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.

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:

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.

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.

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 Medscape.com:

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.

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.