Sunday, 7 February 2016

Webucation 7/2/16

A Happy Lunar New Year to asian readers. Wisdom from the world this edition comes from specialities of trauma to tox and even some nerd evidence thrown in at the end. Do view and credit the original content creators.
The last link is once again superb dogmalysis. Tech does not solve ALL our problems. Some we bring onto ourselves.

Thursday, 28 January 2016

Fencing with snake venom

Lots has been said and lots will be said about tPA in stroke. It matters not which side of the fence you trek so long as you acknowledge that there isaonther side (ie. the fence exists). 

Here is a well put critique of the recent AHA/ASA update

It is worthwhile noting that ACEM and ACEP have updated position statements on this subject. Rightly reflecting that clinicians should neither be lulled nor bullied into poor decisions for our patients.

For those who want a concise summary of the opposing view, go to this site. Here's a succinct snapshot for those with less time:

Thursday, 14 January 2016

All about PE today

This item appeared in Medscape here but is a must read for any physician who deals with acute PE presentations.

Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians

Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD; Clinical Guidelines Committee of the American College of Physicians
Ann Intern Med. 2015;163:701-711
The diagnosis of pulmonary embolism (PE) is definitely one of the great challenges in acute care medicine. I can't think of any condition that is so frequently worked up with negative results and yet is also so often underdiagnosed, with catastrophic results and resulting litigation. In addition, we in EM are often chastised for overordering D-dimer levels and CT pulmonary angiograms (CTPAs), yet we continue to practice in this way for lack of an acceptable standard method of working up patients. However, there may finally be some good news that will decrease workups, misdiagnoses, and litigation.
In November 2015, the American College of Physicians' Clinical Guidelines Committee published a set of recommendations for best practice with regard to working up PE. The document was evidence-based, straightforward, and clinically relevant. The document essentially serves as a guideline recommendation from a major national organization, which provides strong medicolegal protection when following the recommendations.
There were six pieces of "Best Practice Advice" from the Committee, which I have listed below.
  • Best Practice Advice 1: Clinicians should initiate their evaluation of patients with possible PE by using validated clinical prediction rules (eg, Wells or revised Geneva scores) to estimate the pretest probability of PE as low, intermediate, or high risk.
  • Best Practice Advice 2: Clinicians should not obtain D-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all of the pulmonary embolism rule-out criteria (PERC). If the patient with low pretest probability is PERC-negative, PE is considered ruled out and the workup is completed. If the patient is PERC-positive, a D-dimer value may then be obtained.
  • Best Practice Advice 3: A high-sensitivity D-dimer test (enzyme-linked immunosorbent assay) should be obtained as the initial diagnostic test in patients who (1) have a low pretest probability for PE but are PERC-positive, or (2) have an intermediate pretest probability of PE. If the D-dimer value is within normal limits, imaging is deferred and the workup for PE is completed. D-dimer testing should not be performed for patients with high pretest probability for PE (see Best Practice Advice 6, below).
  • Best Practice Advice 4: Clinicians should use an age-adjusted D-dimer threshold (top normal level = age × 10 ng/mL rather than a generic 500 ng/mL cutoff) for patients older than 50 years to determine whether imaging is necessary.
  • Best Practice Advice 5: Clinicians should not obtain imaging studies in patients with D-dimer levels below the cutoffs noted above.
  • Best Practice Advice 6: Clinicians should obtain imaging with CTPA in (1) patients with high pretest probabilities for PE, or (2) patients with elevated D-dimer levels based on the evaluations noted above. Clinicians should reserve ventilation/perfusion scans for patients with contraindications to CTPA or when CTPA is not available.
The authors add a recommendation to obtain lower-extremity ultrasound before CTPA in patients who have lower-extremity symptoms or in pregnant patients during the first trimester.
This set of recommendations, when taken as a whole, is certain to reduce testing, especially imaging and radiation exposure for many patients. The guidelines are a quick read and are chock-full of useful clinical information; they are a must-read for anyone who has an interest in the topic or who desires some of the background information behind these Best Practice Advice statements.

Sunday, 3 January 2016

How dare you SIRS?

Here's a good reminder that risk stratifiers and mnemonics are just that - prognostications. Like a wise man once said - its all a spectrum.

Time to Initial Antibiotic Administration, and Short-term Mortality Among Patients Admitted With Community-Acquired Severe Infections With and Without the Presence of Systemic Inflammatory Response Syndrome

A Follow-Up Study

Daniel Pilsgaard Henriksen; Christian B Laursen; Jesper Hallas; Court Pedersen; Annmarie Touborg Lassen
Emerg Med J. 2015;32(11):846-853. 


