Tuesday, 28 October 2014

Don’t discount clinical gestalt just yet

Whether to ‘rule out’ or ‘rule in’ AMI in the emergency department, we have many tools at our disposal. In brief, though not exhaustive, we have in recent years the following:
1. The HEART score
2. The 2 hour AMI rule out
3. Even the 1 hour rule out AMI

Now, in the latest issue of EMJ, researchers asked if emergency physicians can possibly ‘rule in’ and ‘rule out’ AMI with clinical judgement i.e. clinical gestalt?
This single centre observational study recruited 458 patients with suspected cardiac chest pain. ‘Gestalt’ or clinical judgement about the probability of an ACS was assessed using a five-point Likert scale as follows: ‘definitely not’, ‘probably not’, ‘not sure’, ‘probably’ and ‘definitely’.
So, clinical gestalt alone wouldn’t cut it, with a ROC of 0.76, but with ECG and a hs-cTnT, the sensitivity was 100% in cases in which ACS was determined as ‘definitely not’ and ‘probably not’. Specificity, as with other studies, was low (<50%).
Bottom line
Yep, you don’t really need a score per se. Good clinical judgement, good read of the ECG and with the help of troponin (high sensitive if you have it) will help you make a good clinical decision at the bedside in the emergency department.
Limitations and caveats
  • Still a single centre, observational study. Not an RCT, and probably needs validation
  • Good sample representation – sample has significant number of AMIs and MACE – 21.8%
  • Well defined outcomes and good follow-up – e.g. AMI definitions and 30 day MACE
  • Doctors in study of varying skill level (SHOs all to way to consultants)
  • Still require the use of a custom-designed case report form when assessing patients – i.e. some kind of “score” already in my mind.
  • Single troponin only used when >12 h had already elapsed since peak symptoms, as opposed to latest ACC/AHA guidelines

Friday, 24 October 2014

SEMS 2014: Mok Yee Hui - Transport of the sick child

Dr Mok Yee Hui is a paediatric intensivist and transport guru who runs the KK children's hospital retrieval service. She justifies the case for a specialised paeds service as well as demonstrates the trials and tribulations of tranporting sick kids. This one is for all of the retrievalists out there!

Slides are here:

Sunday, 19 October 2014

Subtle signs of ischaemia that need cath lab NOW...

Dr Steve Smith is not just a great educator and blogger, he is probably the foremost person you wish you could see when you are having chest pain. This talk is essential for anyone who reads ECGs for a living and treats chest pain. Kudos to the SMACC team for releasing this vid to one of the best lectures of the conference.

Steve Smith Subtle ECG Signs of Ischemia from Social Media and Critical Care on Vimeo.

The slides are here:

Sunday, 12 October 2014

Webucation 12/10/14

Web wisdom this time comes from the realms of trauma and radiology mostly. There's also a treat for Star Trek fans and airway enthusiasts all wrapped in one funny promo...

The last link was a promo for the SMACC conference. Semi decent lip-synching but the medical satire is pure gold. Admit it... this has happened in your ED in some shape or form!

Wednesday, 8 October 2014

CEM (UK) on traumatic arrests

The UK College is now active in the FOAM world and here's a good example of modern trauma information being disseminated to the general population.

Tuesday, 30 September 2014

Zdogg on platelets

ZDogg doing what he does best - this time the low down on throbocytopaenia.

Sunday, 28 September 2014

SEMS 2014 - Rahul Goswami - Why do we meet?

What the 2014 SEMS Annual Scientific Meeting is all about. Chairperson Dr Rahul Goswami gave the introductory speech, and set forth the tone and vibe that made this conference truly engaging for all who participated.

See the Video here:


Slides here: