.57; 95% CI, 0.35-0.93; P < .001). This was because faculty made fewer false-negative primary diagnoses (38% vs 62%; OR, 0.23; 95% CI, 0.13-0.41; P < .001) but more false-positive actionable secondary diagnoses (63% vs 37%; OR, 2.11, 95% CI, 1.26-3.54; P = .01). False-negative (19%) and false-positive (14%) results were common. Interrater agreement for overall accuracy was moderate (Gwet agreement coefficient, 0.58).
Conclusion: Unenhanced CT was approximately 30% less accurate than contrast-enhanced CT for evaluating abdominal pain in the ED. This should be balanced with the risk of administering contrast material to patients with risk factors for kidney injury or hypersensitivity reaction.
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ACEP Frontline · Ain’t Easy Being Wheezy – Asthma POC Tool with Dr. Charles EmermanJoined today by Dr. Charles Emerman MD, Department Chair of Emergency Medicine at Metrohealth/Case Western Reserve University to discuss the latest and greatest in best practices related to our asthmatic patients. Dr. Emerman offers up solutions for quick identification and appropriate treatment with bronchodilators, corticosteroids, to prevent further deterioration of this patient population.The post PODCAST: Ain’t Easy Being Wheezy – Asthma POC Tool with Dr. Charles Emerman first appeared on האיגוד הישראלי לרפואה דחופה.
May 5, 2023 / AirwayWritten by Aaron Lacy
When compared to rapid sequence intubation (RSI), this RCT showed decreased peri-intubation hypoxemic events and increased first attempt success in agitated and delirious ED patients with major trauma who underwent delayed sequence intubation (DSI).
Why does this matter?
Proper preparation when intubating is crucial. Adequate preoxygenation, running through procedural checklists, and optimal patient positioning all are associated with increased intubation success and reduced adverse events. When a patient is agitated, could dissociation with ketamine prior to pushing paralytics allow time to prepare for a safer intubation?
A PSA on DSI vs RSI
In this RCT, patients who presented to an academic emergency department in India who were agitated or delirious after suffering major trauma were randomized to either DSI or RSI. One hundred DSI patients were given IV ketamine in 0.5mg/kg boluses until they became dissociated, followed by 3 minutes of facemask preoxygenation before administration of succinylcholine. One-hundred patients randomized to the RSI group underwent 3 minutes of preoxygenation via facemask and then were intubated after administration of ketamine and succinylcholine in rapid succession. Patients with unanticipated difficult airways were excluded from final analysis (n = 36).
Peri-intubation hypoxemia was lower in the DSI group compared to RSI (8% vs 35%; p=0.001). First-attempt intubation success was also higher in the DSI group (83% vs 69%; p=0.02). There was no difference in hemodynamic instability or airway-related adverse events. It is notable that most patients in this trial were intubated because of head injuries, and most had no comorbidities.
I have used DSI in agitated trauma patients to not only help with preoxygenation but also to achieve optimal patient positioning, allow time to run through an intubation checklist, obtain additional IV access or other optimization before intubation, and to protect staff. This trial supports use of DSI in this patient population.
Source
Peri-Intubation Hypoxia After Delayed Versus Rapid Sequence Intubation in Critically Injured Patients on Arrival to Trauma Triage: A Randomized Controlled Trial. Anesth Analg. 2023 May 1;136(5):913-919. doi: 10.1213/ANE.0000000000006171. Epub 2023 Apr 14.
Editor’s note: They excluded both anticipated difficult airway before DSI or RSI and those with unanticipated difficult airway after paralysis. Of note, 12 patients in the DSI group had unanticipated difficult airway vs 24 in the RSI group. These were excluded, but this is also an interesting unmeasured outcome of this study that would likely have made DSI look even better. ~Clay Smith
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May 3, 2023 / Cardiology, ResuscitationWritten by Jason Lesnick
In patients with ROSC after OHCA, these ‘STEMI equivalents’ do not appear to accurately diagnose ACS based on this study.
Why does this matter?
Currently, if a post-ROSC ECG is obtained and there is not a STEMI, there is evidence that delayed cardiac catheterization is equivalent to immediate intervention (as we have covered here and here). However, if emergent cardiac catheterization showed benefit in patients who had post-ROSC ECGs with STEMI equivalents, this could change practice.
STEMI equivalents are more equivocal than diagnostic after ROSC
This retrospective database review of patients ≥ 18 years of age from multiple centers in Japan with non-traumatic OHCA and VF or pulseless VT on arrival of EMS or to the ED who had ROSC obtained included 143 patients.
The authors analyzed the following ‘STEMI equivalents’: isolated T-wave inversion, ST-segment depression, Wellens’ signs, and ST-segment elevation in lead aVR (which really should not be considered a STEMI equivalent). There were too few cases of De Winter ST-T waves, hyperacute T-waves, and resting U-wave inversions to analyze.
From cited article.The authors found that isolated T-wave inversion, low QRS voltage, and Wellens’ sign had high specificity, 0.95 (95%CI 0.87–0.99), 0.98 (0.92–1.00), and 0.92 (0.82–0.97), respectively, but positive likelihood ratios (LR +) were low (from 0.89 to 1.89 – not so great).
The most important limitation of this study is that the diagnosis of ACS as a primary outcome was based on the clinical judgment of the physician expert rather than a universal definition of acute myocardial infarction. Another limitation here was that the timing of the ECG was unclear in this study, which is a key limitation, because the duration from ROSC to ECG would affect the ECG accuracy.
This is an interesting study, and kudos to the authors for trying to shed some light on this relatively common situation. The key takeaway is that we should continue to discuss these patients with our cardiology colleagues if we are concerned for ACS but recognize that without STEMI on post-ROSC ECG, an emergent catheterization is unlikely to happen based on current evidence, consistent with AHA and ESC guidelines.
Source
Diagnostic test accuracy of life-threatening electrocardiographic findings (ST-elevation myocardial infarction equivalents) for acute coronary syndrome after out-of-hospital cardiac arrest withou
The post Do STEMI Equivalents Post-ROSC Need Immediate Cath? first appeared on האיגוד הישראלי לרפואה דחופה.
Melissa K. Cousino, PhD1,2; Victoria A. Miller, PhD3; Cynthia Smith, RN1; et alHeang M. Lim, MD1; Sunkyung Yu, MS1; Ray Lowery, BA1; Karen Uzark, PhD, PNP1,2; Emily M. Fredericks, PhD1; Joanne Wolfe, MD, MPH4; Elizabeth D. Blume, MD4; Kurt R. Schumacher, MS, MD1Author Affiliations Article InformationJAMA Netw Open. 2023;6(5):e2311957. doi:10.1001/jamanetworkopen.2023.11957 Key PointsQuestion What are the medical and end-of-life decision-making preferences of adolescents and young adults (AYA) with advanced heart disease?
Findings In this cross-sectional survey study of 56 patients, the majority of AYA participants stated a preference to discuss adverse effects or risks of treatment (87%), procedural/surgical details (85%), prognosis (79%), and end-of-life care wishes (57%). AYAs preferred more patient-led active decision-making while parents preferred more parent/physician shared decision-making, suggesting significant AYA-parent discordance.
Meaning These findings suggest interventions to better meet the decision-making needs of AYAs with advanced heart disease are warranted.
AbstractImportance Despite high disease morbidity and mortality and complex treatment decisions, little is known about the medical and end-of-life decision-making preferences of adolescents and young adults (AYA) with advanced heart disease. AYA decision-making involvement is associated with important outcomes in other chronic illness groups.
Objective To characterize decision-making preferences of AYAs with advanced heart disease and their parents and determine factors associated with these preferences.
Design, Setting, and Participants Cross-sectional survey between July 2018 and April 2021 at a single-center heart failure/transplant service at a Midwestern US children’s hospital. Participants were AYAs aged 12 to 24 years with heart failure, listed for heart transplantation, or posttransplant with life-limiting complications and a parent/caregiver. Data were analyzed from May 2021 to June 2022.
Main Outcomes and Measures Single-item measure of medical decision-making preferences, MyCHATT, and Lyon Family-Centered Advance Care Planning Survey.
Results Fifty-six of 63 eligible patients enrolled in the study (88.9%) with 53 AYA-parent dyads. Median (IQR) patient age was 17.8 (15.8-19.0) years; 34 (64.2%) patients were male, and 40 patients (75.5%) identified as White and 13 patients (24.5%) identified as members of a racial or ethnic minority group or multiracial. The greatest proportion of AYA participants (24 of 53 participants [45.3%]) indicated a preference for active, patient-led decision-making specific to heart disease management, while the greatest proportion of parents (18 of 51 participants [35.3%]) preferred they and physician(s) make shared medical decisions on behalf of their AYA, representing AYA-parent decision-making discordance (χ2 = 11.7; P = .01). Most AYA participants stated a preference to discuss adverse effects or risks of treatment (46 of 53 participants [86.8%]), procedural and/or surgical details (45 of 53 participants [84.9%]), impact of condition on daily activities (48 of 53 participants [90.6%]), and their prognosis (42 of 53 participants [79.2%]). More than half of AYAs preferred to be involved in end-of-life decisions if very ill (30 of 53 participants [56.6%]). Longer time since cardiac diagnosis (r = 0.32; P = .02) and worse functional status (mean [SD] 4.3 [1.4] in New York Heart Association class III or IV vs 2.8 [1.8] in New York Heart Association class I or II; t-value = 2.7; P = .01) were associated with a preference for more active, patient-led decision-making.
Conclusions and Relevance In this survey study, most AYAs with advanced heart disease favored active roles in medical decision-making. Interventions and educational efforts targeting clinicians, AYAs with heart disease, and their caregivers are needed to ensure they are meeting the decision-making and communication preferences of this patient population with complex disease and treatment courses.
