CME - האיגוד הישראלי לרפואה דחופה: Recent Episodes
CME – האיגוד הישראלי לרפואה דחופה
José A Joglar, Mina K Chung, Anastasia L Armbruster 1, Emelia J Benjamin, Janice Y Chyou, Edmond M Cronin, Anita Deswal 1, Lee L Eckhardt, Zachary D Goldberger, Rakesh Gopinathannair, Bulent Gorenek, Paul L Hess 2, Mark Hlatky, Gail Hogan 3, Chinwe Ibeh, Julia H Indik, Kazuhiko Kido 4, Fred Kusumoto, Mark S Link, Kathleen T Linta 3, Gregory M Marcus, Patrick M McCarthy, Nimesh Patel, Kristen K Patton, Marco V Perez, Jonathan P Piccini, Andrea M Russo 5, Prashanthan Sanders, Megan M Streur, Kevin L Thomas, Sabrina Times 6, James E Tisdale, Anne Marie Valente 7, David R Van Wagoner
Abstract Aim: The “2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation” provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.
Methods: A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.
Structure: Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the “2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation” and the “2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation” have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
Keywords: AHA Scientific Statements; acute coronary syndrome; alcohol; anticoagulants; anticoagulation agents; antiplatelet agents; apixaban; atrial fibrillation; atrial flutter; cardioversion; catheter ablation; coronary artery disease; coronary heart disease; dabigatran; edoxaban; exercise; heart failure; hypertension; idarucizumab; left atrial appendage occlusion; myocardial infarction; obesity; percutaneous coronary intervention; pulmonary vein isolation; risk factors; rivaroxaban; sleep apnea; stents; stroke; surgical ablation; thromboembolism; warfarin.
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In this thought-provoking episode, Dr. Ziad Obermeyer delves into the complex issues of bias, safety, and generalizability of medical AI. Dr. Obermeyer emphasizes the importance of machine learning researchers’ task formulation, an often-overlooked yet significant determinant of bias in AI algorithms. Highlighting the dual impact of machine learning, he compares two of his works that demonstrate how […]
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http://orcid.org/0000-0001-6857-1430Fiona Chen, http://orcid.org/0000-0001-8896-7512Emily Neill, Sally Graglia Correspondence to Dr Fiona Chen, Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA; Fiona.Chen@ucsf.edu Case presentation A 57-year-old man with a history of recently diagnosed diabetes mellitus presented to the ED with 2 weeks of perineal pain and swelling. He was seen at an urgent care centre […]
The post Point-of-care ultrasound for the diagnosis of Fournier gangrene first appeared on האיגוד הישראלי לרפואה דחופה.
Show Notes Swami’s CoreEM Post Hypocalcemia Repletion: IV calcium supplementation with 100-300 mg Ca2+ raises serum Ca2+ by 0.5 – 1.5 mEq For acute but mild symptomatic hypocalcemia: 200-1000mg calcium chloride IV or 1-2g IV calcium gluconate over 2 hours For severe hypocalcemia: 1g calcium chloride IV or 1-2g IV calcium gluconate IV over […]
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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 […]
The post NEJM: Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia first appeared on האיגוד הישראלי לרפואה דחופה.
The 6 STEMI Equivalents: Posterior MI ST Depression V2/V3 (or STE in V7-V9) Right Ventricular MI STE V1 associated with inferior MI ; or STE V4R-V6R Wellens Syndrome Type A: Biphasic T-waves V2/3 Type B: Deep Symmetric T-wave Inversion V2/V3 De Winter’s T Wave ST Depression with a large, symmetric, upright T wave STE avR […]
The post PODCAST: The Ischemic EKG Deep Dive first appeared on האיגוד הישראלי לרפואה דחופה.
ACEP Frontline · Anticoagulant Reversal Quick Hits with Dr. Steven Haywood – ACEP22 In this episode from ACEP22 in San Francisco, we talk with Dr. Steven Haywood about anticoagulant reversal strategies. ACEP23 registration is open! Save $50 on registration with my promo code FRONTLINE at acep.org/acep23.
The post PODCAST: Anticoagulant Reversal Quick Hits with Dr. Steven Haywood – ACEP22. first appeared on האיגוד הישראלי לרפואה דחופה.
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 […]
The post NEJM: Prehospital Tranexamic Acid for Severe Trauma first appeared on האיגוד הישראלי לרפואה דחופה.
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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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.
Hoh BL, Ko NU, Amin-Hanjani S, Hsiang-Yi Chou S, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R, Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. Abstract Aim: The […]
The post 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association first appeared on האיגוד הישראלי לרפואה דחופה.
TAKE-HOME MESSAGE The authors of this systematic review and meta-analysis aimed to evaluate the prevalence and impact of sepsis-induced cardiomyopathy. A total of 16 studies were included in the final meta-analysis, and the findings show a 20% prevalence of sepsis-induced cardiomyopathy among patients with sepsis. The development of sepsis-induced cardiomyopathy was associated with a significant […]
The post Prevalence and Prognosis of Sepsis-Induced Cardiomyopathy first appeared on האיגוד הישראלי לרפואה דחופה.
June 27, 2023 / Neurology, Sports Medicine Written by Ketan Patel Post-concussion return to functional baseline occurs early for symptoms, balance, and mental status along with partial neurocognitive functioning. Visual-memory and reaction-time recovery, however, lag behind the other groups post-concussion. Why does this matter? A variety of tests are utilized in the post-concussive period to gauge an athlete’s […]
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Edlow JA, Carpenter C, Akhter M, Khoujah D, Marcolini E, Meurer WJ, Morrill D, Naples JG, Ohle R, Omron R, Sharif S, Siket M, Upadhye S, E Silva LOJ, Sundberg E, Tartt K, Vanni S, Newman-Toker DE, Bellolio F. Abstract This third Guideline for Reasonable and […]
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ACEP Critical Decisions in Emergency Medicine · April 2023 : Identifying Illnesses of Bioterrorism and Emergency Presentations of Upper GI Bleeds n the April episode of Critical Decisions in Emergency Medicine, Drs. Danya Khoujah and Wendy Chang discuss illnesses of bioterrorism as well as upper GI bleeds. As always, you’ll hear about the hot topics […]
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Bankhead, Brittany K. MD, MS, FACSBichard, Shannon L. MA, PhDSeltzer, Trent MA, PhDThompson, Lisa A. BAChambers, Barbie MA, PhDDavis, Bayli BS, MAKnowlton, Lisa M. MD, MPH, FACS, FRCSCTatebe, Leah C. MDVella, Michael A. MDDumas, Ryan P. MD, MS, FACS Abstract Background Team communication and bias in and out […]
The post BIAS IN THE TRAUMA BAY: A MULTICENTER QUALITATIVE STUDY ON TEAM COMMUNICATION first appeared on האיגוד הישראלי לרפואה דחופה.
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 […]
The post NEJM: Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia first appeared on האיגוד הישראלי לרפואה דחופה.
P.J. Hutchinson, H. Adams, M. Mohan, B.I. Devi, C. Uff, S. Hasan, H. Mee,
M.H. Wilson, D.K. Gupta, D. Bulters, A. Zolnourian, C.J. McMahon, M.G. Stovell,
Y.Z. Al‑Tamimi, M.K. Tewari, M. Tripathi, S. Thomson, E. Viaroli, A. Belli,
A.T. King, A.E. Helmy, I.S. Timofeev, S. Pyne, D.P. Shukla, D.I. Bhat, A.R. Maas,
F. Servadei, G.T. Manley, G. Barton, C. Turner, D.K. Menon, B. Gregson,
and A.G. Kolias, for the British Neurosurgical Trainee Research Collaborative,
NIHR Global Health Research Group on Acquired Brain and Spine Injury,
and RESCUE-ASDH Trial Collaborators*
Abstract BACKGROUNDTraumatic acute subdural hematomas frequently warrant surgical evacuation by means of a craniotomy (bone flap replaced) or decompressive craniectomy (bone flap not replaced). Craniectomy may prevent intracranial hypertension, but whether it is associated with better outcomes is unclear.
METHODSWe conducted a trial in which patients undergoing surgery for traumatic acute subdural hematoma were randomly assigned to undergo craniotomy or decompressive craniectomy. An inclusion criterion was a bone flap with an anteroposterior diameter of 11 cm or more. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOSE) (an 8-point scale, ranging from death to “upper good recovery” [no injury-related problems]) at 12 months. Secondary outcomes included the GOSE rating at 6 months and quality of life as assessed by the EuroQol Group 5-Dimension 5-Level questionnaire (EQ-5D-5L).