Background The prognosis for patients with severe infection is related to early treatment, including early administration of antibiotics. The study aim was to compare the short-term mortality among patients admitted with severe infection with and without systemic inflammatory response syndrome (SIRS) at arrival, and to ascertain whether the presence of SIRS might affect the timing of antibiotic administration.
Methods In this retrospective follow-up study, we included all adult patients (≥15 years) presenting to a medical emergency department in the period between September 2010 and August 2011 with a first-time admission of community-acquired severe infection (infection with evidence of organ dysfunction), with and without SIRS at arrival. The presence of SIRS was defined as two or more of the criteria according to the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) definitions. Cases were identified by manual chart review using predefined criteria of infection. Data on vital signs, laboratory values and antibiotic treatment were obtained electronically.
Results We included 1169 patients with infection and organ dysfunction, treated with antibiotics within 24 h after arrival (median age 76.1 years (IQR 63.1–83.5), 567 (48.5%) men). In all, 886 (75.8%) presented with SIRS, and 283 (24.2%) presented without SIRS. Median time to antibiotics was 4.6 h (IQR 2.9–7.0) in patients with SIRS and 6.7 h (IQR 4.5–10.3) in patients without SIRS (p<0.0001). Thirty-day mortality in patients with and without SIRS was 18.4% (95% CI 15.9% to 21.1%) and 16.6% (95% CI 12.5% to 21.5%), respectively.
Conclusions SIRS was absent in one-quarter of patients admitted with severe infection. The 'door-to-antibiotics' time was significantly shorter for patients with SIRS compared with patients without SIRS, but no difference was found in 30-day mortality.

Tuesday, 22 December 2015

Age-ism in d-dimers

This is something that has been a bug bear of many a physician for years. Your gestalt and experience downtrodden by a slightly raised d-dimer that should not have been sent in the first place. Here's a reason why you should have that leeway.

Original article via

Pulmonary Embolism Guidelines Released by ACP

Beth Skwarecki
September 28, 2015
New pulmonary embolism guidelines suggest that computed tomography (CT) imaging and plasma D-dimer testing are overused in patients suspected of having a pulmonary embolism, and may do more harm than good. The American College of Physicians (ACP) published the guidelines online September 29 in the Annals of Internal Medicine.
Plasma D-dimer tests are more appropriate for those at intermediate risk for a pulmonary embolism, and no testing may be necessary for some patients at low risk.
"Although the use of [computed tomography] for the evaluation of patients with suspected [pulmonary embolism] is increasing in the inpatient, outpatient, and [emergency department] settings, no evidence indicates that this increased use has led to improved patient outcomes," write Ali S. Raja, MD, vice chair, Department of Emergency Medicine, Massachusetts General Hospital, Boston, and colleagues from the ACP's Clinical Guidelines Committee. Potential harms of unnecessary imaging include increased costs, radiation exposure, and follow-up for incidental findings.
Instead, the authors recommend using either the Wells or Geneva rules to choose tests based on a patient's risk for pulmonary embolism.
If the patient is at low risk, clinicians should use the eight Pulmonary Embolism Rule-Out Criteria (PERC); if a patient meets all eight criteria, the risks of testing are greater than the risk for embolism, and no testing is needed. "By avoiding D-dimer testing in these low-risk patients, physicians can avoid false-positive D-dimer results and subsequent CT, which is unnecessary. Of note, the PERC should not be applied to patients at intermediate or high risk for [pulmonary embolism]," they write.
For patients at intermediate risk, or for those at low risk who do not meet all of the rule-out criteria, the authors recommend a high-sensitivity plasma D-dimer test as the initial test. In patients older than 50 years, the authors recommend using an age-adjusted threshold (age × 10 ng/mL, rather than a blanket 500 ng/mL) because normal D-dimer levels increase with age. Patients with a D-dimer level below the age-adjusted cutoff should not receive any imaging studies. Patients with elevated D-dimer levels should then receive imaging.
Patients at high risk should skip the D-dimer test and proceed to CT pulmonary angiography, because a negative D-dimer test will not eliminate the need for imaging in these patients. Clinicians should only obtain ventilation-perfusion scans in patients with a contraindication to CT pulmonary angiography or if CT pulmonary angiography is unavailable.
The new guidelines are being released as a Best Practice Advice statement, meant to guide but not replace clinicians' judgement, based on a nonsystematic literature review.
One author reports that he chairs the Test-Writing Committee for the secure examination of the American Board of Internal Medicine. Another reports that he chaired the Quality and Performance Committee of the American College of Emergency Physicians, in which capacity he helped to develop performance measures of appropriate use of computed tomography for pulmonary embolism. The other authors have disclosed no relevant financial relationships.
Ann Intern Med. Published online September 29, 2015.