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Juan Sanchis, PhD1; Héctor Bueno, PhD2; Gema Miñana, PhD1; et alKey Points Question Does a routine invasive strategy improve outcomes in older adults with frailty and non–ST-segment elevation acute myocardial infarction (NSTEMI)?
Findings In this prematurely terminated randomized clinical trial of 167 older adult patients with frailty and NSTEMI, a routine invasive vs conservative strategy did not significantly increase the number of days alive and out of the hospital from discharge to 1 year. Although the study is small, there is no hint that increasing the number of patients would have confirmed the invasive management superiority hypothesis, as shown in previous studies in older patients where frailty status had not been considered.
Meaning In this randomized clinical trial including frail older patients with NSTEMI, a routine invasive strategy did not increase the number of days alive out of hospital during the first year; results fuel the development of a larger trial with the opposite hypothesis—that is, a policy of watchful observation and careful evaluation may be of choice for frail older patients with NSTEMI.
AbstractImportance To our knowledge, no randomized clinical trial has compared the invasive and conservative strategies in frail, older patients with non–ST-segment elevation acute myocardial infarction (NSTEMI).
Objective To compare outcomes of invasive and conservative strategies in frail, older patients with NSTEMI at 1 year.
Design, Setting, and Participants This multicenter randomized clinical trial was conducted at 13 Spanish hospitals between July 7, 2017, and January 9, 2021, and included 167 older adult (≥70 years) patients with frailty (Clinical Frailty Scale score ≥4) and NSTEMI. Data analysis was performed from April 2022 to June 2022.
Interventions Patients were randomized to routine invasive (coronary angiography and revascularization if feasible; n = 84) or conservative (medical treatment with coronary angiography for recurrent ischemia; n = 83) strategy.
Main Outcomes and Measures The primary end point was the number of days alive and out of the hospital (DAOH) from discharge to 1 year. The coprimary end point was the composite of cardiac death, reinfarction, or postdischarge revascularization.
Results The study was prematurely stopped due to the COVID-19 pandemic when 95% of the calculated sample size had been enrolled. Among the 167 patients included, the mean (SD) age was 86 (5) years, and mean (SD) Clinical Frailty Scale score was 5 (1). While not statistically different, DAOH were about 1 month (28 days; 95% CI, −7 to 62) greater for patients managed conservatively (312 days; 95% CI, 289 to 335) vs patients managed invasively (284 days; 95% CI, 255 to 311; P = .12). A sensitivity analysis stratified by sex did not show differences. In addition, we found no differences in all-cause mortality (hazard ratio, 1.45; 95% CI, 0.74-2.85; P = .28). There was a 28-day shorter survival in the invasive vs conservatively managed group (95% CI, −63 to 7 days; restricted mean survival time analysis). Noncardiac reasons accounted for 56% of the readmissions. There were no differences in the number of readmissions or days spent in the hospital after discharge between groups. Neither were there differences in the coprimary end point of ischemic cardiac events (subdistribution hazard ratio, 0.92; 95% CI, 0.54-1.57; P = .78).
Conclusions and Relevance In this randomized clinical trial of NSTEMI in frail older patients, there was no benefit to a routine invasive strategy in DAOH during the first year. Based on these findings, a policy of medical management and watchful observation is recommended for older patients with frailty and NSTEMI.
The post Effect of Routine Invasive vs Conservative Strategy in Older Adults With Frailty and Non–ST-Segment Elevation Acute Myocardial Infarction A Randomized Clinical Trial first appeared on האיגוד הישראלי לרפואה דחופה.
EM Board Bombs · 174. Cardiogenic Shock: the heart doesn’t care about your sepsis protocolHypotensive patient? Just reflexively give 30 cmL/kg, trend lactates, and broad spec antibiotics right? NOPE. Turns out, the heart could really care less. In fact, it might just decide to kill the patient if you do that. Let’s talk about a lesser common cause of shock.
Want to experience the greatest in board studying? Check out our interactive question bank podcast- the FIRST of its kind here: emrapidbombs.supercast.com.
Cite this podcast as: Briggs, Blake; Husain, Iltifat. Episode 174. Cardiogenic Shock. April 30th, 2023. www.emboardbombs.com/podcasts/174-c…epsis-protocol. Accessed [date]
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May 1, 2023This month for the May 2023 episode of the RCEM Learning Podcast we’ve got two New in EM segments which shoulder relocation technique is best and the use of TXA in haemoptysis. We then speak with Tessa Davis of Don’t Forget The Bubbles fame and her top tips for delivering teaching online. We then speak to Evan Bayton about the RCEM Coat of Arms and what on earth it all means, and then end with New Online. If you’d like to email us, please feel free to do so here.
(02:02) New in EM – Which shoulder relocation technique is best?* A Systematic Review with Pairwise and Network Meta-Analysis of Closed Reduction Methods for Anterior Shoulder Dislocation (Gonai et al., 2023)
(19:01) Tessa Davis – Delivering Teaching Online* Tessa Davis Twitter * Tessa Davis’ Homepage
(34:02) New in EM – IV vs. Nebulised TXA for haemoptysis* Nebulized vs IV Tranexamic Acid for Hemoptysis: A Pilot Randomized Controlled Trial (Gopinath et al., 2023)
(45:53) Evan Bayton – The RCEM Coat of Arms* The RCEM Coat of Arms
(01:02:34) New Online – new articles on RCEMLearning for your CPD* #PEM23 – Nikki Abela and Liz Herrieven * Curriculum Cup – Major Trauma – RCEMLearning * Necrotising Fasciitis – Amy Armstrong The post PODCAST: RCEM Learning May 20230 first appeared on האיגוד הישראלי לרפואה דחופה.
You are working at Clerkship General when the charge nurse comes and grabs you… “Hey doc, we need you in room 2, this kid looks sick…”
Initial Vitals:
BP: 68/40
HR: 128
RR: 22
O2: 99% (Room Air)
Temp: 103.5F
Critical Actions:
- Diagnose Meningitis and Perform Lumbar Puncture
- Give Empiric Antibiotics
- Treat Septic Shock
- Give Steroids
- Give Prophylaxis to Close Contacts
The post PODCAST: Case -Altered Mental Status first appeared on האיגוד הישראלי לרפואה דחופה.
BMJ talk medicine · Primary Survey – the highlights of April 2023The post PODCAST: BMJ talk medicine – Primary Survey – the highlights of April 2023 first appeared on האיגוד הישראלי לרפואה דחופה.
Kori S. Zachrison, MD, MSc Joshua N. Goldstein, MD, PhD Edward Jauch, MD, MS Anshita Chaturvedi, MD, MPH Pawan Goyal, MD Arjun K. Venkatesh, MD, MBA Show all authorsPublished:April 19, 2023DOI:https://doi.org/10.1016/j.annemergmed.2023.03.015 Though select inpatient-based performance measures exist for the care of patients with nontraumatic intracranial hemorrhage, emergency departments lack measurement instruments designed to support and improve care processes in the hyperacute phase. To address this, we propose a set of measures applying a syndromic (rather than diagnosis-based) approach informed by performance data from a national sample of community EDs participating in the Emergency Quality Network Stroke Initiative. To develop the measure set, we convened a workgroup of experts in acute neurologic emergencies. The group considered the appropriate use case for each proposed measure: internal quality improvement, benchmarking, or accountability, and examined data from Emergency Quality Network Stroke Initiative-participating EDs to consider the validity and feasibility of proposed measures for quality measurement and improvement applications. The initially conceived set included 14 measure concepts, of which 7 were selected for inclusion in the measure set after a review of data and further deliberation. Proposed measures include 2 for quality improvement, benchmarking, and accountability (Last 2 Recorded Systolic Blood Pressure Measurements Under 150 and Platelet Avoidance), 3 for quality improvement and benchmarking (Proportion of Patients on Oral Anticoagulants Receiving Hemostatic Medications, Median ED Length of Stay for admitted patients, and Median Length of Stay for transferred patients), and 2 for quality improvement only (Severity Assessment in the ED and Computed Tomography Angiography Performance). The proposed measure set warrants further development and validation to support broader implementation and advance national health care quality goals. Ultimately, applying these measures may help identify opportunities for improvement and focus quality improvement resources on evidence-based targets.The post Clinical Performance Measures for Emergency Department Care for Adults With Intracranial Hemorrhage first appeared on האיגוד הישראלי לרפואה דחופה.
Alexander Bracey MD a, Lyndsay Massey MD b, Andrew C. Pellet MD a, Henry C. Thode PhD b, Thomas R. Holman MD a, Adam J. Singer MD b, Matthew McClure DO b, Michael A. Secko MD bAbstractBackgroundChest pain is a common presentation to the Emergency Department (ED) with roughly 6 million visits a year. The primary diagnostic modality for the identification of acute coronary syndrome (ACS) is the electrocardiogram (ECG), which is used to screen for electrocardiographic findings representing acute coronary occlusion. It is known that the ischemia generated by an acutely occluded coronary vessel generates a wall motion abnormality which can be visualized by echocardiogram; however, emergency physician-performed focused cardiac ultrasound (FOCUS) currently does not have a formal role in the diagnosis of OMI within the emergency department.
PurposeWe sought to define the characteristics of FOCUS performed by emergency physicians of variable training levels in the identification of RWMA in patients presenting to the emergency department with high suspicion for ACS before undergoing cardiac catheterization or formal echocardiography. We also explored whether RWMA was associated with OMI in these patients.
MethodsWe performed a structured, retrospective review of adult patients presenting to a large, academic, tertiary care center with suspected ACS from July 1st, 2019, and October 24th, 2020. Patients were included if they underwent FOCUS in the ED during the time-period above for suspected ACS looking for RWMA and FOCUS images were stored and reviewable in our middleware software. The primary outcome was the accuracy, sensitivity, and specificity of FOCUS compared to formal echocardiography for the detection of RWMA. Secondary outcomes were sensitivity of FOCUS compared to formal echocardiography for detection of RWMA in patients with and without cardiac catheterization proven OMI and sensitivity and specificity of FOCUS operators based on training.
