Was going to do a piece on the new STEMI Guidelines from the AHA, but Simon Carley from St. Emlyns just did a great job at it

The post New STEMI Guidelines appeared first on Practical Evidence.

Today, we discuss two new Trauma Guidelines

ATLS 9th Ed.

The 9th edition of ATLS has been published. In this episode, I review the changes from the 8th edition.

Management of C-Spine Injuries

We also go over the new management of spinal cord injuries from the Neurosurgeons

What’s EMCrit Drinking?

The post Episode 12 – New Trauma Guidelines: ATLS and Spine appeared first on Practical Evidence.

Ischemic Stroke Guidelines from the ASA

Hot off the presses; the 2013 Ischemic Stroke Guidelines from AHA/ASA (Stroke 2013;44:870)

Want the full recommendations as written by the AHA/ASA?

Stroke Centers

• Comprehensive Stroke Centers are god
• Should have neurocritical care unit
• EMS should bypass hospitals that can’t care for stroke
• Should have tele-rads if no in-house radiologists

Initial Eval

• Door to Drug within 60 minutes (80% compliance)
• Use a Stroke Scale, preferably NIHSS
• Get labs, but glucose is the only one that needs to be done before tPa
• Get EKG and troponin, don’t delay tPA for this

ED-Based Care

Imaging

• Get either a NCCT or MRI to exclude hemorrhage prior to tPA
• tPA indicated even if ischemic signs, unless a frank hypodensity is noted
• A non-invasive intracranial vascular study is strongly recommended during initial imaging if IA tPA or mechanical thrombectomy is contemplated. This should not delay tPA administration
• In tPA candidates, the CT or MRI should be read within 45 minutes of arrival by a physician with expertise in reading CTs or MRIs of the brain
• Consider CT Perfusion or MRI perfusion in patients outside of the window for IV tPA
• If frank hypodensity involves more than 1/3 of the MCA territory, IV tPA should be withheld

TIAs

• They should get imaging of their cervical vasculature
• Noninvasive imaging by CTA or MRA of the intracranial vasculature is rec. to exclude proximal intracranial stenosis or occlusion. Intracranial lesions may need confirmatory angio if occlusion seen on CTA
• Pts with transient sx should receive imaging within 24 hours, preferably by MRI

Acute Treatment

• Cardiac Monitoring
• New BP meds allowed to get the pt <180/110. Shoot for 180/105 for first 24 hours
• Intubate airway compromise or bulbar dysfunction
• Shoot for pulse ox > 94%. Don’t give supplemental O2 in patients with normal RA pulse ox
• Lower temps >38 C
• Until further evidence, use the same BP goals for IA/mech treatments
• In Non-tPA, only treat if SBP>220 or DBP>120
• Treat hypovolemia with NS and treat CO-reducing dysrhythmias
• Treat hypoglycemia
• May restart home anti-hypertensives after 24 hours
• Treat hyperglycemia to achieve a Blood Sugar of 140–180 mg/dl

IV Fibrinolysis

• Give IV tPA in patients who meet 3 hour criteria (IA)
• Getting it within window is not enough, shoot for the <60 minutes timeframe
• Give IV tPA to pts who meet criteria within 4.5 hours (IB)
• Be prepared to treat complications including bleeding and angioedema
• tPA is reasonable if pt had a seziure if treating team feels deficit is from stroke and not post-ictal state (IIaC)
• Benefits of sono-thrombolysis are unknown at this time
• Other agents besides tPA should only be used in clinical trials
• Benefit of tPA unknown in patients in the 3–4.5 hr range with one of the additional contra-indications
• Use of tPA in pts with mild deficits, rapidly improving deficits, major surgery in prior 3 months, and recent MI may be considered and should be based on risk benefit assessment
• Don’t use streptokinase
• The use of intravenous rtPA in patients taking direct thrombin inhibitors or direct factor Xa inhibitors may be harmful and is not recommended unless sensitive laboratory tests such as aPTT, INR, platelet count, and ECT, TT, or appropriate direct factor Xa activity assays are normal, or the patient has not received a dose of these agents for >2 days (assuming normal renal metabolizing function). Similar consideration should be given to patients being considered for intra-arterial rtPA (Class III; Level of Evidence C)

3-hour-inclusion

4.5-hour-inclusion

BP Management

tPA Administration

IA Fibrinolysis

• Pts eligible for IV should receive it even if IA is being contemplated
• Use if < 6hrs duration caused by MCA lesion not eligible for IV tPA
• Minimize delays
• Credential practitioners and track outcomes
• They prefer solitaire FR and Trevo (stent retrievers) over coil retriever (MERCI). Penumbra benefit still being studied
• All mech devices still need additional study to demonstrate benefit
• IA or retrieval are reasonable in pts with contra-indications to IV
• Rescue IA or mech is reasonable in pts who have not fully responded to IV
• Other devices need additional trials
• Intracranial angio and/or stenting requires additional study
• Extracranial angio and/or stenting in unselected patients is not well established