RESULTSA total of 228 patients were assigned to the craniotomy group and 222 to the decompressive craniectomy group. The median diameter of the bone flap was 13 cm (interquartile range, 12 to 14) in both groups. The common odds ratio for the differences across GOSE ratings at 12 months was 0.85 (95% confidence interval, 0.60 to 1.18; P=0.32). Results were similar at 6 months. At 12 months, death had occurred in 30.2% of the patients in the craniotomy group and in 32.2% of those in the craniectomy group; a vegetative state occurred in 2.3% and 2.8%, respectively, and a lower or upper good recovery occurred in 25.6% and 19.9%. EQ-5D-5L scores were similar in the two groups at 12 months. Additional cranial surgery within 2 weeks after randomization was performed in 14.6% of the craniotomy group and in 6.9% of the craniectomy group. Wound complications occurred in 3.9% of the craniotomy group and in 12.2% of the craniectomy group.
CONCLUSIONSAmong patients with traumatic acute subdural hematoma who underwent craniotomy or decompressive craniectomy, disability and quality-of-life outcomes were similar with the two approaches. Additional surgery was performed in a higher proportion of the craniotomy group, but more wound complications occurred in the craniectomy group. (Funded by the National Institute for Health and Care Research; RESCUE-ASDH ISRCTN Registry number, ISRCTN87370545. opens in new tab.)
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Lorena FY Zhang BMed, MD, BSci (Med) (Hons), CCPU, Minh-Tu Duong BMBS, FACEM, CCPU, Justin Bowra MBBS, FACEM, CCPUFirst published: 04 November 2022 AbstractSLICE is an algorithm for the integration of point-of-care ultrasound in the assessment and resuscitation of the shocked or breathless patient. It aims to determine the patient’s fluid status, and identify reversible causes for the patient’s clinical picture. SLICE stands for ‘In a patient who is Shocked/Short of breath, scan the Lungs, IVC, Cardiac and Extra regions as indicated’. Its key advantages are that it explicitly guides resuscitative fluid management, can be performed rapidly and by clinicians with a broad range of sonographic experience, and can be used in a broad range of clinical scenarios. Its use has been successfully taught and implemented in routine clinical practice at our local institution.
Key findings* SLICE is simple to follow, to learn and to teach. * SLICE guides initial management as well as diagnosis. * SLICE does not replace other diagnostic modalities, but it does augment them. The post SLICE: An algorithm for incorporating ultrasonography in the assessment of shocked or breathless patients first appeared on האיגוד הישראלי לרפואה דחופה.
“This learning material is sourced from Emergency Medicine Cases and has been published here with permission as per creative commons copyright”In this ECG Cases blog we look at how awareness of STEMI and Occlusion MI complications can help identify false positive STEMI and Occlusion MI that doesn’t meet STEMI criteria, and consider specific treatments…
Written by Jesse McLaren; Peer Reviewed and edited by Anton Helman. April 2023
10 patients presented with potentially ischemic symptoms. Which had an acute coronary occlusion, STEMI or Occlusion MI, what were the complications, and how would this change management?
Case 1: 75 year old with syncope and chest discomfort. HR 140 and BP 100, other vitals normal
Case 2: 75 year old, prior Occlusion MI, with one hour of chest pain and diaphoresis, HR 200 and BP 80, other vitals normal
Case 3: 70 year old, prior Occlusion MI, with 3 hours of epigastric pain, normal vitals except bradycardia
Case 4: 65 year old with one hour of chest pain, HR 45 and BP 150, other vitals normal
Case 5: 55 year old with acute chest pain and diaphoresis
Case 6: 75 year old admitted with anterior STEMI. First ECG 5 days after admission, and then rhythm strips during episode of unresponsiveness
Case 7: 70 year old previously well, with one week shortness of breath, acutely worse. HR 150, BP 180/110, RR 32, oxygen 80%
Case 8: 80 year old, chest pain 2 days prior, presenting with right sided weakness and dysarthria
Case 9: 80 year old with a few days of shortness of breath, suddenly worse. HR 110, BP 80/50, RR 36, oxygen 87%. First ECG on arrival and repeat after intubation and inotropic support.
Case 10: 60 year old, 2 months post-CABG, with shoulder pain. Old then new ECG:
5 spheres of STEMI, Occlusion MI complicationsSTEMI is associated with a variety of electrical and mechanical complications. Some are common and may resolve without specific treatment, like some bradydysrhythmias associated with inferior STEMI, whereas some are rare and life-threatening like mechanical complications requiring surgery.[1] As the European guidelines summarize[2] these can occur at different times or co-exist, and often require specific treatment in addition to reperfusion:
- Myocardial dysfunction (acute or subacute):
- LV dysfunction, including LV aneurysm and LV thrombus requiring anticoagulation
- RV infarct with inferior STEMI, requiring fluids rather than nitro
- Heart failure (acute or subacute)
- Pulmonary congestion requiring oxygen, diuretics, +/- nitro
- Cardiogenic shock requiring inotropes and treatment of underlying cause(s)
- Dysrhythmias and conduction disturbances (acute)
- Bradycardia/block: inferior STEMI can cause AV block that responds to atropine, anterior STEMI can cause infranodal block requiring pacing
- Tachycardia: atrial fibrillation which may or may not require treatment, or VF/VT (often polymorphic) requiring defibrillation
- Mechanical complications (subacute) requiring emergency surgery
- Including free wall rupture with tamponade
- Ventricular septal rupture
- Papillary muscle rupture with acute mitral regurgitation, associated with posterolateral STEMI
- Pericarditis (early or late) and pericardial effusion
These complications can often be diagnosed by ECG, complemented by POCUS, but they can also complicate the diagnosis. In the ED we see patients with undifferentiated complaints, with ECG changes that may or may not reflect acute coronary occlusion. There are many causes of ST elevation besides acute coronary occlusion (false positive STEMI), and many acutely occluded coronary arteries don’t manifest STEMI criteria (false negative STEMI).
How can we use the awareness of complications to identify false positive STEMI and Occlusion MI that doesn’t meet classic STEMI criteria, and consider specific treatment?1. Is there Occlusion Myocardial Infarction (Occlusion MI)?
ST elevation may not be caused by an acute coronary occlusion. Tachycardia is rare with Occlusion MI unless complicated by hemodynamic instability.[3] On the other hand, tachycardia from non-cardiac shock states or tachydysrhythmia (including scar-mediated monomorphic VT from old MI) are common causes of diffuse ST depression with reciprocal ST elevation in aVR.[4] Similarly, prior MI can produce LV aneurysm morphology (anterior QS waves with persisting ST elevation) that can cause false positive STEMI, but can be distinguished from acute or subacute Occlusion MI by symptom duration and T/QRS ratio: anterior T/QRS ratio > 0.36 identifies acute LAD occlusion, with lower ratios reflecting either subacute presentations or old LV aneurysm morphology [5] Pericarditis can also cause ST elevation post-MI, but this is a diagnosis of exclusion.
On the other hand, patients may have Occlusion MI without meeting STEMI criteria, i.e. STEMI(-)OMI. In these cases the presence of complications can sometimes help make the diagnosis. For example, bradycardia and AV block can raise suspicion for subtle inferior Occlusion MI because they are common complications of RCA occlusion. New RBBB +LAFB can raise suspicion of proximal LAD or left main occlusion because these can cause acute bifascicular block.[6] Polymorphic VT with a normal QT is caused by acute ischemia, and AIVR is a sign of reperfusion – both of which can indicate the need for reperfusion if not done already.
- If there’s Occlusion MI, is there a complication that changes management?
Bradycardia and AV block associated with inferior Occlusion MI involves the AV node and is often transient and atropine responsive, while bradycardia or bifascicular blocks from LAD occlusion is infranodal and requires pacing. Occlusion MI accompanied by sinus tachycardia or hypotension reflects pump failure or mechanical complications, and requires identification and treatment of the underlying cause(s). Proximal RCA occlusion can produce RV infarct that requires fluids rather than nitro, and posterolateral Occlusion MI can result in papillary muscle rupture with acute MR requiring surgery. As STEMI guidelines state, cardiogenic shock is an indication for emergent revascularization regardless of time delay from symptom onset,[7] and Non-STEMI guidelines advise urgent reperfusion for refractory ischemia or hemodynamic/electrical instability even in the absence of ECG changes.[8]
Back to the cases of STEMI/OMI complications10 patients presented with potentially ischemic symptoms. Which had an acute coronary occlusion, what were the complications, and how would this change management?
Case 1: false STEMI from tachy-arrhythmia
- Heart rate/rhythm: atrial fibrillation with rapid ventricular response
- Electrical conduction: incomplete RBBB
- Axis: borderline right axis
- R-wave progression: normal R wave progression
- Tall/small voltages: normal voltages
- ST/T changes: diffuse ST depression with reciprocal STE-aVR
Impression: STE-aVR reciprocal to diffuse ST depression from tachy-arrhythmia. Code STEMI was activated by there were no obstructive lesions, and ST changes resolved after patient cardioverted:
Case 2: monomorphic VT from old occlusion MI
- H: regular wide complex tachycardia
- E: atypical LBBB pattern
- A: left axis
- R: atypical R wave progression
- T: normal voltages
- S: secondary ST/T changes
Impression: monomorphic VT. Cardioverted back into sinus. First post-cardioversion ECG had diffuse ST depression with reciprocal ST elevation in aVR from recent tachydysrhythmia, which resolved on repeat, along with inferior Q waves from prior Occlusion MI.