ResultsFOCUS for RWMA performed by emergency physicians had a sensitivity of 94% (95% CI, 82–98), specificity 35% (95% CI, 15–61), and overall accuracy of 78% (95% CI, 66–87). Of all subjects, 82% underwent urgent or emergency coronary angiography, of which 71% had OMI at the time of coronary angiography of the procedure. FOCUS identified RWMA in 87% of patients with coronary angiography proven OMI. Residents (PGY-1 – PGY-3) (n = 31) were able to detect RWMA with a sensitivity of 86% (95% CI, 64–96), a specificity of 56% (95% CI, 23–85%), and an accuracy of 77 (95% CI, 58–90%). Emergency ultrasound fellows and attendings (n = 34) were able to detect RWMA with a sensitivity of 85% (95% CI, 64–95%), a specificity of 75% (95% CI, 36–96%), and an accuracy of 82% (95% CI, 65–93%).
ConclusionsOur retrospective study concludes FOCUS performed by emergency physicians may be used to detect RWMA in patients with high concern for acute coronary syndrome. This may have its greatest utility in patients presenting without STEMI where the ECG is felt to be equivocal, but the clinician has high concern for OMI, in which the presence of RWMA might result in emergent cath lab activation, though this requires further study. The presence of RWMA in such cases may help to rule in OMI as a cause; however, the absence of RWMA should exclude OMI. Further research is necessary to confirm these findings.
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ReviewMathias J. Holmberga,b , Guillaume Geric,d , Sebastian Wibergb,e , Anne-Marie Guerguerianf ,
Michael W. Donninob,g , Jerry P. Nolanh , Charles D. Deakini , Lars W. Andersena,b,⁎ , for the
International Liaison Committee on Resuscitation’s (ILCOR) Advanced Life Support and Pediatric
Task Forces
Aim: To assess the use of extracorporeal cardiopulmonary resuscitation (ECPR), compared with manual ormechanical cardiopulmonary resuscitation (CPR), for out-of-hospital cardiac arrest (OHCA) and in-hospital
cardiac arrest (IHCA) in adults and children.
Methods: The PRISMA guidelines were followed. We searched Medline, Embase, and Evidence-Based Medicine
Reviews for randomized clinical trials and observational studies published before May 22, 2018. The population
included adult and pediatric patients with OHCA and IHCA of any origin. Two investigators reviewed studies for
relevance, extracted data, and assessed risk of bias using the ROBINS-I tool. Outcomes included short-term and
long-term survival and favorable neurological outcome.
Results: We included 25 observational studies, of which 15 studies were in adult OHCA, 7 studies were in adult
IHCA, and 3 studies were in pediatric IHCA. There were no studies in pediatric OHCA. No randomized trials were
included. Results from individual studies were largely inconsistent, although several studies in adult and pediatric IHCA were in favor of ECPR. The risk of bias for individual studies was overall assessed to be critical, with
confounding being the primary source of bias. The overall quality of evidence was assessed to be very low.
Heterogeneity across studies precluded any meaningful meta-analyses.
Conclusions: There is inconclusive evidence to either support or refute the use of ECPR for OHCA and IHCA inadults and children. The quality of evidence across studies is very low.The post Extracorporeal cardiopulmonary resuscitation for cardiac arrest first appeared on האיגוד הישראלי לרפואה דחופה.
Michael Brouner, MD1; Jamey Hammock, MD2; Harish Doppalapudi, MD3Author Affiliations Article InformationJAMA Intern Med. 2023;183(3):261-262. doi:10.1001/jamainternmed.2022.5901Case Presentation Apatient in their 50s with a history of hypertension, chronic obstructive pulmonary disease, heavy alcohol use, and tobacco use presented to the emergency department with a 2-month history of nausea and vomiting that worsened in the 3 days prior to presentation to the point that the patient had been unable to tolerate anything by mouth. The patient denied chest pain or dyspnea. On arrival, the patient was afebrile with a heart rate of 129 beats/min, blood pressure of 70/48 mm Hg, and oxygen saturation of 94% on room air. Physical examination revealed nonlabored respirations with clear lung fields bilaterally, normal heart sounds with no appreciable murmurs, and warm and well-perfused extremities. There was mild tenderness to palpation of the epigastrium. Pertinent laboratory findings included a high-sensitivity troponin T of 0.008 ng/mL (to convert to μg/L, multiply by 1.0), lactic acid of 3.8 mmol/L, creatinine of 1.5 mg/dL (to convert to μmol/L, multiply by 76.25), and white blood cell count of 11 900/μL (to convert to ×109/L, multiply by 0.001). A 12-lead electrocardiogram (ECG) was obtained (Figure).
Figure. Initial 12-Lead Electrocardiogram on ArrivalQuestions: How would you interpret this ECG? What are some common causes of this ECG tracing?
Interpretation and DiscussionThe 12-lead ECG revealed sinus tachycardia with ST depression in inferior and lateral leads (II, III, aVF, V4 to V6) and ST elevation of 2 mm in leads aVR and V1. This ECG pattern of significant ST elevation in aVR and V1 coupled with diffuse ST depression was once widely accepted to be an ominous finding suggestive of acute occlusion of the left main coronary artery or proximal left anterior descending artery that required emergent invasive assessment for revascularization.1 The 2013 ST-elevation myocardial infarction (STEMI) guidelines classified this pattern as a STEMI equivalent, necessitating immediate action and emergent timely transport either to a facility capable of left heart catheterization and percutaneous coronary intervention or thrombolytic therapy otherwise.2
In the current patient, cardiology was consulted to consider emergent left heart catheterization. In the interim, the patient was appropriately resuscitated with intravenous fluids with improvement in blood pressure to the 120s mm Hg systolic within 30 minutes from initial evaluation. A repeated 12-lead ECG was obtained at that time, which revealed normal sinus rhythm with complete resolution of all ST changes.
Further workup for the patient involved computed tomography imaging of the abdomen and pelvis that revealed gastric outlet obstruction secondary to a duodenal stricture, for which the patient underwent a successful robotic gastrojejunostomy later in the hospital course and was ultimately able to be discharged home. A transthoracic echocardiogram was notable for an ejection fraction of 60% to 65% and normal left and right ventricular systolic function with normal wall motion. Given the rapid resolution of ECG changes and lack of chest pain, further investigation with left heart catheterization was appropriately deferred, in turn avoiding any potential complications involved with the procedure, heparinization, or other treatments.
In the appropriate context, diffuse ST depression coupled with ST elevation in leads aVR and V1 can signify acute occlusion of the left main or proximal left anterior descending artery. In addition to acute occlusion of a coronary artery, diffuse subendocardial ischemia and repolarization abnormalities are important diagnostic considerations that can each in turn require vastly different choices in management.
In total there are 3 main categories to consider as underlying causes of ST elevation within aVR: occlusion of a coronary vessel, subendocardial ischemia, and repolarization abnormalities. Diffuse subendocardial ischemia can result from severe nonocclusive coronary artery disease (left main or 3-vessel) or from a demand/supply mismatch due to various causes, such as severe hypotension, sepsis, aortic stenosis, and uncontrolled hypertension. Repolarization abnormalities due to severe left ventricular hypertrophy or electrolyte abnormalities such as hypokalemia can also result in this ECG pattern.
In a study of more than 130 patients with ST elevation in lead aVR and diffuse ST depression, only about one-fourth of patients had acute coronary syndrome.3 In this patient, the rapid resolution of ECG changes after normalizing the blood pressure strongly suggests supply/demand mismatch from severe hypotension as the mechanism driving the initial presenting ECG changes. If instead the ECG changes had been secondary to either occlusion of the left main or left anterior descending artery, or instead due to significant nonocclusive coronary artery disease, the ECG findings would not have been expected to resolve with merely fluid resuscitation. Furthermore, there were no reversible causes of repolarization abnormalities identified to suggest that as the cause. This case helps put into perspective the importance of taking the entire clinical picture into account while also reinforcing the many differentials that can cause ST elevation within lead aVR.
While diffuse ST-segment depression with ST-segment elevation in aVR is an important indicator of a possible acute coronary syndrome, one must remain vigilant of the broad differential for this ECG pattern. Obtaining a complete history remains fundamental to providing the best care for patients.
Take-home Points* The ECG finding of ST elevation within lead aVR is no longer classified as a STEMI equivalent. * There are 3 main categories to consider as underlying causes of ST elevation within lead aVR: occlusion of a coronary vessel, subendocardial ischemia (from either severe nonocclusive coronary artery disease or from a demand/supply mismatch), and repolarization abnormalities. * Obtaining a complete history is fundamental to approaching a patient with ST elevation within lead aVR and determining the best course in patient care.
Back to topArticle InformationCorresponding Author: Michael Brouner, MD, Tinsley Harrison Internal Medicine Residency Program, University of Alabama–Birmingham Department of Medicine, 1802 Sixth Ave S, Birmingham, AL 35233 (mrbrouner@uabmc.edu).
The post Does ST Elevation in Lead aVR Require an Emergent Trip to the Catheterization Laboratory? first appeared on האיגוד הישראלי לרפואה דחופה.
Apr 24, 2023
Contributor: Meghan Hurley, MD
Educational Pearls:
-
Two main reasons to choose non-traditional RSI
- Anatomically challenging airway
- Physiologically difficult patients: hypoxia, metabolic acidosis, hemodynamic instability
- Ketamine may help patients remain hemodynamically stable
- In critical patients, it is important to consider non-traditional RSI medications to improve outcomes
References
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Lyon RM, Perkins ZB, Chatterjee D, Lockey DJ, Russell MQ. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care. 2015;19(1). doi:10.1186/s13054-015-0872-2
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Merelman AH, Perlmutter MC, Strayer RJ. Alternatives to rapid sequence intubation: Contemporary airway management with ketamine. West J Emerg Med. 2019;20(3):466-471. doi:10.5811/westjem.2019.4.42753
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Anthony S. Kim, MD, reviewing Sarraj A et al. JAMA Neurol 2022 Dec 27
In an observational study, functional outcomes were better, although symptomatic intracerebral hemorrhage was more common, with endovascular thrombectomy than with medical management.