Other Meds

• Thrombin inhibitor benefit unknown
• Anti-coag for severe carotid stenosis is unknown
• Don’t give urgent anti-coag to prevent recurrence, or halt neuro symptoms
• Don’t start within 24 hours of tPA
• Dose of 325 mg of ASA recommended with 24–48 hours of stroke
• Clopidogrel benefit is unknown
• Tirofiban and eptifibatide have unknown benefit
• Don’t use IV IIb/IIIa agents
• Don’t give ASA until after 24 hours from tPA

Blood Pressure Manipulations

• In extreme cases of hypotension that do not respond to fluids, use vasopressors
• Need more evidence for high dose albumin
• Devices to augment CPP are not established yet
• Drug induced hypertension not established
• Don’t hemodilute
• Vasodilatory agents are not recommended

Other Stuff

• If pt was taking statins, you may continue
• Induced hypothermia needs further study
• Laser therapy not recommended yet
• No neuroprotectants have worked out yet

CEA

• Indications for emergent Cardia EA are unknown

Stroke Units

• See full guideline

Neurocritical Care Interventions, etc.

• Patients with major infarctions can crap out, watch them
• Cerebellar infarction will probably need surgery
• Decomp Crani for malignant edema is good
• Treat recurrent seizures like you would in other patients
• Place EVD in pts with hydrocephalus
• Though medical interventions for malignant edema are used, there is not evidence for their efficacy
• No Steroids
• No proph anti-convulsants

ACEP 2013 Ischemic Stroke Guidelines

Available on the ACEP Site

Questions

1. Is IV tPA safe and effective for acute ischemic stroke patients if given within 3 hours of symptom onset?
2. Is IV tPA safe and effective for acute ischemic stroke patients treated between 3 to 4.5 hours after symptom onset?

Patient Management Recommendations

• Level A recommendations: In order to improve functional outcomes, IV tPA should be offered to acute ischemic stroke patients who meet National Institute of Neurological Disorders and Stroke (NINDS) inclusion/exclusion criteria and can be treated within 3 hours after symptom onset.
• Level B recommendations: In order to improve functional outcomes, IV tPA should be considered in acute ischemic stroke patients who meet European Cooperative Acute Stroke Study (ECASS) III inclusion/exclusion criteria and can be treated between 3 to 4.5 hours after symptom onset.

The effectiveness of tPA has been less well established in institutions without the systems in place to safely administer the medication.Within any time window, once the decision is made to administer IV tPA, the patient should be treated as rapidly as possible. As of this writing, tPA for acute ischemic stroke in the 3- to 4.5-hour window is not FDA approved.

What is EMCrit Drinking?

White Rascal by Avery Brewing

Now on to the podcast…

The post Episode 11 – Ischemic Stroke 2013 appeared first on Practical Evidence.

See the Guidelines at (CCM 2013;41(2):580)

Diagnosis of Sepsis

Diagnosis of Severe Sepsis

The New Bundles

A. Initial Resuscitation

1. Protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration ≥ 4 mmol/L). Goals during the first 6 hrs of resuscitation:
   • Central venous pressure 8–12 mm Hg
   • Mean arterial pressure (MAP) ≥ 65 mm Hg
   • Urine output ≥ 0.5 mL/kg/hr
   • Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (grade 1C).
2. In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C).

B. Screening for Sepsis and Performance Improvement

1. Routine screening of potentially infected seriously ill patients for severe sepsis to allow earlier implementation of therapy (grade 1C).
2. Hospital–based performance improvement efforts in severe sepsis (UG).

C. Diagnosis

1. Cultures as clinically appropriate before antimicrobial therapy if no significant delay (> 45 mins) in the start of antimicrobial(s) (grade 1C). At least 2 sets of blood cultures (both aerobic and anaerobic bottles) be obtained before antimicrobial therapy with at least 1 drawn percutaneously and 1 drawn through each vascular access device, unless the device was recently (<48 hrs) inserted (grade 1C).
2. Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan antibody assays (2C), if available and invasive candidiasis is in differential diagnosis of cause of infection.
3. Imaging studies performed promptly to confirm a potential source of infection (UG).

D. Antimicrobial Therapy

1. Administration of effective intravenous antimicrobials within the first hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) as the goal of therapy.
2. Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis (grade 1B). Antimicrobial regimen should be reassessed daily for potential deescalation (grade 1B).
3. Use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection (grade 2C).
4. Combination empirical therapy for neutropenic patients with severe sepsis (grade 2B) and for patients with difficult-to-treat, multidrugresistant bacterial pathogens such as Acinetobacter and Pseudomonas spp. (grade 2B). For patients with severe infections associated with respiratory failure and septic shock, combination therapy with an extended spectrum beta-lactam and either an aminoglycoside or a fluoroquinolone is for P. aeruginosa bacteremia (grade 2B). A combination of beta-lactam and macrolide for patients with septic shock from bacteremic Streptococcus pneumoniae infections (grade 2B). Empiric combination therapy should not be administered for more than 3–5 days. De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known (grade 2B).
5. Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have a slow clinical response, undrainable foci of infection, bacteremia with S. aureus; some fungal and viral infections or immunologic deficiencies, including neutropenia (grade 2C).
6. Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin (grade 2C).
7. Antimicrobial agents should not be used in patients with severe inflammatory states determined to be of noninfectious cause (UG).

