Cardiac Risk factors, How important are they?

This is an old study by Annals of EM, The Role of Cardiac Risk Factor Burden in Diagnosing Acute Coronary Syndromes in the Emergency Department Setting, Feb 2007. Of 10,806 eligible patients, 871 (8.1%) had acute coronary syndromes. Cardiac risk factors was identified: diabetes, hypertension, smoking, hypercholesterolemia, and family history of coronary artery disease. Interestingly in patients less than 40 years old without cardiac risk factors had a negative likelihood ratio of 0.17 and having 4 or more risk factors had a positive likelihood ratio of 7.39. In patients between 40 and 65 years of age, having no risk factors had a negative likelihood ratio of 0.53, and having 4 or more risk factors had a positive likelihood ratio of 2.13. In patients older than 65 years, having no risk factors had a negative likelihood ratio of 0.96 , and having 4 or more risk factors had a positive  likelihood ratio of 1.09.  The conclusion was:”Cardiac risk factor burden has limited clinical value in diagnosing acute coronary syndromes in the ED setting, especially in patients older than 40 years”.

Link to article

Still MAP of 65 Works!

NEJM published a study regarding appropriate MAP among patients with septic shock. Originally MAP of 65 was a target but the Surviving Sepsis Campaign guideline was recommending patients with HTN, may have benefit for higher MAP. In this study 776 patients with septic shock during resuscitation targeted MAP of 65- 70 mm Hg vs 80-85 mm Hg.  No significant mortality was found between these groups at 28 days and 90 days. They found higher rate of new atrial fibrillation among higher MAP group(80-85). Conclusions is “Targeting a mean arterial pressure of 80 to 85 mm Hg, as compared with 65 to 70 mm Hg, in patients with septic shock undergoing resuscitation did not result in significant differences in mortality at either 28 or 90 days”.

 

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EGDT or ProCESS , That is the question!

NEJM published The ProCESS study. Basically, this study aimed to challenge EGDT by Manny Rivers in 2001, a very prestigious and novel approach to septic patient in ED. The EGDT was ED based approach. although some of the components were very difficult to acheived in ED such as Scvo2. The EGDT study showed 16% reduction in mortality, but Rivers faced lots of questions including feasibility of this approach in ED, and necessity of blood transfusion and etc… The whole concept was to have better oxygen delivery to tissue!
The ProCESS study published in NEJM this month enrolled 1351 patients from  March 2008 through May 2013  lead by the University of Pittsburgh. Patients were assigned to one of the 3 groups:
1. protocol-based EGDT: mainly Rivers protocol
2. protocol-based standard therapy: less aggressive approach: blood transfusion at Hb 7.5 and no mandatory central line access, etc
3. usual care: community based approach, they let providers take care of patient without any prompt or protocol
the study conclusion is :
They found no significant advantage, with respect to mortality or morbidity, of protocol-based resuscitation over bedside care that was provided according to the treating physician’s judgment.
******
The Rivers concept that we should remember and nobody can challenge is :
early resuscitation
early recognition of patient’s pathology
early oxygenation
Volume(IVF, or Blood transfusion)
early treatment(Abx)
Hospital Admission
and this is all we do in ED: Cath attack, Brain attack, Trauma activation, all have good outcomes because they are EGDT. We all know if you see a patient and order early cardiac monitor, o2 , IV … you will have a better understanding of patient, I believe we should do EGDT as our approach to every single patient regardless of  disease process and symptom/sign.  The concept of EGDT should stay with us regardless being true in sepsis or not!
Don’t forget to practice EARLY and GOAL DIRECTED in EM!

ACEP Practice Guideline on Procedural Sedation

ACEP published Clinical Policy on Procedural Sedation and Analgesia in the Emergency Department in Feb 2014. as usual critical questions and very useful answers. Let’s review them:

1. In patients undergoing procedural sedation and analgesia in the emergency department, does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration?

Level B recommendations. Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.

2. In patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events?

Level B recommendations. Capnography* may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone in patients undergoing procedural sedation and analgesia in the ED.

*Capnography includes all forms of quantitative exhaled carbon dioxide analysis.

3. In patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications?

Level C recommendations. During procedural sedation and analgesia, a nurse or other qualified individual should be present for continuous monitoring of the patient, in addition  to the provider performing the procedure. Physicians who are working or consulting in the ED should coordinate procedures requiring procedural sedation and analgesia with the ED staff.

4. In patients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil, and remifentanil be safely administered?

Level A recommendations. Ketamine can be safely administered to children for procedural sedation and analgesia in the ED. Propofol can be safely administered to children and adults for procedural sedation and analgesia in the ED.

Level B recommendations. Etomidate can be safely administered to adults for procedural sedation and analgesia in the ED. A combination of propofol and ketamine can be safely administered to children and adults for procedural sedation and analgesia.

Level C recommendations. Ketamine can be safely administered to adults for procedural sedation and analgesia in the ED. Alfentanil can be safely administered to adults for procedural sedation and analgesia in the ED. Etomidate can be safely administered to children for procedural sedation and analgesia in the ED.

Link to Policy on ACEP website

 

 

Glucagon and Food bolus

This is a challenging question that always comes up in patients with food bolus. What evidence do we have to recommend Glucagon in this situation? is this another version of Kayexalate in case of hyperkalemia? ;) Tibbling et al in Dysphagia 1995 described a multicenter, placebo-controlled, double-blind study of Glucagon and Diazepam vs placebo. They rejected  their hypothesis of muscle spasm as an important cause of esophageal obstruction but study was very small.  Sanjay Arora and Galich in CJEM, 2009 did a review of this topic and found “Glucagon is an effective first-line therapy for esophageal foreign body impaction” was a MYTH. Their conclusion was there is no clear evidence that glucagon  can help in bolus impaction and with regards to side effects of it, nausea, vomiting and risk of perforation and aspiration, we should consider other alternatives. Leopard et al, 2011, had another review on this topic and showed that Glucagon was not better than placebo. The whole idea comes from a theory that Glucagon decrease the esophageal motor function in mid and distal portion. I should echo the messages of all these study that there is no clear data to show Glucagon is effective or safe, So, call your GI colleague!

 

 

INR overestimates coagulopathy in stable trauma and surgical patients

From OHSU, Portland, Oregon study came out in Journal of Trauma and Acute Care Surgery in Dec 2013.  The main idea was that INR should not guide to transfuse FFP in stable trauma patient. This was a prospective observational study with 106 patients enrolled. They checked all clotting factors, and as well TEG. The median TEG was in normal limits, with clotting factors  function remained adequate Pre and Post FFP transfusion. The conclusion is: “INR is not a predictor of coagulopathy and should not be used to guide coagulation factor replacement in stable trauma and surgical patients.”

 

Link to article