Randomized clinical trial data have established the efficacy of endovascular thrombectomy for selected patients with large-vessel occlusion stroke up to 24 hours after last known well time, but whether treatment beyond 24 hours would be beneficial is unclear, since randomized trial data for this ultra-extended time window are not yet available. To explore this possibility with available observational data, researchers identified 301 adults with acute large-vessel occlusion stroke involving the internal carotid artery or M1 or M2 segments of the middle cerebral artery who had received either endovascular thrombectomy (185; 61%) or medical management (116; 39%) beyond 24 hours after symptom onset at 17 centers across the U.S., Spain, Australia, and New Zealand from 2012 through 2021.
Patients who had received endovascular thrombectomy were significantly more likely to be functionally independent (modified Rankin Scale score, 0–2; 38% vs. 10%), despite an increased risk for symptomatic intracranial hemorrhage (10.1% vs. 1.7%), than those that had received medical management. Similar robust results came from a series of subsequent analyses using propensity score matching to address potential selection bias by balancing clinical characteristics and Alberta Stroke Program Early CT Score (ASPECTS); clinical characteristics and perfusion imaging parameters; and clinical characteristics, ASPECTS, and perfusion parameters.
COMMENTThese observational data are exploratory but provide strong justification for prospective studies to determine precisely which patients might benefit most from extending the endovascular treatment time window further. These efforts may expand the indications for endovascular stroke treatment in the future.
CITATIONSSarraj A et al. Association of endovascular thrombectomy vs medical management with functional and safety outcomes in patients treated beyond 24 hours of last known well: The SELECT late study. JAMA Neurol 2022 Dec 27; [e-pub]. (https://doi.org/10.1001/jamaneurol.2022.4714)
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| ניהול כעסים: דרך אחרת לטיפול בשחיקה
| By Shannon L. Gollnick, DBA, NRP, FP-C |
| Shannon L. Gollnick, MSM, NRP, FP-Cבמהלך השנים האחרונות, למדתי שחיקה והשפעתה על EMS מתוך כוונה להבין טוב יותר את הבעיה ולהיות חלק מהפתרון. מחקרי השחיקה שסקרתי מכילים שלושה נושאים נפוצים:1. הראשונה היא שאין הגדרה מוסכמת לחלוטין מהי בדיוק שחיקה2. השני הוא שהמטפלים בבריאות רגישים יותר לחוות שחיקה3. ושלישית, הוא שהמונחים “שחיקה”, “מתח” ו”עייפות חמלה” משמשים שם נרדף בציבור הרחב, ובכל זאת שום דבר לא יכול להיות רחוק יותר מהאמתעייפות חמלה, מושג הדורש דיון משלו, היא, על פני השטח, מחיר שנדרש בשל דאגה לאחרים. שחוקים ולחוצים, למרות שהם משתמשים בהם לעתים קרובות לסירוגין, הם לא אותו דבר. מתח, בזמן שהוא מצטבר, הוא עומס או מתח נפשי או רגשי הנובע מנסיבות תובעניות. מתח הוא לא תמיד רע למעשה, רבים מאיתנו בתעשיית ה-EMS מפרגנים לעצמנו על היכולת שלנו לעבוד היטב תחת לחץ ולשגשג.עם זאת, שחיקה אינה זהה בשום אופן למתח. הצבת שחיקה ולחץ באותה רמה תהיה שווה ערך להשוואה בין כאב של עצם שבורה ללב שבור. הראשון כואב אך ניתן לתיקון, השני הוא כאב רגשי עמוק שמתבטא בדרכים שמילים אינן יכולות לכלול במלואן.מה שאין במחקר הוא השפעת הכעס על השחיקה. כאשר אנו מעריכים את מי שנשרף, עלינו להבין תחילה שאבחון עצמי הוא בעיה בפני עצמה. שום סימפטומולוגיה אחרת לא נותנת את עצמה לאבחון עצמי פורה כמו שחיקה. שנית, כמעט כל אלה שכן מתארים את עצמם כשחוקים, עושים זאת מתוך תסכול. זה כאן, אני מאמין, המקור האמיתי לשחיקה.כעס, תיסכול ואגרסיותב-EMS, יש מספר רב של דברים שאנחנו כחובשים ופרמדיקים חייבים ללמוד “להתמודד איתם”. זה כולל שיחות מאוחרות, החזקות חובה, מטופלים שאינם עומדים בדרישות וגסות רוח, דרישות תיעוד שלוקח יותר זמן להשלמתם מאשר השיחה בפועל וכו’. רשימת הדברים שאנחנו חייבים ללמוד להתמודד איתם היא ממושכת, עם זאת, אנחנו אף פעם לא באמת מדברים על “איך” להתמודד איתה. כמו האדוות על פני בריכה דוממת מסלע זעיר, התסכולים האלה הולכים וגדלים. רשימה נרחבת והולכת וגדלה של תסכולים מובילה בסופו של דבר לכאוס. כאוס מוביל לאובדן שליטה, ואובדן שליטה זה מוביל לכעס – כעס שאנו רואים ושומעים משפיע על החובשים שלנו מדי יום ביומו.כעס הוא רגש אנושי בסיסי מאוד. בבסיסו, זוהי ההגנה של הקו הראשון שלנו נגד אנטגוניסט שמאיים על כל היבט של הזהות העצמית שלנו. זהו הדחף הטבעי שלנו לכל התקפה נתפסת על ההערכה העצמית הפסיכולוגית שלנו, הזהות שלנו או האישיות הציבורית שלנו. השערת התסכול-תוקפנות שפותחה לפני למעלה מ-80 שנה על ידי פסיכולוגים חברתיים טוענת שתוקפנות היא תוצאה של חסימה או תסכול של מאמציו של אדם להשיג מטרה. נשמע מוכר?במחקרים מסוימים, יש השוואה משמעותית בין שחיקה ודיכאון. כאן טמון גם בסיס של כעס. זיגמונד פרויד ציין ב-1917 שדיכאון הוא כעס המופנה פנימה: התסכול של אובדן פסיכולוגי כלשהו אך ללא האשמה עצמית. זו פילוסופיה שעדיין בולטת בקרב פסיכולוגים כיום.שורש המחזורהמחקר על שחיקה נרחב, עם זאת, כאנשי אקדמיה וקלינאים, עלינו לשקול תמיד אם אנו שואלים את השאלות הנכונות. לעתים קרובות, מה שאנחנו הכי מחפשים זה מה שנמצא ממש מולנו. החובשים והפאראמדיקים שלנו עוזבים את התעשייה שלנו בהמוניהם, ומסיבות הנפוצות בארגונים ובאזורים גיאוגרפיים; שכר נמוך , איזון גרוע בין עבודה לחיים, מנהיגות לקויה וכו’. אנו רואים את התוצאות בציוני מעורבות. אנו רואים את התוצאות בשיעורי התחלופה . המציאות היא שספקים רבים מתוסכלים. הם כועסים. אנחנו אומרים להם בעקביות “להתמודד עם זה”, אך לעולם לא מספקים פתרונות כיצד.מחקר התזה שלי מצא ששיעורי השחיקה היו למעשה נמוכים יותר אצל חובשים קבועים (10+ שנות שירות) מאשר אצל צעירים יותר (< 3 שנות שירות). אם הלחץ הוא מצטבר, אז איך זה יכול להיות? כפי שצוין קודם לכן, שרופים ולחוצים אינם זהים. אולי ותיקי העונה האלה למדו “להתמודד עם זה?” אולי הם הצליחו למלא בהצלחה את הפער בין הציפייה למציאות.כך או כך, המאמצים שלנו להילחם בשחיקה לא צלחו עד כה. הירידה בכוח העבודה של EMS נמצא ברמת משבר ובו זמנית בזמן שבו הצורך בתגובה להתפרצויות מגיפה מתגברות, אסונות טבע ומערכת בריאות מתקשה גובר.אני לא מציע שכעס הוא השורש הבלעדי של האתגרים שלנו; אני פשוט שואל אם אנחנו שואלים את השאלות הנכונות? במקום לשאול ספקים אם הם שרופים ולמה, האם עלינו לשאול מה מתקתק אותם? האם בנוסף לאימון חוסן, האם עלינו לספק הדרכה לניהול כעסים?כענף, איננו יכולים להמשיך בדרך זו מבלי להעריך תחילה האם זו הדרך הנכונה להיות בה מלכתחילה. אם נצליח בעתיד, עלינו לשאול שאלות טובות יותר. האם הכעס שצריך לטפל בו כמניעה לשחיקה?על הסופרשאנון ל. גולניק היא פרמדיקית רשומה ארצית וחובשת טיסה מוסמכת עם 20 שנות ניסיון. הוא משמש כמנהל פרויקטים של שירותי חירום לניהול וייעוץ (EMS|MC) בוינסטון-סאלם, צפון קרוליינה, ופרמדיק מתאמן ב-Fort Mill EMS ו-Piedmont Health EMS בדרום קרוליינה.Additional resources:* Reignite EMS passion by banishing burnout (eBook) * On-demand webinar: How to create a mental health-friendly environment at your service * Research analysis: Burnout in frontline ambulance staff |
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February 3, 2023 / GI, ToxicologyWritten by Laura Murphy
Patients with alcohol-associated hepatitis have a high rate of complications and short-term mortality of 20-50%. Prompt recognition and treatment, including initiation of treatment for alcohol use disorder, is important to improve patient outcomes.
Why does this matter?