Troponin I rose to a small peak of 2,000ng/L (normal <26 in males and <16 in females) from demand ischemia, and admitted for angiogram that showed chronically occluded RCA from old Occlusion MI.
Case 3: false STEMI from old LV aneurysm morphology
- H: sinus bradycardia
- E: normal conduction
- A: right axis from lateral Q
- R: poor R wave progression, anterior QS waves
- T: normal voltages
- S: anterolateral mild convex ST elevation with shallow and inverted T waves
Impression: acute symptoms but history of old MI with chronic LV aneurysm morphology. Cath lab activated but only chronically occluded LAD. ECG was same as prior, and troponin was negative.
Case 4: bradycardia from inferior STEMI(-)OMI, followed by AIVR post-reperfusion
- Heart rate/rhythm: sinus bradycardia
- Electrical conduction: normal intervals
- Axis: normal
- R-wave progression: normal
- Tall/small voltages: normal
- ST/T: mild straight ST elevation in III with reciprocal TWI in aVL and ST depression in V2
Impression: bradycardia from subtle inferoposterior OMI. Repeat ECG had increasing ST depression in I and V2-3:
Cath lab activated: 100% RCA occlusion. First troponin I was normal and peak 50,000 ng/L. Post-reperfusion had transient episode of AIVR, and discharge ECG had reperfusion T wave inversion inferior/lateral and posterior (tall T waves V2-3):
Case 5: acute RBBB/LAFB from proximal LAD occlusion
- H: sinus tachycardia (biphasic P waves in V1)
- E: intermittent RBBB
- A: left axis from LAFB
- R: anterior Q waves
- T: normal voltages
- S: massive anterolateral ST elevation (concordant to RBBB in the anterior leads) and inferior reciprocal ST depression
Impression: tachycardic with intermittent RBBB + LAFB + anterolateral STE, reflecting proximal LAD or left main occlusion with cardiogenic shock. Cath lab activated: proximal LAD occlusion. First trop Trop 85 and peak > 50,000. Post-reperfusion ECG showed resolution of bifascicular block, with anterior Q waves but persisting ST elevation and lack of reperfusion T wave inversion suggesting ongoing microvascular ischemia (no re-flow). Subsequently developed VF arrest and could not be resuscitated.
Case 6: polymorphic VT with normal QT, from recurring ischemia
- H: first ECG normal sinus, next developed polymorphic VT
- E: normal conduction including normal QT
- A: normal axis
- R: loss of R waves from anterior infarct
- T: low limb lead voltages
- S: first ECG convex ST and shall inverted T waves, but pseudonormalized prior to VT
Impression: from LAD reperfusion to polymorphic VT (with normal QT) suggesting reocclusion. Treated with defibrillation and amiodarone.
Case 7: LAD occlusion with tachycardia from hemodynamic instability
- H: sinus tach
- E: normal conduction
- A: left axis from inferior Q waves
- R: poor R wave progression, anterior QS waves
- T: normal voltages
- S: mild anterior ST elevation and upright T waves
Impression: anterior/inferior Q waves of undetermined age, with anterior ST elevation that could be exaggerated by severe tachycardia. But patient had no prior history and presented with flash pulmonary edema, so all ECG changes could be acute. Despite oxygenation and nitro the patient went into cardiac arrest, but was resuscitated with thrombolytics and then sent to the cath lab: triple vessel disease with 95% LAD occlusion which was stented. First trop 65 and peak 37,000, with echo showing anterolateral akinesis and inferior hypokinesis, and EF 25%. Follow up ECGs showed resolution of inferior Q waves, ongoing anterior QS waves and development anterior reperfusion T wave inversion:
Case 8: cardioembolic stroke with apical thrombus from subacute LAD occlusion
- H: normal sinus
- E: normal conduction
- A: normal axis
- R: loss of anterior R waves, anterior QS waves
- T: normal voltages
- S: anterolateral ST elevation and hyperacute T wave, with inferior reciprocal ST depression
Impression: proximal LAD occlusion with subacute history but ongoing hyperacute T waves (T/QRS>0.36), presenting with stroke. POCUS showed anterior regional wall motion abnormality and apical thrombus. Cath lab activated: 100% proximal LAD occlusion, first trop 22,000 and peak 50,000. Discharge ECG had resolution of hyperacute T waves, ongoing LV aneurysm morphology:
Case 9: infero-postero-lateral STEMI(-)OMI with cardiogenic shock from papillary muscle rupture
- H: initial sinus tach
- E: normal conduction
- A: normal axis
- R: normal R wave progression
- T: normal voltages
- S: subtle inferior ST elevation with reciprocal STD/TWI in I/aVL, STD V2-4, and STE in V6
Impression: infero-postero-lateral OMI with hemodynamic instability. POCUS showed posterior wall motion abnormality and severe MR. Cath lab activated: circumflex occlusion, first trop 2,000 and peak 90,000. Echo showed severe MR with flail of posterior leaflet from papillary muscle rupture, too high risk for surgery so transitioned to comfort measures.
Case 10: possible post-CABG pericarditis vs early repolarization
- H: normal sinus
- E: normal conduction
- A: normal axis
- R: normal R wave progression
- T: normal voltages
- S: mild new inferolateral concave STE without reciprocal change in aVL (making inferior OMI less likely), but also with more prominent J waves
Impression: possible post-CABG pericarditis (if other causes and complications ruled out) vs early repolarization. Repeat angiogram showed patent stents, serial troponin was negative, POCUS showed no pericardial effusion.
Take home points for STEMI, Occlusion MI complications1. Is there Occlusion MI? False positive STEMI include STE-aVR from tachydysrhythmias (including scar-mediated monomorphic VT) and persisting anterior STE with small T waves from LV aneurysm, while false negative STEMI include bradycardia from subtle inferior Occlusion MI or new bifascicular block from subtle LAD occlusion 2. Is there a complication that changes management? This may include pacing for bradycardia, fluids for RV infarct, surgery for MR/VSD/rupture, and reperfusion for unstable ACS regardless of time of onset or ECG changes
References for ECG Cases 41 – STEMI/OMI complications
- Damluji AA, van Dipen S, Katz JN, et al. Mechanical complications of acute myocardial infarction: a scientific statement from the American Heart Association
- Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018 Jan 7;39(2): 119-177
- Trostel S, Meyers HP, McLaren J, et al. Sinus tachycardia is rare among hemodynamically stable patients with Occlusion Myocardial Infarction. Ann Emerg Med 2022 Oct;80(4):S115-116
- Harhash AA, Huang JJ, Reddy S, et al. aVR ST segment elevation: acute STEMI or not? Incidence of an acute coronary occlusion. Am J Med 2019, 132(5):622-630
- Klein LR, Shroff GR, Beeman W, et al. Electrocardiographic criteria to differentiate acute anterior ST-elevation myocardial infarction from left ventricular aneurysm. Am J Emerg Med 2015;33:786-790
- Widimsky P, ROhac F, Stasek J, et al. Primary angioplasty in acute myocardial infarction with right bundle branch block: should new onset right bundle branch block be added to future guidelines as an indication for reperfusion therapy? Eur Heart J 2012 Jan;33(1):86-95
- O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:e362-e425
- Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA Guidelines for the Management of Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). Circ 2000;102:1193-1209 The post ECG Cases 41 – STEMI, Occlusion MI Complications first appeared on האיגוד הישראלי לרפואה דחופה.
Xiaochuan Huo, M.D., Ph.D., Gaoting Ma, M.D., Ph.D., Xu Tong, M.D., Ph.D., Xuelei Zhang, M.D., Ph.D.,
Yuesong Pan, Ph.D., Thanh N. Nguyen, M.D., Guangxiong Yuan, M.D., Hongxing Han, Ph.D.,
Wenhuo Chen, Ph.D., Ming Wei, M.D., Jiangang Zhang, M.D., Zhiming Zhou, M.D.,
AbstractBACKGROUNDThe role of endovascular therapy for acute stroke with a large infarction has not been extensively studied in differing populations.
METHODSWe conducted a multicenter, prospective, open-label, randomized trial in China involving patients with acute large-vessel occlusion in the anterior circulation and an Alberta Stroke Program Early Computed Tomography Score of 3 to 5 (range, 0 to 10, with lower values indicating larger infarction) or an infarct-core volume of 70 to 100 ml. Patients were randomly assigned in a 1:1 ratio within 24 hours from the time they were last known to be well to undergo endovascular therapy and receive medical management or to receive medical management alone. The primary outcome was the score on the modified Rankin scale at 90 days (scores range from 0 to 6, with higher scores indicating greater disability), and the primary objective was to determine whether a shift in the distribution of the scores on the modified Rankin scale at 90 days had occurred between the two groups. Secondary outcomes included scores of 0 to 2 and 0 to 3 on the modified Rankin scale. The primary safety outcome was symptomatic intracranial hemorrhage within 48 hours after randomization.