Sunday, 13 December 2015

Webucation 13/12/15

This episode of web wisdom hails from the realms of almost all specialities. Make sure you visit the content on the sites and all credit to them.
The last link is a great resource for a population that goes under our radar. Good to know it is a safe, universal strategy nowadays to start analgesia first and then followed by sedation. 

Monday, 30 November 2015

Give me something for the pain!

The original article was found in Medscape but presented at ACEP 2015. We like it for obvious reasons. Anything to do with ketamine has a place on this site... and we believe oligoanalgesia should be a thing of the past.

Our infusion and dosing on it can be found here.
Bon Jovi's take on the idea can be found here.

Low-dose Ketamine Eases Pain, Reduces Opioid Use in ED

Neil Osterweil

BOSTON — The use of low-dose ketamine as an adjunct to opioids for pain control in the emergency department led to reductions in pain scores, total opioid dosing, and frequency of opioid dosing, results from a randomized, placebo-controlled trial indicate.
"The reduced frequency of opioid dosing, in particular, may be clinically significant," said lead investigator Karen Bowers, MD, from the Emory University School of Medicine in Atlanta, Georgia.
She presented the study results here at the American College of Emergency Physicians (ACEP) 2015 Scientific Assembly.
Previous studies have shown short-term pain control with ketamine at doses two to three times higher than the 0.1-mg/kg dose used in this study.
A recently published randomized trial using a 0.3-mg/kg dose showed that although ketamine was effective for pain control, "it had a pretty tough side-effect profile to swallow," Dr Bowers reported. "They had a lot of patients reporting side effects that they felt were very unpleasant."
Dr Bowers and her colleagues hypothesized that patients treated with low-dose ketamine as an adjunct to opioids would require less opioid for effective pain control, report increased satisfaction with pain control, have more effective control than with opioids alone for up to 2 hours, and have tolerable adverse effects.
To test this, they randomly assigned 63 patients to receive ketamine, 0.1 mg/kg, and 53 patients to receive placebo. All patients also received protocol-based dosing of morphine or another opioid analgesic.
Pain Control
The investigators assessed pain at baseline and every 30 minutes thereafter for 2 hours. A 10-point pain scale, with 0 indicating no pain and 10 indicating the worst pain imaginable, was used to evaluate pain. A 4-point Likert scale was used to evaluate satisfaction with pain control, the presence of adverse effects, sedation level, and the need for additional pain medications.
Total opioid dosage was significantly lower in patients treated with ketamine plus opioids than in those treated with placebo plus opioids (P = .02), as was average pain score (P = .015). Ketamine-treated patients required fewer repeat opioid doses, although this difference was not significant.
However, patient-reported satisfaction with pain control did not significantly differ between groups.
If I just give somebody opiates in the emergency department, I don't have to do the whole procedural sedation protocol for them.Dr Judd Hollander
Adverse effects, primarily light-headedness and dizziness, were more frequent in the ketamine group than in the placebo group, but there were no serious adverse events. Two patients, one in each group, withdrew because of oversedation.
These findings support previous studies that have suggested a dose-response relation with ketamine for both efficacy and tolerability, Dr Bowers said.
The comparatively low dose used in this study was effective, but not as effective as the doses used in other studies. However, it appeared to have a better, more acceptable tolerability profile, she said.
There are a few things to consider with use of using ketamine in an acute-care setting, said Judd Hollander, MD, from Thomas Jefferson University in Philadelphia, Pennsylvania.
"If I just give somebody opiates in the emergency department, I don't have to do the whole procedural sedation protocol for them," he told Medscape Medical News. But "if I give them ketamine or some other procedural sedation agent and opiates, I need more people in the room, and it's a whole different monitoring system."
It would be difficult to conduct a larger randomized trial of this kind, he pointed out. Although the additional cost of ketamine is relatively modest, "the nursing costs of the ketamine arm far exceed the extra costs of the extra dose of morphine you're giving in the other arm."
The study was internally supported. Dr Bowers and Dr Hollander have disclosed no relevant financial relationships.
American College of Emergency Physicians (ACEP) 2015 Scientific Assembly. Abstract 2. Presented October 26, 2015.