Alcohol is responsible for 50% of deaths due to liver disease, and 35% of patients with alcohol use disorder will develop some form of alcoholic liver disease (ALD). As incidence of alcohol-associated liver disease is increasing, it is imperative that emergency physicians recognize and initiate appropriate treatment for patients presenting with alcohol-associated hepatitis, which carries a particularly high short-term mortality rate.
Whiskey, you’re the devil…
Alcoholic hepatitis is a severe clinical state characterized by abrupt onset of jaundice, malaise, decompensated liver disease, and coagulopathy. Severe cases have an estimated 3-month mortality of 20-50%. Hepatocellular failure and portal hypertension is caused by a variety of cellular and molecular pathways causing direct hepatotoxicity, changes in the gut-liver axis, and associated local and systemic inflammatory response.
Diagnosis: Signs and symptoms include jaundice, malaise, ascites or edema, fever, tender hepatomegaly, confusion and/or asterixis; lab findings include hyperbilirubinemia, transaminitis with AST>ALT, hypoalbuminemia, thrombocytopenia and increased INR. NIAAA Consortium criteria include prolonged alcohol intake (>60 g/day for men, >40 g/day for women) until <8 weeks prior to presentation, acute onset of jaundice with bilirubin >3 mg/dL, AST> 50 IU/L, AST:ALT>1.5 (with both values <400 IU/L). It is important to rule out other causes of liver disease including obstruction, drug-induced injury, viral hepatitis, or ischemia and to treat if present. Biopsy can be pursued in ambiguous cases.
Complications: Liver-related complications include ascites, edema, hepatic encephalopathy (which portends a particularly poor prognosis) as well as GI bleeding, and hepatorenal syndrome. Patients generally require aggressive nutritional support and vitamin supplementation. Workup and treat concomitant infections (up to 12.5% of patients present with a concomitant infection, and 23% develop infection during treatment). Incidence of fungal infections is high (up to 16%) in this population.
Treatment: Glucocorticoids (prednisone 40 mg/day) decrease short-term mortality for patients with MELD>20. Concomitant use of N-acetylcysteine has also shown promise for improving short-term survival. For patients who do not respond to steroids, early liver transplantation should be considered. However, there are often barriers to transplant, including psychosocial factors, stigma, and selection bias.
The main factor influencing long-term prognosis after an episode of alcohol-associated hepatitis is prolonged abstinence, so initiation of treatment for alcohol use disorder is imperative! This includes treatment for withdrawal, identification and treatment of concomitant psychiatric conditions, consultation with addiction specialists, behavioral therapy, and consideration of anti-craving drugs at discharge (baclofen and acamprosate best for patients with ALD).
Source
Alcohol-Associated Hepatitis. NEJM. 2022 Dec 29; 387 (26): 2436-2448.
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January 31, 2023 / Imaging, Trauma, UltrasoundWritten by Ketan Patel
An initial diagnostic workup that includes an E-FAST exam and targeted chest and pelvis x-rays allows clinicians an opportunity to assess and intervene appropriately on the majority of patients prior to WBCT in the setting of blunt trauma.
Why does this matter?
Few studies have assessed the diagnostic value of a E-FAST exam prior to the gold standard WBCT in blunt trauma patients. This study quantifies that value to validate a diagnostic approach that utilizes targeted plain x-ray, E-FAST exams, and WBCT in the paradigm of care of these patients.
Straight to the donut of truth? Not so FAST.
This study was a prospective cohort of blunt trauma patients presenting to 6 French trauma centers. A workup that included targeted radiographs, E-FAST and eventual WBCT were utilized in the management of these patients. The care of these patients was then evaluated for appropriateness by an expert panel who reviewed the cases.
In this cohort, care was deemed appropriate in 96.7% of cases (493 total). It is important to note that the E-FAST exam that they utilized included a transcranial Doppler exam to assess cerebral blood flow. In most patients, the E-FAST and targeted radiographs provided clinicians with information to allow them to abstain from any therapeutic interventions and safely perform the WBCT (233 patients).
On the other patients, the initial imaging provided crucial information to dictate immediate interventions and stabilization prior to WBCT. Of the deemed inappropriate cases (17), 13 were the result of deviation from guidelines, and 4 were due to errors in interpreting the E-FAST exam.
While there are several limitations to this study due mode of assessment of appropriateness and inability to blind, it does support the current practice of utilizing all 3 imaging modalities in blunt trauma. The utility of E-FAST and radiographs especially support decision-making in unstable patients before WBCT.
Source
Appropriateness of Initial Course of Action in the Management of Blunt Trauma Based on a Diagnostic Workup Including an Extended Ultrasonography Scan. JAMA Netw Open. 2022 Dec 1;5(12):e2245432. doi: 10.1001/jamanetworkopen.2022.45432.
The post Does E-FAST Add Value Before CT Traumagram? first appeared on האיגוד הישראלי לרפואה דחופה.
Jan 30, 2023
Contributor: Travis Barlock, MD
Educational Pearls:
- Early repolarization a benign EKG pattern that can mimic an anterior STEMI
- Can be seen in the anterior leads typically in young male patients
- Can differentiate Early Repolarization vs Anterior STEMI by looking at four variables:
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- Corrected QT interval
- QRS amplitude in V2
- R wave amplitude in V4
- ST elevation 60 ms after J point in V3
- These four variables can be plugged into a formula (available on MDCalc)
- Note that a longer QT is more corelated with STEMI
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February 1, 2023 / Imaging, TraumaWritten by Gabby Leonard
The Western Trauma Association Algorithms Committee has released new evaluation and management guidelines and a step-by-step algorithm (see below) surrounding blunt thoracic aortic injury.
Why does this matter?
Blunt thoracic aortic injury (BTAI) most often occurs distal to the takeoff of the left subclavian artery and is associated with high risk for mortality. Recent updates based on prospective and retrospective cohort studies guide decision making and intervention in these injuries.
Blunt thoracic aortic injury – no longer a mystery
From cited articleScreening: Consider BTAI in high-energy mechanisms such as MVC or fall from height. CXR may show wide mediastinum, hemothorax, blunting of aortic knob, but beware of false negative screening CXR.
Diagnosis: CTA of chest (sensitivity 95-100%, NPV 99-100%) is best for ED evaluation. You may also consider transesophageal echocardiogram, intravascular ultrasound, or aortography – though this depends on your local resources.
Management: Use anti-impulse control with esmolol targeting a HR <100 and SBP <100. Consider diltiazem or vasodilator if no contraindication (i.e. TBI requiring cerebral perfusion). Avoid pure vasodilators (i.e. nitroprusside) as first-line agents. Medical management is meant to decrease risk of progression or free-rupture of the injury.
Grading: Grades I (intimal tear) and II (intramural hematoma) are low-grade injuries that may be managed with anti-impulse therapy and repeat CTA 2-3 days after admission. Grade III (pseudoaneurym) and Grade IV (rupture) are high-grade injuries that typically require surgical intervention after initial anti-impulse control.
Endovascular vs. Open Repair: TEVAR (thoracic endovascular aortic repair) is treatment of choice for BTAI to reduce mortality and paraplegia when compared to left posterolateral thoracotomy.
Post-repair Management: ICU admission is needed after TEVAR for monitoring. Goal is normal BP and heart rate. Consider surveillance of endograft with serial chest CTs.
Source
Blunt thoracic aortic injury: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2023 Jan 1;94(1):113-116. doi: 10.1097/TA.0000000000003759. Epub 2022 Aug 24.
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M.M. Suverein, T.S.R. Delnoij, R. Lorusso, G.J. Brandon Bravo Bruinsma, L. Otterspoor, C.V. Elzo Kraemer,
A.P.J. Vlaar, J.J. van der Heijden, E. Scholten, C. den Uil, T. Jansen, B. van den Bogaard, M. Kuijpers, K.Y. Lam,
J.M. Montero Cabezas, A.H.G. Driessen, S.Z.H. Rittersma, B.G. Heijnen, D. Dos Reis Miranda, G. Bleeker,
J. de Metz, R.S. Hermanides, J. Lopez Matta, S. Eberl, D.W. Donker, R.J. van Thiel, S. Akin, O. van Meer,
J. Henriques, K.C. Bokhoven, L. Mandigers, J.J.H. Bunge, M.E. Bol, B. Winkens, B. Essers, P.W. Weerwind,
J.G. Maessen, and M.C.G. van de Poll
AbstractBACKGROUNDExtracorporeal cardiopulmonary resuscitation (CPR) restores perfusion and oxygenation in a patient who does not have spontaneous circulation. The evidence with regard to the effect of extracorporeal CPR on survival with a favorable neurologic outcome in refractory out-of-hospital cardiac arrest is inconclusive.
METHODSIn this multicenter, randomized, controlled trial conducted in the Netherlands, we assigned patients with an out-of-hospital cardiac arrest to receive extracorporeal CPR or conventional CPR (standard advanced cardiac life support). Eligible patients were between 18 and 70 years of age, had received bystander CPR, had an initial ventricular arrhythmia, and did not have a return of spontaneous circulation within 15 minutes after CPR had been initiated. The primary outcome was survival with a favorable neurologic outcome, defined as a Cerebral Performance Category score of 1 or 2 (range, 1 to 5, with higher scores indicating more severe disability) at 30 days. Analyses were performed on an intention-to-treat basis.
RESULTSOf the 160 patients who underwent randomization, 70 were assigned to receive extracorporeal CPR and 64 to receive conventional CPR; 26 patients who did not meet the inclusion criteria at hospital admission were excluded. At 30 days, 14 patients (20%) in the extracorporeal-CPR group were alive with a favorable neurologic outcome, as compared with 10 patients (16%) in the conventional-CPR group (odds ratio, 1.4; 95% confidence interval, 0.5 to 3.5; P=0.52). The number of serious adverse events per patient was similar in the two groups.