RESULTSA total of 456 patients were enrolled; 231 were assigned to the endovascular-therapy group and 225 to the medical-management group. Approximately 28% of the patients in both groups received intravenous thrombolysis. The trial was stopped early owing to the efficacy of endovascular therapy after the second interim analysis. At 90 days, a shift in the distribution of scores on the modified Rankin scale toward better outcomes was observed in favor of endovascular therapy over medical management alone (generalized odds ratio, 1.37; 95% confidence interval, 1.11 to 1.69; P=0.004). Symptomatic intracranial hemorrhage occurred in 14 of 230 patients (6.1%) in the endovascular-therapy group and in 6 of 225 patients (2.7%) in the medical-management group; any intracranial hemorrhage occurred in 113 (49.1%) and 39 (17.3%), respectively. Results for the secondary outcomes generally supported those of the primary analysis.
CONCLUSIONSIn a trial conducted in China, patients with large cerebral infarctions had better outcomes with endovascular therapy administered within 24 hours than with medical management alone but had more intracranial hemorrhages. (Funded by Covidien Healthcare International Trading [Shanghai] and others; ANGEL-ASPECT ClinicalTrials.gov number, NCT04551664. opens in new tab.)
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Margaret M. Redfield, MD1; Barry A. Borlaug, MD1Author Affiliations Article InformationJAMA. 2023;329(10):827-838. doi:10.1001/jama.2023.2020Abstract Importance Heart failure with preserved ejection fraction (HFpEF), defined as HF with an EF of 50% or higher at diagnosis, affects approximately 3 million people in the US and up to 32 million people worldwide. Patients with HFpEF are hospitalized approximately 1.4 times per year and have an annual mortality rate of approximately 15%.
Observations Risk factors for HFpEF include older age, hypertension, diabetes, dyslipidemia, and obesity. Approximately 65% of patients with HFpEF present with dyspnea and physical examination, chest radiographic, echocardiographic, or invasive hemodynamic evidence of HF with overt congestion (volume overload) at rest. Approximately 35% of patients with HFpEF present with “unexplained” dyspnea on exertion, meaning they do not have clear physical, radiographic, or echocardiographic signs of HF. These patients have elevated atrial pressures with exercise as measured with invasive hemodynamic stress testing or estimated with Doppler echocardiography stress testing. In unselected patients presenting with unexplained dyspnea, the H2FPEF score incorporating clinical (age, hypertension, obesity, atrial fibrillation status) and resting Doppler echocardiographic (estimated pulmonary artery systolic pressure or left atrial pressure) variables can assist with diagnosis (H2FPEF score range, 0-9; score >5 indicates more than 95% probability of HFpEF). Specific causes of the clinical syndrome of HF with normal EF other than HFpEF should be identified and treated, such as valvular, infiltrative, or pericardial disease. First-line pharmacologic therapy consists of sodium-glucose cotransporter type 2 inhibitors, such as dapagliflozin or empagliflozin, which reduced HF hospitalization or cardiovascular death by approximately 20% compared with placebo in randomized clinical trials. Compared with usual care, exercise training and diet-induced weight loss produced clinically meaningful increases in functional capacity and quality of life in randomized clinical trials. Diuretics (typically loop diuretics, such as furosemide or torsemide) should be prescribed to patients with overt congestion to improve symptoms. Education in HF self-care (eg, adherence to medications and dietary restrictions, monitoring of symptoms and vital signs) can help avoid HF decompensation.
Conclusions and Relevance Approximately 3 million people in the US have HFpEF. First-line therapy consists of sodium-glucose cotransporter type 2 inhibitors, exercise, HF self-care, loop diuretics as needed to maintain euvolemia, and weight loss for patients with obesity and HFpEF.
The post Heart Failure With Preserved Ejection Fraction A Review first appeared on האיגוד הישראלי לרפואה דחופה.
הצגת המקרהמטופל בשנות ה-50 לחייו הציג 20 דקות של כאבי חזה תת-סטרנליים המקרינים לכתף ולגב שמאל, אשר לוו בקוצר נשימה והזעה. ההיסטוריה הרפואית של החולה הייתה יתר לחץ דם בשליטה גרועה ועישון כבד. בכניסה, לחץ הדם של המטופל היה 185/104 מ”מ כספית בגפה העליונה הימנית ו-113/98 מ”מ כספית בגפה העליונה השמאלית, קצב הלב שלו היה 58 פעימות לדקה, ורמת ריווי החמצן שלו הייתה 98% באוויר החדר. . אוושה דיאסטולית מוקדמת חלשה נמצאה באזור אבי העורקים, והריאות היו נקיות. בדיקת מעבדה: רמת D-dimer של 3.914 מיקרוגרם/ליטר (ערך תקין, 0-0.3 מיקרוגרם/מ”ל; להמרה ל-nmol/L, להכפיל ב-5.476), ורמת טרופונין I בטווח התקין. אלקטרוקרדיוגרמה (ECG) שהתקבלה עם הקבלה מוצגת בתרשים .
תרשים אק”ג בקבלהView LargeDownloadא.ק.ג. הקבלה הראה קצב סינוס בקצב של 58 פעימות לדקה, עם העלאת מקטע ST ב-Leads I, aVL, ו-V 1 עד V 4 , וצניחות מקטע ST ב-Leads II, III ו-aVF.
שאלה: מה השכיחה ביותר לשינויים ב אק”ג? מה תעשה עכשיו?
פענוחא.ק.ג בהצגת ( איור ) הראה קצב סינוס בקצב של 58 פעימות לדקה, עם עליית מקטע ST (STE) ב-Leads I, aVL ו-V 1 עד V 4 , כמו גם צניחה מקטע ST ב-Leads II, III ו-aVF. שינויים אלה ב-ECG תואמים את הקריטריונים האבחוניים של חסימת העורק השמאלי הראשי (ULM), כלומר המחלה הראשית השמאלית ללא שתל מעקף פטנט לעורק הכלילי היורד הקדמי או העוקף.
מהלך קליניעל פי תסמיני המטופל וממצאי ה-ECG, האבחנה הראשונית הייתה ST-segment elevation myocardial infarction (STEMI). עם זאת, בהתחשב בעובדה שחולה זה הציג אסימטריה משמעותית של לחץ דם דו-צדדי, כאבי גב עזים, רמת טרופונין I תקינה ורמת D-dimer מוגברת מאד, היה חשד חזק לאבחנה של דיסקציה של אבי העורקים. לכן, המטופל הועבר במהירות לבדיקת אנגיוגרפיה ממוחשבת באבי העורקים עם שיפור ניגודיות. תוצאות האנגיוגרמה הממוחשבת הראו דיסקציה חריפה של אבי העורקים מסוג סטנפורד (AAD) הנובעת מסינוס אבי העורקים לעורק הכסל המשותף הימני ומערבת את האוסטיה של העורקים הכליליים השמאלי והימני. המטופל הועבר למחלקה לניתוחי לב וכלי דם ועבר החלפת קשת אבי העורקים במקביל להחלפת מסתם אבי העורקים. למרבה הצער, המטופל מת יומיים לאחר ההליך.
דיוןאבחנות דיפרנציאליות לכאבים חריפים בחזה כוללים בעיקר תסחיף ריאתי (PE), תסמונת כלילית חריפה ותסמונת אאורטה חריפה (AAS). תסמונת אבי העורקים החריפה מורכבת מניתוח חריף של אבי העורקים (AAD), המטומה תוך מוורית וכיב טרשת עורקים חודר. דיסקציה של אבי העורקים מוגדרת כהפרעה של השכבה המדיאלית הנגרמת על ידי דימום תוך-מוראלי, אשר לאחר מכן מתרחשת הפרדה של שכבות דופן אבי העורקים ולאחר מכן היווצרות לומן אמיתי ולורן כוזב. מקרה של AAD או hematoma intramural המערב את אבי העורקים העולה וקשת אבי העורקים מוגדר כתסמונת אבי העורקים מסוג A; אם רק אבי העורקים היורד מעורב, זו תסמונת אבי העורקים מסוג B.1 כאב חזה טיפוסי של AAD מופיע בדרך כלל עם כאב חזה קורע המקרין לגב, ועל הרופאים להיות מודעים לאפשרות של AAD במקרים כאלה.