CONCLUSIONSIn patients with refractory out-of-hospital cardiac arrest, extracorporeal CPR and conventional CPR had similar effects on survival with a favorable neurologic outcome. (Funded by the Netherlands Organization for Health Research and Development and Maquet Cardiopulmonary [Getinge]; INCEPTION ClinicalTrials.gov number, NCT03101787. opens in new tab.)
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January 27, 2023 / ED Operations, WellnessWritten by Vivian Lei
Emergency physicians (EPs) suffer from poor sleep quality and lower sleep quantity than recommended. EPs were also objectively more fatigued during late afternoon and evening shifts and spend almost a quarter of their shift in a fatigued state.
Why does this matter?
Shift workers are susceptible to fatigue and its related risks. EPs often have complex and varied shift schedules, but objective measurements of fatigue have not been well-studied.
The human cost of 24/7/365
In this small study of 17 EPs at an academic medical center, participants wore a Readiband, which is a commercially available wrist-worn movement tracking device that provides sleep metrics and predicted fatigue scores. Data was collected over 2 months, for an average of 23 shifts per physician (range 10-41 shifts). The average sleep quality score was 7.71/10 (optimal range <6) and sleep quantity was 6.77 hours (optimal range 7-9 hours). A calculated hourly fatigue score, or Readiscore, was assessed as a function of the preceding sleep metrics based upon the validated Sleep, Activity, Fatigue, and Task Effectiveness (SAFTE) model. Across all participants, 50.6% of the work period was spent in a high-performance state with Readiscores >90, while 23.5% of the work period was spent with Readiscores <80, which corresponds with increased risk of error due to fatigue. When Readiscores were plotted against shift start time, they found that Readiscores increased for shift start times between 6 AM and 2 PM, but then decreased from 2 PM to 11 PM.
This was essentially a pilot study to assess whether a specific method of measuring EP sleep quantity, sleep quality, and predicted fatigue was feasible. Further validation of the fatigue prediction model in clinicians is necessary before it can be applied toward investigating risk-reduction interventions.
Source
Objective assessment of sleep and fatigue risk in emergency medicine physicians. Acad Emerg Med. 2022 Oct 14. doi: 10.1111/acem.14606. Epub ahead of print.
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Fluvoxamine for Outpatients With Mild to Moderate COVID-19, Accuracy of Stroke Risk Prediction Models, Organization and Performance of US Health Systems, and moreEditor’s Summary by Kirsten Bibbins-Domingo, PhD, MD, MAS, Editor in Chief of JAMA, the Journal of the American Medical Association, for the January 24/31, 2023, issue.
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Annals of Emergency Medicine · January 2023ory and Ryan start off the new year discussing telehealth outcomes in patients with sepsis, COVID-19 patients discharged on supplemental O2, documenting social risk factors in the ED, and much more.The post PODCAST: January 2023 Annals of Emergency Medicine first appeared on האיגוד הישראלי לרפואה דחופה.
Jacky Tu1,2, Mitchell Haines1,3, Peter Gowdie3,4, Simon Craig3,5 Correspondence to Dr Simon Craig, Monash Medical Centre Clayton, Clayton 71326, Victoria, Australia; simon.craig@monash.edu Abstract Background Acute non-traumatic limp in children has many causes, ranging from common benign and self-limiting disease to serious time-sensitive emergencies such as septic arthritis. We aimed to (1) describe the epidemiology and workup of paediatric acute non-traumatic limp […]
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Topics in this EM Quick Hits podcast Justin Morgenstern on fluids in acute pancreatitis – WATERFALL Trial (0:38) Leeor Sommer on nasal fractures in the emergency department (6:45) Christina Shenvi on acute delirium identification and workup (15:21) Sheldon Cheskes & Rohit Mohindra on the DOSE VF trial (25:23) Noor Khatib & Kari Sampsel on intimiate partner violence (61:13) Podcast content, production, editing and sound design […]
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Regular Use of Morphine for Chronic Breathlessness in COPD, Treatment Time and In-Hospital Mortality With STEMI, Change in Travel Time to US Abortion Facilities After Dobbs Decision, and more
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http://orcid.org/0000-0003-3218-2470Beat Lehmann, Ursina Koeferli, http://orcid.org/0000-0002-6646- 5789Thomas C Sauter, Aristomenis Exadaktylos, http://orcid.org/0000-0002-2445-984XWolf E Hautz Correspondence to Dr Beat Lehmann, Emergency Medicine, Inselspital University Hospital Bern, Bern 3010, Switzerland; beat.lehmann@insel.ch Abstract Background Systematic imaging reduces the rate of missed appendicitis and negative appendectomies in patients with suspected acute appendicitis (AA). Little is known about the utility of ultrasound as a first […]
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Risk of Cardiovascular Diseases Associated With Medications Used in Attention-Deficit/Hyperactivity DisorderA Systematic Review and Meta-analysis Le Zhang, MPH1; Honghui Yao, MSc1; Lin Li, PhD1,2; et alEbba Du Rietz, PhD1; Pontus Andell, MD, PhD3,4; Miguel Garcia-Argibay, PhD2; Brian M. D’Onofrio, PhD1,5; Samuele Cortese, MD, PhD6,7,8; Henrik Larsson, PhD1,2; Zheng Chang, PhD1 Author Affiliations Article Information JAMA Netw Open. 2022;5(11):e2243597. doi:10.1001/jamanetworkopen.2022.43597 Key PointsQuestion Are attention-deficit/hyperactivity disorder (ADHD) medications associated with the risk of cardiovascular disease (CVD)? Findings This systematic review and meta-analysis based on 19 observational studies with more than […]
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November 23, 2022 / Resuscitation Written by Joshua Campbell Relative thoracic distention pattern seen on capnography during cardiac arrest may have a negative impact on blood pressure and cerebral perfusion. Here’s how to recognize and fix it. If you’re not a subscriber yet, become a JournalFeed member today! Since you need to know these ETCO2 patterns, the link to […]
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November 22, 2022 / Resuscitation Written by Joshua Campbell With ventilation rate standardized, chest compression (CC) depth explains variations in ETCO2 better than chest compression rate. Why does this matter? We want to optimize CPR in cardiac arrest. ETCO2 is a very useful clinical tool to assess a patient’s condition during CPR, but how do we assess […]
The post How to Optimize CPR Quality – Compression Depth or Rate? first appeared on האיגוד הישראלי לרפואה דחופה.
Nov 21, 2022 It’s a tough time to practice medicine right now, which makes paying attention to self care even more important. In this episode we break down three specific strategies for: improving mental and physical performance, sustaining shift endurance, and building a scaffolding for joy at work. Interested in one-on-one coaching? Learn more at roborman.com […]
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Nov 21, 2022 Contributor: Aaron Lessen,MD Educational Pearls: Recent study looked at mechanically ventilated patients in ED and ICU to determine if O2 saturation level impacted patient outcomes 2541 patients randomized to one of three target O2 saturation levels Low: 90% (Range: 88-92%) Intermediate: 94% (Range: 92-96%) High: 98% (Range: 96-100%) Outcome indicators Primary: Number […]
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Peter Cosgrove, MBBChBAO Baruch S. Krauss, MD, EdM Joseph P. Cravero, MD Eric W. Fleegler, MD, MPH Published:June 23, 2022DOI:https://doi.org/10.1016/j.annemergmed.2022.05.002 Study objective Laryngospasm is a rare but potentially life-threatening complication of sedation. The objective of this study was to perform a predictor analysis of biologically plausible predictors and the interventions and outcomes associated with laryngospasm. Methods Secondary […]
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Nov 8, 2022 Contributor: Nick Hatch, MD Educational Pearls: In the setting of traumatic injury, tranexamic acid (TXA) is given to stabilize clots which minimizes bleeding and decreases risk of hemorrhagic shock Current TXA dose for trauma is 1 g bolus followed by a 1 g infusion; both doses should be given within 3 hours […]
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Alice Rogan1,2, Annabelle Sik1, Emily Dickinson2, Vimal Patel3, Brad Peckler2, David McQuade1,2, Peter D Larsen1 Endorsed by ACEM Emergency Department Epidemiology Network Correspondence to Dr Alice Rogan, Department of Surgery and Anaesthesia, University of Otago Wellington, Wellington 6242, New Zealand; alice.rogan@otago.ac.nz Abstract Background Traumatic brain injury is a common ED presentation. CT-head utilisation is escalating, exacerbating resource pressure in the ED. The biomarker […]
The post Diagnostic performance of S100B as a rule-out test for intracranial pathology in head-injured patients presenting to the emergency department who meet NICE Head Injury Guideline criteria for CT-head scan first appeared on האיגוד הישראלי לרפואה דחופה.
November 9, 2022 / Neurosurgery, Trauma Written by Gabby Leonard The EZ-IO may be considered as a temporizing measure for trepanation of an epidural hematoma (EDH) in rural ED settings. This should be considered only under the guidance of a skilled neurosurgeon when immediate transportation to a higher level of care is not possible. Why does this matter? […]
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ACEP Frontline · Tackling Pediatric Airways- Al Sacchetti- ACEP22 In this episode we review the approach and management of the difficult pediatric airway with Dr. Al Sacchetti. This was recorded at ACEP22 in San Francisco.
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Mohamed I. Elsaid, PhD, MPH1,2; You Li, MSc3; John F. P. Bridges, PhD1,4; et alGuy Brock, PhD1,2; Carlos D. Minacapelli, MD3; Vinod K. Rustgi, MD, MBA3,5 Author Affiliations Article Information JAMA Netw Open. 2022;5(10):e2235003. doi:10.1001/jamanetworkopen.2022.35003 Key Points Question Is bariatric surgery a factor in reducing the risk of cardiovascular outcomes in adults with severe obesity and nonalcoholic fatty liver disease (NAFLD)?Findings In this large cohort study of 86 964 individuals with NAFLD and severe obesity, compared with […]
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Mohamed I. Elsaid, PhD, MPH1,2; You Li, MSc3; John F. P. Bridges, PhD1,4; et alGuy Brock, PhD1,2; Carlos D. Minacapelli, MD3; Vinod K. Rustgi, MD, MBA3,5 Author Affiliations Article Information JAMA Netw Open. 2022;5(10):e2235003. doi:10.1001/jamanetworkopen.2022.35003 Key Points Question Is bariatric surgery a factor in reducing the risk of cardiovascular outcomes in adults with severe obesity and nonalcoholic fatty liver disease (NAFLD)?Findings In this large cohort study of 86 964 individuals with NAFLD and severe obesity, compared with […]
The post Association of Bariatric Surgery With Cardiovascular Outcomes in Adults With Severe Obesity and Nonalcoholic Fatty Liver Disease first appeared on האיגוד הישראלי לרפואה דחופה.
Key Points Question What were the treatment times and in-hospital mortality among US patients with ST-segment elevation myocardial infarction (STEMI) between 2018 and 2021? Findings In this serial cross-sectional registry study that included 114 871 patients with STEMI, the median time to treatment was 86 minutes in the second quarter of 2018 and 91 minutes in the first […]
The post Treatment Time and In-Hospital Mortality Among Patients With ST-Segment Elevation Myocardial Infarction, 2018-2021 first appeared on האיגוד הישראלי לרפואה דחופה.
Key Points Question What were the treatment times and in-hospital mortality among US patients with ST-segment elevation myocardial infarction (STEMI) between 2018 and 2021? Findings In this serial cross-sectional registry study that included 114 871 patients with STEMI, the median time to treatment was 86 minutes in the second quarter of 2018 and 91 minutes in the first […]
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Nov 7, 2022 Contributor: Aaron Lessen, MD Educational Pearls: Recent study evaluated if early exposure to an allergen impacted the rate of allergy development later in childhood Children were exposed to peanut, milk, wheat, and egg allergens at 3 months of age and then followed for 3 years 2.5-3% of children who were not exposed […]
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Nov 7, 2022 Contributor: Aaron Lessen, MD Educational Pearls: Recent study evaluated if early exposure to an allergen impacted the rate of allergy development later in childhood Children were exposed to peanut, milk, wheat, and egg allergens at 3 months of age and then followed for 3 years 2.5-3% of children who were not exposed […]
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November 4, 2022 / Imaging, Wellness Written by Jonathan Brewer Despite a high number of portable radiographs obtained in the ED, exposure to this ionizing radiation does not appear to be a significant occupational hazard, and existing precautions appear to be adequate. Why does this matter? Emergency providers are commonly found in situations in which a portable radiograph […]
The post Guess the Radiation Risk – Portable X-Rays in the Emergency Department first appeared on האיגוד הישראלי לרפואה דחופה.
November 4, 2022 / Imaging, Wellness Written by Jonathan Brewer Despite a high number of portable radiographs obtained in the ED, exposure to this ionizing radiation does not appear to be a significant occupational hazard, and existing precautions appear to be adequate. Why does this matter? Emergency providers are commonly found in situations in which a portable radiograph […]
The post Guess the Radiation Risk – Portable X-Rays in the Emergency Department first appeared on האיגוד הישראלי לרפואה דחופה.
November 8, 2022 / ED Operations, Wellness Written by Amanda Mathews Resident and nurse teams that worked together exclusively performed better on advanced medical simulations, were more likely to have nurses present on patient rounds, and had improved teamwork earlier in the year than rotating resident/nurse teams. Why does this matter? Interdisciplinary teamwork is vital to safe and […]
The post New RCT – Teamwork Makes the… Hospital Work first appeared on האיגוד הישראלי לרפואה דחופה.
November 8, 2022 / ED Operations, Wellness Written by Amanda Mathews Resident and nurse teams that worked together exclusively performed better on advanced medical simulations, were more likely to have nurses present on patient rounds, and had improved teamwork earlier in the year than rotating resident/nurse teams. Why does this matter? Interdisciplinary teamwork is vital to safe and […]
The post New RCT – Teamwork Makes the… Hospital Work first appeared on האיגוד הישראלי לרפואה דחופה.
Jaqueline Betina Broenstrup Correa, Vinicius Brenner Felice, Graciele Sbruzzi, http://orcid.org/0000-0001-9369-2488Gilberto Friedman Correspondence to Professor Gilberto Friedman, Programa de Pós-graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, 90010-150, Brazil; gfriedman@hcpa.edu.br Abstract Background Airway management is challenging in trauma patients because of the fear of worsening cervical spinal cord damage. Video-integrated and optic-integrated devices and intubation laryngeal mask […]
The post Systematic review: Cervical spine movements during laryngoscopy and orotracheal intubation: a systematic review and meta-analysis first appeared on האיגוד הישראלי לרפואה דחופה.
Jaqueline Betina Broenstrup Correa, Vinicius Brenner Felice, Graciele Sbruzzi, http://orcid.org/0000-0001-9369-2488Gilberto Friedman Correspondence to Professor Gilberto Friedman, Programa de Pós-graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, 90010-150, Brazil; gfriedman@hcpa.edu.br Abstract Background Airway management is challenging in trauma patients because of the fear of worsening cervical spinal cord damage. Video-integrated and optic-integrated devices and intubation laryngeal mask […]
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November 2, 2022 / OB/GYN, Trauma Written by Seth Walsh-Blackmore The primary survey and standard initial interventions are the same. Here is how a viable pregnancy changes the algorithm beyond that. Why does this matter? Severe trauma is uncommon in pregnancy, so there is less experience in resuscitating these challenging patients. Data quality is lower, as there are […]
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November 2, 2022 / OB/GYN, Trauma Written by Seth Walsh-Blackmore The primary survey and standard initial interventions are the same. Here is how a viable pregnancy changes the algorithm beyond that. Why does this matter? Severe trauma is uncommon in pregnancy, so there is less experience in resuscitating these challenging patients. Data quality is lower, as there are […]
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Edited by Amal Mattu, MD Program Director, Emergency Medicine ResidencyCo-Program Director, Emergency Medicine/InternalMedicine Combined ResidencyAssociate Professor of Emergency MedicineUniversity of Maryland School of MedicineBaltimore, Maryland and This text is dedicated to the residents and faculty inEmergency Medicine at the University of Maryland MedicalCenter for providing the inspiration for this work; to my col-league Deepi Goyal, […]
The post Emergency Medicine:Trauma in the ED, Avoiding the Pitfalls and Improving the Outcomes first appeared on האיגוד הישראלי לרפואה דחופה.
Edited by Amal Mattu, MD Program Director, Emergency Medicine ResidencyCo-Program Director, Emergency Medicine/InternalMedicine Combined ResidencyAssociate Professor of Emergency MedicineUniversity of Maryland School of MedicineBaltimore, Maryland and This text is dedicated to the residents and faculty inEmergency Medicine at the University of Maryland MedicalCenter for providing the inspiration for this work; to my col-league Deepi Goyal, […]
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November 20220 Nov 1, 2022 This month we’ve got a New in EM looking at IV paracetamol, look at some guidelines for sedation, we have the second part of the highlights from the Thames Valley Air Ambulance Cardiac Arrest symposium, and finish off with some more articles in New Online. (02:25) New in EM – […]
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November 20220 Nov 1, 2022 This month we’ve got a New in EM looking at IV paracetamol, look at some guidelines for sedation, we have the second part of the highlights from the Thames Valley Air Ambulance Cardiac Arrest symposium, and finish off with some more articles in New Online. (02:25) New in EM – […]
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Nov 1, 2022 Contributor: Travis Barlock, MD Educational Pearls: The presence of a STEMI has traditionally been used to determine if a patient with acute chest pain requires urgent cath lab management STEMI indicates an occluded coronary artery, and urgent intervention is needed to restore perfusion to ischemic tissue Patients with occluded coronary arteries can […]
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Nov 1, 2022 Contributor: Travis Barlock, MD Educational Pearls: The presence of a STEMI has traditionally been used to determine if a patient with acute chest pain requires urgent cath lab management STEMI indicates an occluded coronary artery, and urgent intervention is needed to restore perfusion to ischemic tissue Patients with occluded coronary arteries can […]
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Topics in this EM Quick Hits podcast Yaron Finkelstein on pediatric cannabis poisoning pitfalls Brit Long on recognition and management of esophageal perforation Jesse McLaren on 3 questions to diagnose Brugada Syndrome Tahara Bhate on QI Corner – we don’t want to give anything away for this one! Constance Leblanc on maintaining wellness in career transitions Podcast production, editing and […]
The post PODCAST: EM Quick Hits 43 Pediatric Cannabis Poisoning, Esophageal Perforation, Brugada, Career Transitions in EM first appeared on האיגוד הישראלי לרפואה דחופה.
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The post ?Should Chest radiography routinely performed prior to cardiac catheterization in patients with ST-elevation myocardial infarction first appeared on האיגוד הישראלי לרפואה דחופה.
October 13, 2022 With the recently confirmed outbreak of Ebola Virus Disease (EVD) in Uganda, the Centers for Disease Control are asking emergency physicians to consider the virus in presenting patients who are residents or travelers with relevant exposure. This week, the CDC and the Department of Homeland Security began routing travelers from Uganda into five United […]
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Analysis of the LOOP Randomized Clinical Trial Søren Zöga Diederichsen, MD, PhD1; Kristian Steen Frederiksen, MD, PhD2; Lucas Yixi Xing, MD1; et alKetil Jørgen Haugan, MD, PhD3; Søren Højberg, MD, PhD4; Axel Brandes, MD, DMSc5,6,7; Claus Graff, PhD8; Morten Salling Olesen, MSc, PhD9; Derk Krieger, MD, PhD10; Lars Køber, MD, DMSc1,11; Jesper Hastrup Svendsen, MD, DMSc1,11 Author Affiliations Article Information JAMA Neurol. 2022;79(10):997-1004. doi:10.1001/jamaneurol.2022.3031 Key PointsQuestion Can implantable loop recorder screening for atrial fibrillation reduce the risk of severe stroke in persons with risk factors or with prior stroke? Findings In […]
The post Severity and Etiology of Incident Stroke in Patients Screened for Atrial Fibrillation vs Usual Care and the Impact of Prior Stroke A Post Hoc first appeared on האיגוד הישראלי לרפואה דחופה.