אוטם שריר הלב (AMI) הוא גורם שכיח ל-STE. עם זאת, AMI אינו הגורם היחיד ל-STE. האבחנה המבדלת ל-STE כוללת מצבים כגון AMI, repolarization מוקדם, היפרטרופיה של החדר השמאלי, חסימת צרור-ענף שמאלי, פריקרדיטיס חריפה, היפרקלמיה, תסמונת Brugada ו-PE.2 שינויים באלקטרוקרדיוגרמה עבור PE כוללים טכיקרדיה בסינוס, תזוזה ימינה בציר QRS, בלוק צרור-ענף ימני שלם או לא שלם, היפוך גלי T פרה-קורדיאלי, תבנית S1Q3T3 ו-STE; STE של PE מופיע בעיקר בהפצה הקדמית-מחיצה והתחתון.3 עם זאת, במטופל זה, ה-STE הוצג בהובילים I, aVL ו-V 1 עד V 4 . בנוסף, למטופל היה גם סינוס ברדיקרדיה. ממצאים אלו שונים משינויי ה-ECG האופייניים שנצפו ב-PE. בנוסף, יש לראות ב-AAS כגורם ל-STE.
AAD מסוג A מראה לעתים קרובות הפרעות ST-T במצגת. Kosuge et al 4 דיווח כי השכיחות של דפוסי א.ק.ג במקרי דיסקציה חריפה של אבי העורקים מסוג A הייתה 51% עבור הפרעות ST-T (4% עבור STE ו-47% עבור דיכאון מקטע ST ו/או גלי T שליליים), 30% עבור ממצאי אק”ג תקינים או ללא שינויים משמעותיים ב-ST-T, ו-19% עבור מבלבלים ב-ECG, כגון בלוק ענפי צרור או היפרטרופיה של חדר שמאל, בעוד ששינויי ST-T ב-AAD מסוג A אינם ספציפיים למדי. דווח שכאשר מערבים את אבי העורקים העולה, כ-2.5% מהחולים עם AAD מסוג A עשויים להתקדם ל-STEMI. 1 , 5 ב-AAD מסוג A, הקרום המנותח מתרחב מדי פעם לאוסטיום כלילית, מה שגורם ל-AMI הקשור לשינויים איסכמיים חריפים ב-ST-T ב-ECG. בין הפרעות ST-T, STE היה נדיר אך היה קשור מאוד למעורבות אוסטיאלית כלילית, כמו גם לשיעור הגבוה ביותר של תמותה בבית החולים (30%).
חסימה מוחלטת חריפה של ULM היא אירוע נדיר אך קטסטרופלי קליני. ממצאי ה-ECG של ULM במצב של AMI משתנים. מספר דפוסי א.ק.ג. דווחו כקשורים לחסימת ULM 6 : עלייה במקטע ST המתחיל ב-V 2 עד V 4 מובילים קדם-קורדיאליים וממשיך דרך עופרת V 6 ובמובילי הגפיים הצידיים I ו-aVL ו-STE ב-AVR או aVR עופרת aVL עם שקעים נרחבים במקטע ST. עם זאת, חלק מהחולים עם חסימת ULM חריפה עשויים להופיע עם STE ב-aVR או aVR ו-aVL מובילים. Liu et al 7 דיווח כי דפוסי אק”ג שונים אלו היו קשורים לטריטוריות השונות למילוי בטחונות בחסימת ULM: (1) STE ב-Leads הקדמי הצביע על היעדר זרימה ביטחונית; (2) הזרימה הביטחונית מהעורק הכלילי הימני לתוך הטריטוריה השמאלית היורדת של העורק הפחיתה את עליית ST באזור הקדמי, מה שגרם לחולים להציג STE ב-aVR ו-aVL מוביל במצב זה; (3) הזרימה הביטחונית מהעורק הכלילי הימני לתוך העורק היורד הקדמי השמאלי והטריטוריה השמאלית של העורק הכלילי circumflex, החלישה את ה-STE בעילי הגפיים הקדמיים והצדדיים, ואחריו STE בעופרת aVR בלבד.
תסמינים מסוג AAD ו-STEMI דומים. והטיפול ב-2 המחלות שונה מהותית. לכן הבחנה בין AAS לתסמונת כלילית חריפה היא חשובה ביותר. כאשר מטופל עם כאבים בחזה מראה א.ק.ג של STE, הרופאים צריכים להיות מודעים לאפשרות של AAD מסוג A.
נקודות לקחת הביתה* כאב חריף בחזה כולל בעיקר תסחיף ריאתי, תסמונת כלילית חריפה ותסמונת אבי העורקים חריפה. * האבחנות המבדלת של STE כוללות AMI, AAD מסוג A, repolarization מוקדם, היפרטרופיה של חדר שמאל, חסימת ענף שמאל, פריקרדיטיס חריפה, היפרקלמיה, תסמונת Brugada ו-PE. * מטופלים עם כאבי חזה קורעים קלאסיים המקרינים לגב, דפוס STE ECG ורמת טרופונין תקינה יש לחשוד מאוד ב-AAD מסוג A.
Please enable JavaScript in your browser to complete this form.לאור הכתוב האם אשנה את צורת העבודה שלי?* כן, אני אשנה * לא, אני כבר נוהג כך * זה לא במסגרת העסוק שלי * לא אני בפנסיה * אחר איזה שינוי תעשה?Submit The post הצגת מקרה : סיבה לא שכיחה לכאב חזה חד first appeared on האיגוד הישראלי לרפואה דחופה.
February 17, 2023 / ENT/Face, NeurologyWritten by Aaron Lacy
After a training session, both interns and senior emergency providers (EPs) could accurately distinguish between central and peripheral vertigo using the 4-step STANDING algorithm.
Why does this matter?
Distinguishing between central and peripheral vertigo is fraught with challenges. Neuroimaging is not as sensitive as we would like, and there is question about emergency providers utilizing the HINTS exam accurately. Does this step-by-step algorithm provide a guide to help distinguish between central or peripheral vertigo?
All these vertigo articles are making me dizzy
Interns were trained using videos and a supervised session on the 4-step STANDING algorithm for differentiating the etiology of vertigo. 312 patients with acute vertigo presenting to the ED were first evaluated by an intern and then a senior EP. Using the algorithm, the patients were classified into either a worrisome (central disease), benign (peripheral disease), or inconclusive category. The reference test of comparison was a brain MRI.
Outline of tortured STANDING acrostic, adapted from cited articleThe algorithm showed good sensitivity (84.8% [75.6-93.9] and 89.8% [82.1-97.5]), specificity (88.9% [85.1-92.8] and 91.3% [87.8-94.8]), and agreement (0.77) between interns and seniors.
My takeaway: While this algorithm is nice, the key is that the EPs underwent a training session. There is more evidence that EPs can accurately use HINTS, but after formal training. Given how challenging it can be to diagnose and treat vertigo, more formalized training for EPs is likely indicated.
Another Spoonful
Here is a link to the validation study of the STANDING algorithm with instructions on how to complete it.
Editor’s note: STANDING is a hideous acrostic. Personally, I would have gone with ‘NASTY-HEIST’ or ‘NERDIEST.’ Anyway, the 4 steps are: nystagmus presence+direction, head-impulse test, and stance/gait. NYPD HITS anyone? In STANDING, nystagmus is determined using Frenzel glasses, so NERDIEST may be the best acrostic after all. ~Clay Smith
Source
Effectiveness and reliability of the 4-step STANDING algorithm performed by emergency interns and seniors for predicting central causes of vertigo. Acad Emerg Med. 2023 Jan 11. doi: 10.1111/acem.14659. Online ahead of print.
The post I’m Still STANDING – Can this New Algorithm Distinguish Peripheral vs Central Vertigo? first appeared on האיגוד הישראלי לרפואה דחופה.
A. Sarraj, A.E. Hassan, M.G. Abraham, S. Ortega-Gutierrez, S.E. Kasner, M.S. Hussain, M. Chen, S. Blackburn, C.W. Sitton, L. Churilov, S. Sundararajan, Y.C. Hu, N.A. Herial, P. Jabbour, D. Gibson, A.N. Wallace, J.F. Arenillas, J.P. Tsai, R.F. Budzik, W.J. Hicks, O. Kozak, B. Yan, D.J. Cordato, N.W. Manning, M.W. Parsons, R.A. Hanel, A.N. Aghaebrahim, T.Y. Wu, P. Cardona-Portela, N. Perez de la Ossa, J.D. Schaafsma, J. Blasco, N. Sangha, S. Warach, C.D. Gandhi, T.J. Kleinig, D. Sahlein, L. Elijovich, W. Tekle, E.A. Samaniego, L. Maali, M.A. Abdulrazzak, M.N. Psychogios, A. Shuaib, D.K. Pujara, F. Shaker, H. Johns, G. Sharma, V. Yogendrakumar, F.C. Ng, M.H. Rahbar, C. Cai, P. Lavori, S. Hamilton, T. Nguyen, J.T. Fifi, S. Davis, L. Wechsler, V.M. Pereira, M.G. Lansberg, M.D. Hill, J.C. Grotta, M. Ribo, B.C. Campbell, and G.W. Albers, for the SELECT2 Investigators*
ABSTRACT
BACKGROUND
Trials of the efficacy and safety of endovascular thrombectomy in patients with large ischemic strokes have been carried out in limited populations.