Oct 3, 2022 Contributor: Aaron Lessen, MD Educational Pearls: 2020 retrospective study with dat from two California hospitals compared rates of cardiovascular admissions in a five day period two weeks before and the five days after the presidential election Hospitalization rate for acute cardiovascular disease increased by 17% and rate of acute myocardial infarction increased […]
The post פודקאסט זה מובא במיוחד בשבוע לפני הבחירות שימו לב לכותרת : MI Risk during Elections first appeared on האיגוד הישראלי לרפואה דחופה.
Oct 4, 2022 Contributor: Don Stader, MD Educational Pearls: There are two major groups of local anesthetics: Amide and Esther To recall what group an anesthetic belongs to, use this memory trick: Amide has an ‘i’ in the name and Amide anesthetics have 2 ‘i’s e.g., Lidocaine. Ester has no ‘i’ and most common Ester […]
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Hsuan Lai a , Caroline V. Choong b , Stephanie Fook-Chongc , Yih Yng Ng d ,Eric A. Finkelsteine , Benjamin Haalandf,g , E. Shaun Gohh , Benjamin Sieu-Hon Leongi ,Han Nee Ganj , David Fook , Lai Peng Thaml , Rabind Charles m, Marcus Eng Hock Ong n,e,∗ ,For the PAROS study group a […]
The post INTERVENTIONAL STRATEGIES ASSOCIATED WITH IMPROVEMENTS IN SURVIVAL FOR OUT-OF-HOSPITAL CARDIAC ARRESTS IN SINGAPORE OVER 10 YEARS first appeared on האיגוד הישראלי לרפואה דחופה.
In this main episode podcast, Dr. Arun Sayal creator of the CASTED course and Dr. Yatin Chadha a radiologist with a fellowship in MSK radiology, join Anton for Part 1 of 2 podcasts on Emergency Orthopedic Injuries. This episode focuses on a differential diagnosis of MSK injuries that are occult to X-ray with the help of the SCARED OF […]
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Oct 25, 2022 Contributor: Travis Barlock, MD Educational Pearls: Catheter related blood infections were thought to be caused by skin flora seeding the catheter. Thus, significant effort is applied to sterility and skin preparation. However, studies have shown that bacteria growing on the tip of the catheter is not consistent with growth on cultures of […]
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October 25, 2022 / Neurology, Pediatrics, Pharmacy/Pharmacology Written by Clay Smith There was no statistical difference in 1, 3, or 6 month facial recovery with prednisolone vs placebo for children with Bell’s palsy in this underpowered RCT. I plan to keep using steroids, though opinions on this will differ. Why does this matter? Glucocorticoids benefit adults with Bell’s palsy, but does […]
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October 26, 2022 / Cardiology Written by Clay Smith This is the latest on how to work up possible acute coronary syndrome in the ED. Why does this matter? The AHA released Chest Pain Guidelines in 2021. The ACC thought, “practical guidance was needed.” My troponin is leaking Here is the algorithm and my thoughts below. From cited article Symptoms: We […]
The post New Expert Pathway for Chest Pain from ACC – Spoon-Feed Version first appeared on האיגוד הישראלי לרפואה דחופה.
October 7, 2022 / Education, Wellness Written by Clay Smith Spoon Feed Physician burnout has extensive negative effects, not just on individuals, but on hospital systems and on patient safety and satisfaction. Why does this matter? Burnout consists of three parts: emotional exhaustion, depersonalization, and reduced sense of personal accomplishment. It makes individual physicians feel awful, but does it […]
The post Do Burned Out Doctors Give Low Quality Care? first appeared on האיגוד הישראלי לרפואה דחופה.
Oct 24, 2022 Contributor: Jared Scott, MD Educational Pearls: Immediate resuscitative thoracotomy can be performed in the ED to gain rapid access to the thoracic cavity in cases of traumatic cardiac arrest Western Trauma Association Society Criteria for ED thoracotomy Blunt trauma + <10 min of prehospital CPR Penetrating trauma to torso + <15 min […]
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ACEP Frontline · Treating Sickle Cell Patients in the ED: Gaps and Opportunities In this episode of The Frontline, we talk with Dr. Paula Tanabe about sickle cell disease and the current landscape in emergency medicine with some of the challenges and opportunities to take care of these patients.
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In the US, pulmonary embolism (PE) affects approximately 370 000 patients annually and is estimated to cause 60 000 to 100 000 deaths per year. In this podcast, JAMA Senior Editor Kristin Walter, MD, MS, discusses the clinical presentation, diagnostic strategies, and treatment of PE with Yonathan Freund, MD, PhD, professor of emergency medicine at […]
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Tyler W Barrett 1, Nicholas M Garland 2, Clifford L Freeman 2, Katharine Klar 2, Jan Dahlke 2, Penny Lancaster 2, Larry Prisco 2, Sam S Chang 2, Laura W Goff 2, Stephan Russ 2, Ian D Jones 2 Abstract Study objective: Abnormal findings unrelated to the indication for testing are identified on emergency department (ED) imaging studies. We report the design and implementation of an electronic health record-based interdisciplinary referral system and our experience from the […]
The post Catching Those Who Fall Through the Cracks: Integrating a Follow-Up Process for Emergency Department Patients with Incidental Radiologic Findings first appeared on האיגוד הישראלי לרפואה דחופה.
Yonathan Freund, MD, PhD1,2; Fleur Cohen-Aubart, MD, PhD1,3; Ben Bloom, MD, PhD4 Author Affiliations Article Information JAMA. 2022;328(13):1336-1345. doi:10.1001/jama.2022.16815 Abstract Importance Pulmonary embolism (PE) is characterized by occlusion of blood flow in a pulmonary artery, typically due to a thrombus that travels from a vein in a lower limb. The incidence of PE is approximately 60 to 120 per 100 000 people per year. Approximately 60 000 to […]
The post Acute Pulmonary Embolism, A Review first appeared on האיגוד הישראלי לרפואה דחופה.
Matheus Kiszka Scheffer, MD1; Mariana Fuziy Nogueira De Marchi, MD1; Ana Carolina Muniz Costa, MD1 Author Affiliations Article Information JAMA Intern Med. Published online October 24, 2022. doi:10.1001/jamainternmed.2022.4708 Case Presentation Apatient in their 70s presented to the emergency department with a history of syncope that occurred 7 days before admission without preceding signs or symptoms. Since then, the patient had been experiencing fatigue, mainly from […]
The post Right Bundle-Branch Block Pattern in Precordial Leads and Left Bundle-Branch Block Pattern With Left Axis Deviation in Frontal Plane Leads—What Does This Mean? first appeared on האיגוד הישראלי לרפואה דחופה.
A Statement for Healthcare Professionals From a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care […]
The post Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest first appeared on האיגוד הישראלי לרפואה דחופה.
Tudor G. Jovin, M.D., Chuanhui Li, M.D., Longfei Wu, M.D., Chuanjie Wu, M.D., Jian Chen, M.D., Changchun Jiang, M.D., Zhonghua Shi, M.D., Zongen Gao, M.D., Cunfeng Song, M.D., Wenhuo Chen, M.D., Ya Peng, M.D., Chen Yao, M.D., et al., for the BAOCHE Investigators* Abstract BACKGROUND The effects and risks of endovascular thrombectomy 6 to 24 hours after stroke onset due to basilar-artery occlusion […]
The post NEJM: Trial of Thrombectomy 6 to 24 Hours after Stroke Due to Basilar-Artery Occlusion first appeared on האיגוד הישראלי לרפואה דחופה.
Louise Cullen ABSTRACT ,1 Paul O Collinson ,2 Evangelos Giannitsis3 Abstract Methods to improve the safety, accuracy and efficiency of assessment of patients with suspected acute coronary symptoms have occupied decades of study and have supported significant changes in clinical practice. Much of the progress is reliant on results of laboratory-based high-sensitivity cardiac troponin assays […]
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Annabel Vincent,1 Scott Pearson,1 John W Pickering Leanne Toney,1 Laura Hamill,1 Michael Hurrell ,1,2 James Weaver,1 ,3 Martin Than Abstract Background CT performed within 6 hours of headache onset is highly sensitive for the detection of subarachnoid haemorrhage (SAH). Beyond this time frame, if the CT is negative for blood, a lumbar puncture is often performed. Technology […]
The post Sensitivity of modern multislice CT for subarachnoid haemorrhage at incremental timepoints after headache onset: a 10-year analysis first appeared on האיגוד הישראלי לרפואה דחופה.
Jeremy M. Shefner, MD, PhD1; Richard Bedlack, MD, PhD2; Jinsy A. Andrews, MD3; et alJames D. Berry, MD, PhD4; Robert Bowser, PhD1; Robert Brown, MD, DPhil5; Jonathan D. Glass, MD6; Nicholas J. Maragakis, MD7; Timothy M. Miller, MD, PhD8; Jeffrey D. Rothstein, MD, PhD7; Merit E. Cudkowicz, MD4 Author Affiliations Article Information JAMA Neurol. Published online October 17, 2022. doi:10.1001/jamaneurol.2022.3282 Abstract Importance Clinical trial activity in amyotrophic lateral sclerosis (ALS) is dramatically increasing; as a result, trial modifications have been introduced to improve efficiency, outcome measures have been reassessed, and […]
The post Review: Amyotrophic Lateral Sclerosis Clinical Trials and Interpretation of Functional End Points and Fluid Biomarkers first appeared on האיגוד הישראלי לרפואה דחופה.