METHODS
We performed a prospective, randomized, open-label, adaptive, international trial involving patients with stroke due to occlusion of the internal carotid artery or the first segment of the middle cerebral artery to assess endovascular thrombectomy within 24 hours after onset. Patients had a large ischemic-core volume, defined as an Alberta Stroke Program Early Computed Tomography Score of 3 to 5 (range, 0 to 10, with lower scores indicating larger infarction) or a core volume of at least 50 ml on computed tomography perfusion or diffusion-weighted magnetic resonance imaging. Patients were assigned in a 1:1 ratio to endovascular thrombectomy plus medical care or to medical care alone. The primary outcome was the modified Rankin scale score at 90 days (range, 0 to 6, with higher scores indicating greater disability). Functional independence was a secondary outcome.
RESULTS
The trial was stopped early for efficacy; 178 patients had been assigned to the thrombectomy group and 174 to the medical-care group. The generalized odds ratio for a shift in the distribution of modified Rankin scale scores toward better outcomes in favor of thrombectomy was 1.51 (95% confidence interval [CI], 1.20 to 1.89; P<0.001). A total of 20% of the patients in the thrombectomy group and 7% in the medical-care group had functional independence (relative risk, 2.97; 95% CI, 1.60 to 5.51). Mortality was similar in the two groups. In the thrombectomy group, arterial access-site complications occurred in 5 patients, dissection in 10, cerebral-vessel perforation in 7, and transient vasospasm in 11. Symptomatic intracranial hemorrhage occurred in 1 patient in the thrombectomy group and in 2 in the medical-care group.
CONCLUSIONS
Among patients with large ischemic strokes, endovascular thrombectomy resulted in better functional outcomes than medical care but was associated with vascular complications. Cerebral hemorrhages were infrequent in both groups. (Funded by Stryker Neurovascular; SELECT2 ClinicalTrials.gov number, NCT03876457.)
Editorial:Improved Prospects for Thrombectomy in Large Ischemic Stroke The post NEJM: Trial of Endovascular Thrombectomy for Large Ischemic Strokes first appeared on האיגוד הישראלי לרפואה דחופה.
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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Michael Klompas, MD, MPH1,2; Chanu Rhee, MD, MPH1,2; Mervyn Singer, MD3Author Affiliations Article InformationJAMA. Published online January 20, 2023. doi:10.1001/jama.2023.0340Sepsis continues to be a leading cause of death and disability worldwide. In the US alone, more than a quarter million adults hospitalized with sepsis die each year. Clinicians, patients, regulators, and quality improvement advocates recognize the necessity of doing more to prevent sepsis and improve sepsis outcomes.
One of the highest-profile measures designed to improve sepsis outcomes is the Centers for Medicare & Medicaid Services (CMS) Severe Sepsis/Septic Shock Early Management Bundle (SEP-1). SEP-1 requires hospitals to report adherence to a strictly defined initial management bundle that includes obtaining blood cultures, measuring lactate, and administering broad-spectrum antibiotics within 3 hours of a patient meeting sepsis criteria, infusing at least 30 mL/kg of intravenous crystalloids for hypotension or hyperlactatemia, and rechecking lactate and initiating vasopressors within 6 hours for refractory shock. It is an all-or-nothing bundle; hospitals receive credit only if all components are performed or contraindications documented. SEP-1 is currently a pay-for-reporting measure, but CMS recently proposed changing it to a pay-for-performance measure.
SEP-1 was launched in 2015 with high expectations that it would improve outcomes for patients with sepsis. Unfortunately, it has not done so. Four large, rigorous, multicenter time-series analyses now document the disappointing real-world impact of SEP-1 across hundreds of US hospitals.1–4 Broad-spectrum antibiotic use has increased since SEP-1 went into effect, but SEP-1 has not lowered mortality rates.
The first study included 111 hospitals and reported that broad-spectrum antibiotic use increased by 0.4% per month after SEP-1 was implemented.1 The second study included 114 hospitals and reported a 25% increase in anti–methicillin-resistant Staphylococcus aureus antibiotic use in patients with possible sepsis between 2013 and 2017 (from 19.8% to 26.3%) and a 45% increase in antipseudomonal antibiotic use (from 27.7% to 40.5%) but no change in the combined outcome of hospital death or discharge to hospice (from 20.3% to 20.4%; odds ratio, 1.00; 95% CI, 0.97-1.04).2 University of Pittsburgh Medical Center investigators reported similar trends among 11 affiliated hospitals.3 The fourth study, including 26 hospitals, reported that (1) antibacterial use increased by 24% between 2014 and 2016 and (2) overall hospital mortality rates were decreasing before SEP-1 but the trend leveled off after SEP-1 went into effect.4
The only studies that claim a benefit from SEP-1 are a subset of those comparing outcomes among patients who received SEP-1–compliant vs noncompliant care (ie, all components of the SEP-1 bundle were or were not performed).5 These studies are unreliable, however, because the patients who receive care that is not compliant with SEP-1 are very different from those who receive care that is compliant with SEP-1: they tend to have more severe illness and more ambiguous clinical presentations, and are more likely to have shock (and thus require clinicians to complete more steps to be compliant with SEP-1). This was evident in an analysis of 245 740 patients that reported SEP-1 compliance was associated with lower mortality rates than SEP-1 noncompliance (21.8% vs 27.5%); despite propensity matching, patients who received noncompliant care were more likely to have hyperlactatemia (17.3% vs 9.4%) and septic shock (25% vs 15.1%).5 When the investigators focused exclusively on patients with septic shock (a more apples-to-apples comparison), mortality rates were similar for SEP-1–compliant vs noncompliant care (38% vs 35%; P = .33). Similarly, studies with more robust risk adjustment report no differences in mortality rates for SEP-1–compliant vs noncompliant care.6
There are many possible explanations for SEP-1’s failure to improve outcomes. The antibiotic and fluid components of the bundle are controversial because the measure does not account for the complexity of diagnosing sepsis, selecting an appropriate initial antibiotic regimen, and the heterogeneity of sepsis patients, presentations, and credible management strategies.6 Approximately one-third of patients treated for sepsis in emergency departments and intensive care units are found to have nonbacterial infections or noninfectious mimicking conditions.7 These patients are at risk of the adverse effects of broad-spectrum antibacterial therapy without their potential benefits. Similarly, not all patients with hypotension require or are able to tolerate 30 mL/kg of fluids (eg, patients with heart failure and fluid overload, patients with tenuous respiratory status, and some patients with kidney disease).
The term sepsis encompasses a very wide range of patient populations, infectious precipitants, primary sites of infection, secondary organ dysfunctions, and severity of illness. It is inappropriate to require clinicians to treat all these patients in a single, rigid, uniform fashion. The COVID-19 pandemic helped reaffirm the fallacy that all patients with possible sepsis require immediate broad-spectrum antibiotics and aggressive fluid resuscitation. About one-third of individuals hospitalized for COVID-19 meet international consensus criteria for sepsis (infection leading to organ dysfunction), but only a small minority have concurrent bacterial infection or require aggressive fluid resuscitation. The common practice early in the pandemic of treating all COVID-19 patients with antibiotics typically offered no benefits but selected for multidrug-resistant bacteria and, ironically, may have increased these patients’ future risk of sepsis by disrupting the microbiome.8
One may wonder why SEP-1 has not been able to reproduce the mortality reductions reported by New York State and other sepsis quality improvement initiatives using similar bundles.9 New York State’s sepsis regulations, however, allow hospitals more flexibility in bundle design, report compliance with 3- and 6-hour bundle components separately, require hospitals to actively educate staff, and track sepsis outcomes in addition to processes of care.3 More broadly, determining the true impact of bundles is challenging because they focus on increasing sepsis recognition as well as care. This typically leads to more sepsis diagnoses, inclusion of patients with milder syndromes, and, thus, a decrease in net sepsis mortality rates that could reflect labeling more patients with sepsis, improvements in care, or both.10 A strength of the SEP-1 time-series analyses cited previously2,3 is that these analyses used consistent clinical indicators to identify possible sepsis (obtaining clinical cultures, administering antibiotics, and signs of organ dysfunction) rather than physician diagnoses, thus sidestepping the risk of ascertainment bias associated with analyses that use sepsis registries or diagnosis codes to track sepsis rates and outcomes.
The broader limitation of SEP-1 is that it focuses exclusively on the initial hours of care and lacks incentives to optimize subsequent care. Patients with sepsis are often hospitalized for long periods. Their clinical courses can include intensive care admission, mechanical ventilation, invasive catheters, sedation, catecholamines, and antibiotics for secondary infections. Such patients are at very high risk of nosocomial complications, including acute lung injury, health care–associated infections, delirium, deconditioning, and pressure ulcers. These risks are reflected in the Surviving Sepsis Campaign guidelines that describe at length both the initial resuscitation of patients with sepsis and strategies to minimize subsequent complications. SEP-1’s focus on initial management alone ignores the enormous importance of optimizing every aspect of care for patients with sepsis from first contact through hospital discharge and, given the long-term adverse sequelae of sepsis, postdischarge care for sepsis survivors.
We believe the solution to SEP-1’s failure to improve patient outcomes is to change the focus of sepsis quality metrics from processes to outcomes, particularly short-term mortality. This will shift the emphasis to what matters most to patients and clinicians. It will sidestep some of SEP-1’s potentially deleterious incentives and allow clinicians to tailor care to patients’ variable syndromes, underlying conditions, precipitating pathogens, and potential complications. Hospitals can still opt to embrace early management bundles, but focusing on outcomes will incentivize hospitals to address the full continuum of sepsis care and not just limited aspects of the initial resuscitation.
Moreover, shifting from processes to outcomes will encourage more innovation in areas that are more likely to improve outcomes. Examples include adopting emerging technologies that accelerate identification of infecting organisms and antimicrobial susceptibilities, implementing tools to predict impending sepsis, partnering with emergency medical services to provide antibiotics for the sickest patients before they reach the hospital, improving not just time-to-antibiotic orders but also timely antibiotic delivery and redosing, achieving effective antibiotic concentrations, ensuring expeditious and thorough source control, tailoring treatment to specific syndromes and pathogens, setting appropriate antibiotic courses and stopping unnecessary antibiotics to minimize selection for resistant pathogens, preventing health care–associated infections, avoiding delirium, and providing effective restorative care for sepsis survivors both before and after discharge.
CMS is well underway with developing a new sepsis mortality measure that will hopefully replace SEP-1. The new measure is designed to be collected electronically, a promising step forward that has the potential to allow hospitals to shift the substantial resources they currently devote to measuring SEP-1 manually toward optimizing care. Important details, including precise criteria for defining sepsis and how to perform risk adjustment for hospital-to-hospital comparisons, remain in development. However, the forthcoming measure’s focus on outcomes is what matters most. The proposal by CMS to entrench SEP-1 by making it a pay-for-reporting measure, in contrast, is a step backward.
SEP-1 helped usher in a new era of accountability and focus on sepsis care, but data from hundreds of hospitals now show that it has not met its core goal of improving outcomes. It is time to shift the focus of sepsis quality metrics from narrowly defined, controversial, and constraining process measures to patient-centered outcomes, with all the attendant breadth of opportunity and responsibility that this entails.
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ההרצאה עלתה לאתר
ד”ר עירוני הוא המנהל של המחלקה לרפואה דחופה במרכז הרפואי
על שם חיים שיבא, תל השומר. אחרי סיום התמחות ברפואת פנימית
והתמחות על ברפואה דחופה, עבר בקינגסטון, קנדה, תת התמחות בהחייאה, וב2010 חזר לארץ. בנוסף לניהול המחלקה לרפואה דחופה הוא חלק מצוות של המרכז לסימולציה רפואית, אחראי על שלב ב ברפואה דחופה ב10 שנים האחרונות. יש לו עניין מיוחד בנושאים: החייאה, ניהול של החולה בספסיס ובמצבים קריטיים בחדר הלם.
הגישה לחולה קריטי בחדר הלם
הגישה לחולה קריטי בחדר הלם 1/20 * < > הגישה לחולה קריטי בחדר הלם ד"ר אבי עירוני ד"ר עירוני הוא המנהל של המחלקה לרפואה דחופה במרכז הרפואי על שם חיים שיבא, תל השומר. אחרי סיום התמחות ברפואת פנימית והתמחות על ברפואה דחופה, עבר בקינגסטון, קנדה, תת התמחות בהחייאה, וב2010 חזר לארץ. בנוסף לניהול המחלקה לרפואה דחופה הוא חלק מצוות של המרכז לסימולציה רפואית, אחראי על שלב ב ברפואה דחופה ב10 שנים האחרונות. יש לו עניין מיוחד בנושאים: החייאה, ניהול של החולה בספסיס ובמצבים קריטיים בחדר הלם
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In this episode, Sam Ashoo, MD, interviews Ara Festekjian, MD, one of the authors of the November 2022 Pediatric Emergency Medicine Practice article on Pediatric Septic Shock in the Emergency Department
Introduction: How common is sepsis in kids and what is the mortality rate in the US?
Definitions
- Septic shock
- Sepsis associated organ dysfunction
- Sepsis-3
- Compensated vs uncompensated shock
Etiology
- Neonate
- Central line and VP shunts
- Asplenia
- Immunocompromised children
Differential Diagnosis
Prehospital Care
ED Evaluation
- History
- Examination
- Septic shock + cardiogenic shock
- Warm vs cold shock
- Evolution of physical exam findings
Diagnostics
- Labs
- Imaging
Treatment
- IV/IO placement
- Fluid boluses
- Antibiotics
- Pressors
- Airway management
Special Populations
- Febrile neutropenia
- Newborns with septic shock
Controversies
- Fluid volume
- Fluid type
- Antibiotic timing
- Corticosteroids
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FROM CirculationAbstractThis 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.
Keywords: AHA Scientific Statements; advanced life support; basic life support; cardiac arrest; first aid; infant, newborn; pediatrics; resuscitation.
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A Systematic ReviewCora H. Ormseth, MD1; Sara C. LaHue, MD2; Mark A. Oldham, MD3; et alS. Andrew Josephson, MD2; Evans Whitaker, MD4; Vanja C. Douglas, MD2Author Affiliations Article InformationJAMA Netw Open. 2023;6(1):e2249950. doi:10.1001/jamanetworkopen.2022.49950Key PointsQuestion What predisposing and precipitating factors are associated with delirium?
Findings In this systematic review of 315 studies of delirium representing 101 144 patients across all settings and populations, 33 predisposing and 112 precipitating factors were associated with delirium. Putative pathophysiological mechanisms associated with these factors were heterogeneous.
Meaning This study found physiological heterogeneity represented across studies, suggesting that delirium may not be not restricted to a singular physiological account.
AbstractImportance Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups.
Objective To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting.
Evidence Review A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium.
Findings A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity.
Conclusions and Relevance In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium’s heterogeneous pathophysiology and treatment.
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Presentation of CaseDr. Megan E. Bunnell (Obstetrics and Gynecology): A 31-year-old woman was admitted to this hospital 15 days after the birth of her first child because of abdominal pain and fever.
The patient had received routine prenatal care at this hospital. Serologic screening during the pregnancy showed immunity to rubella. Rectovaginal culture was positive for group B streptococcus. Tests for syphilis, hepatitis B virus surface antigen, gonorrhea, chlamydia, and human immunodeficiency virus were negative.
Sixteen days before this admission, the patient went into labor at 38 weeks 1 day of gestation. She was admitted to this hospital. The white-cell count was 13,800 per microliter (reference range, 4500 to 11,000), and the hemoglobin level was 14.0 g per deciliter (reference range, 12.0 to 16.0); treatment with intravenous penicillin was started. On hospital day 2, an epidural anesthetic agent was administered. Artificial rupture of the membranes revealed clear, odorless fluid, and infusion of oxytocin was started. Six hours after artificial rupture of the membranes, the patient gave birth to a healthy baby by vaginal delivery. Three minutes later, the placenta was delivered intact. Immediately after delivery, hemorrhage due to uterine atony occurred; there was an estimated blood loss of 500 ml. Bimanual massage of the uterus was performed, and oxytocin and methylergonovine were administered; hemostasis was subsequently achieved. A perineal laceration was repaired. The patient began breast-feeding, and on postpartum day 1, she was discharged.
Six days before the current admission, on postpartum day 9, pain in the left upper quadrant developed. The pain was dull, radiated to the left flank and back, and was worse with movement and deep breathing. The patient presented to a local urgent care clinic; urine was obtained for culture, and empirical treatment with amoxicillin–clavulanate was started.
Five days before this admission, on postpartum day 10, abdominal pain persisted, and a fever with a temporal temperature of 38.3°C developed. The patient sought evaluation in the emergency department of this hospital. She rated the abdominal pain at 10 on a scale of 0 to 10, with 10 indicating the most severe pain. A review of systems was notable for nausea and minimal lochia; there was no diarrhea, constipation, dysuria, hematuria, or breast tenderness.
Table 1.Laboratory Data.
On examination, the abdomen was soft, and there was mild tenderness on palpation of the left upper quadrant, the uterine fundus, the suprapubic region, and the left costovertebral angle. Pelvic examination, including examination with the use of a speculum, revealed no dehiscence, drainage, or hematoma at the site of the perineal laceration repair and no discharge from the cervical os; there was mild cervical motion tenderness. The white-cell count was 20,700 per microliter. The level of hemoglobin was 11.4 g per deciliter. Blood cultures were obtained. The urine culture obtained at the urgent care clinic was positive for group B streptococcus. Other laboratory test results are shown in Table 1. Treatment with ceftriaxone was started, and the patient was admitted to the hospital for presumed pyelonephritis. On hospital day 3, when the fever and abdominal pain resolved, the patient was discharged home to complete a course of amoxicillin.
During the subsequent 2 days, the patient continued to take amoxicillin at home, but fever and abdominal and flank pain returned. On postpartum day 15, when the pain did not abate after she took acetaminophen, she returned to the emergency department of this hospital.
The patient’s medical history included high-grade cervical dysplasia that had led to a loop electrosurgical excision procedure 5 years earlier, as well as a ruptured ovarian cyst 3 years earlier and nephrolithiasis on the left side 5 months earlier. The patient had not been pregnant before the recent pregnancy; before this pregnancy, she had taken oral contraceptives for 12 years. She took prenatal vitamins, as well as polyethylene glycol, docusate, acetaminophen, and ibuprofen as needed. She had no known drug allergies. She lived with her husband and newborn infant in an urban area of New England and worked as an office manager. She did not smoke tobacco, drink alcohol, or use illicit drugs. Her mother had multiple sclerosis and her father had coronary artery disease; her brother was healthy.
On examination, the abdomen was soft, and there was mild tenderness in the left upper quadrant and at the left costovertebral angle. There was no tenderness on palpation of the uterine fundus or the suprapubic region and no cervical motion tenderness. The white-cell count was 10,330 per microliter. The hemoglobin level was 11.2 g per deciliter, the alanine aminotransferase (ALT) level 153 U per liter (reference range, 7 to 33), the aspartate aminotransferase (AST) level 44 U per liter (reference range, 9 to 32), and the alkaline phosphatase level 194 U per liter (reference range, 30 to 100). Other laboratory test results are shown in Table 1. The patient was admitted to this hospital. The next day, the hemoglobin level decreased to 9.7 g per deciliter.
Additional studies were performed, and a diagnosis was made.
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More than 200 000 individuals in the US develop acute cholecystitis annually. The majority of these cases are caused by gallstones blocking the cystic duct. However, about 5% to 10% of people with acute cholecystitis have acalculous cholecystitis. JAMA Associate Editor Kristin Walter, MD, MS, discusses the recent JAMA article “Acute Cholecystitis: A Review” with one of the authors, JAMA Associate Editor Anthony Charles, MD, MPH, who is Chief of the Division of Trauma, Critical Care and Acute Care Surgery, Director of the ECMO program, and Director of Global Surgery at University of North Carolina in Chapel Hill.
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Acute coronary syndromes are characterized by a sudden reduction in blood supply to the heart, and the syndromes include ST-segment elevation myocardial infarction (or STEMI), non-ST-segment elevation myocardial infarction (or NSTEMI), and unstable angina. Each year, an estimated more than 7 million people in the world are diagnosed with acute coronary syndromes, including more than 1 million people hospitalized in the US. In this podcast with Deepak L. Bhatt, MD, MPH, of Brigham and Women’s Hospital Heart and Vascular Institute, we bring our listeners up-to-date on these common and potentially serious conditions.
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Jade Julienne1, http://orcid.org/0000-0001-7986-7552Delphine Douillet2,3, Marie-Sophie Mozziconacci2, http://orcid.org/0000-0002-3376-3982Jean-Christophe Callahan4 Correspondence to DrJean-ChristopheCallahan, Intensive Care, Centre Hospitalier du Mans, Le Mans 72037, France; jccallahan@ch-lemans.fr
AbstractBackground The aim of this study was to determine whether: (1) the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) and National Early Warning Score (NEWS) clinical prediction tools alone, (2) modified versions of these prediction tools that integrate lactate into their scores, or (3) use of the two tools in tandem with lactate better predicts in-hospital 28-day mortality among adult EDpatients with suspected infection.
Methods From 1 January through 31 December 2018, this retrospective cohort study enrolled consecutive adult patients with suspected infection evaluated at two EDs in France. Patients were included if blood cultures were obtained and non-prophylactic antibiotics were administered in the ED. qSOFA, NEWS criteria and lactate measurements were recorded when patients were clinically suspected of having an infection. Two composite scores (lactate qSOFA (LqSOFA) and lactate NEWS (LNEWS)) integrating lactate were created. Diagnostic test performances for predicting in-hospital mortality within 28days were assessed for qSOFA≥2, LqSOFA≥2, qSOFA≥2 or lactate≥2 mmol/L, and for NEWS≥7, LNEWS≥7, and NEWS≥7 or lactate≥2 mmol/L.
Results 1003 patients were included, 130 (13%) of whom had died by day 28. Sensitivities for 28-day mortality were 50% (95%CI41% to 59%) for qSOFA≥2,69% (95% CI60% to 77%) for LqSOFA≥2,77% (95% CI69% to 84%) for qSOFA or lactate≥2 mmol/L; and 69% (95% CI60% to 77%) for NEWS≥7, 80% (95% CI72% to 86%) for LNEWS≥7, 87% (95% CI80% to 92%) for NEWS≥7 or lactate≥2 mmol/L.
Conclusion Lactate used in tandem with qSOFA or NEWS yielded higher sensitivities in predicting in-hospital 28-day mortality, as compared with integration of lactate into these prediction tools or usage of the tools independently.
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BMJ talk medicine · Primary Survey – the highlights of December 2022A selection of the best papers from our December 2022, picked apart and distilled for you by Rick Body and Sarah Edwards. In this festive issue we cover anaesthesia for paediatric forearm fractures, ultrasound diagnosis of acute appendicitis, a deep dive into the predictive value of vital signs, clinical judgement versus early warning scores, pulmonary embolism and… Do you know what calibration drift is? If not, listen and you’ll find out!
Read the highlights: emj.bmj.com/content/39/12/881.
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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 […]
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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, […]
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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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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 […]
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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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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 […]
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” data-title=”EM Quick Hits 42 CARD” data-caption=”” aria-label=”EM Quick Hits 42 CARD”> Topics in this EM Quick Hits podcast Salim Rezaie on venous thromboembolism recurrence in subsegmental pulmonary embolism (1:23) Andrew Petrosoniak on pain management in the polytrauma patient (6:44) Nour Khatib on rural case on management of near-drowning patient (17:09) Sara Reid on polio primer (24:30) Anand Swaminathan on head-up cardiopulmonary resuscitation (32:20) Podcast […]
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To the Video Click here Joseph Offenbacher, MD is an Assistant Professor of Emergency Medicine at the New York University (NYU) School of Medicine and an Associate Program Director at the NYU/Bellevue Emergency Medicine Residency Program. He completed the ALLNYC Resident Fellowship in Medical Education Leadership and has also participated as a faculty member at […]
The post הרצאת ה CME האחרונה עלתה לאתר Intubating the Acidemic Patient first appeared on האיגוד הישראלי לרפואה דחופה.
Aug 22, 2022 Contributor: Jared Scott, MD Educational Pearls: Physicians are typically advised not to trust computer interpretation of ECGs Retrospective study was done of computer interpreted normal ECGs to evaluate the accuracy of such an interpretation 989 ECGs were interpreted as “Normal sinus rhythm, Normal ECG” by proprietary cardiology software on MUSE Cardiology Information […]
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J.P. Thornhill, S. Barkati, S. Walmsley, J. Rockstroh, A. Antinori, L.B. Harrison, R. Palich, A. Nori, I. Reeves, M.S. Habibi, V. Apea, C. Boesecke, L. Vandekerckhove, M. Yakubovsky, E. Sendagorta, J.L. Blanco, E. Florence, D. Moschese, F.M. Maltez, A. Goorhuis, V. Pourcher, P. Migaud, S. Noe, C. Pintado, F. Maggi, A.-B.E. Hansen, C. Hoffmann, J.I. […]
The post NEJM: Monkeypox Virus Infection in Humans across 16 Countries – April-June 2022 first appeared on האיגוד הישראלי לרפואה דחופה.
Josef Dankiewicz, M.D., Ph.D., Tobias Cronberg, M.D., Ph.D., Gisela Lilja, O.T., Ph.D., Janus C. Jakobsen, M.D., Ph.D., Helena Levin, M.Sc., Susann Ullén, Ph.D., Christian Rylander, M.D., Ph.D., Matt P. Wise, M.B., B.Ch., D.Phil., Mauro Oddo, M.D., Alain Cariou, M.D., Ph.D., Jan Bělohlávek, M.D., Ph.D., Jan Hovdenes, M.D., Ph.D., Abstract BACKGROUND Targeted temperature management is recommended for patients after cardiac arrest, but the supporting evidence is of […]
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