E. Source Control

1. A specific anatomical diagnosis of infection requiring consideration for emergent source control be sought and diagnosed or excluded as rapidly as possible, and intervention be undertaken for source control within the first 12 hr after the diagnosis is made, if feasible (grade 1C).
2. When infected peripancreatic necrosis is identified as a potential source of infection, definitive intervention is best delayed until adequate demarcation of viable and nonviable tissues has occurred (grade 2B).
3. When source control in a severely septic patient is required, the effective intervention associated with the least physiologic insult should be used (eg, percutaneous rather than surgical drainage of an abscess) (UG).
4. If intravascular access devices are a possible source of severe sepsis or septic shock, they should be removed promptly after other vascular access has been established (UG).

F. Infection Prevention

1. Selective oral decontamination and selective digestive decontamination should be introduced and investigated as a method to reduce the incidence of ventilator-associated pneumonia; This infection control measure can then be instituted in health care settings and regions where this methodology is found to be effective (grade 2B).
2. Oral chlorhexidine gluconate be used as a form of oropharyngeal decontamination to reduce the risk of ventilator-associated pneumonia in ICU patients with severe sepsis (grade 2B).

G. Fluid Therapy of Severe Sepsis

1. Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B).
2. Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock (grade 1B).
3. Albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (grade 2C).
4. Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion with suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (a portion of this may be albumin equivalent). More rapid administration and greater amounts of fluid may be needed in some patients (grade 1C).
5. Fluid challenge technique be applied wherein fluid administration is continued as long as there is hemodynamic improvement either based on dynamic (eg, change in pulse pressure, stroke volume variation) or static (eg, arterial pressure, heart rate) variables (UG).

H. Vasopressors

1. Vasopressor therapy initially to target a mean arterial pressure (MAP) of 65 mm Hg (grade 1C).
2. Norepinephrine as the first choice vasopressor (grade 1B).
3. Epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain adequate blood pressure (grade 2B).
4. Vasopressin 0.03 units/minute can be added to norepinephrine (NE) with intent of either raising MAP or decreasing NE dosage (UG).
5. Low dose vasopressin is not recommended as the single initial vasopressor for treatment of sepsis-induced hypotension and vasopressin doses higher than 0.03–0.04 units/minute should be reserved for salvage therapy (failure to achieve adequate MAP with other vasopressor agents) (UG).
6. Dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia) (grade 2C).
7. Phenylephrine is not recommended in the treatment of septic shock except in circumstances where (a) norepinephrine is associated with serious arrhythmias, (b) cardiac output is known to be high and blood pressure persistently low or (c) as salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target (grade 1C).
8. Low-dose dopamine should not be used for renal protection (grade 1A).
9. All patients requiring vasopressors have an arterial catheter placed as soon as practical if resources are available (UG).

I. Inotropic Therapy

1. A trial of dobutamine infusion up to 20 micrograms/kg/min be administered or added to vasopressor (if in use) in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP (grade 1C).
2. Not using a strategy to increase cardiac index to predetermined supranormal levels (grade 1B).

J. Corticosteroids

1. Not using intravenous hydrocortisone to treat adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (see goals for Initial Resuscitation). In case this is not achievable, we suggest intravenous hydrocortisone alone at a dose of 200 mg per day (grade 2C).
2. Not using the ACTH stimulation test to identify adults with septic shock who should receive hydrocortisone (grade 2B).
3. In treated patients hydrocortisone tapered when vasopressors are no longer required (grade 2D).
4. Corticosteroids not be administered for the treatment of sepsis in the absence of shock (grade 1D).
5. When hydrocortisone is given, use continuous flow (grade 2D).

K. Blood Product Administration

1. Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart disease, we recommend that red blood cell transfusion occur only when hemoglobin concentration decreases to <7.0 g/dL to target a hemoglobin concentration of 7.0 –9.0 g/dL in adults (grade 1B).
2. Not using erythropoietin as a specific treatment of anemia associated with severe sepsis (grade 1B).
3. Fresh frozen plasma not be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures (grade 2D).
4. Not using antithrombin for the treatment of severe sepsis and septic shock (grade 1B).
5. In patients with severe sepsis, administer platelets prophylactically when counts are <10,000/mm3 (10 x 109/L) in the absence of apparent bleeding. We suggest prophylactic platelet transfusion when counts are < 20,000/mm3 (20 x 109/L) if the patient has a significant risk of bleeding. Higher platelet counts (≥50,000/mm3 [50 x 109/L]) are advised for active bleeding, surgery, or invasive procedures (grade 2D).

L. Immunoglobulins

1. Not using intravenous immunoglobulins in adult patients with severe sepsis or septic shock (grade 2B).

M. Selenium

1. Not using intravenous selenium for the treatment of severe sepsis (grade 2C).

N. History of Recommendations Regarding Use of Recombinant Activated Protein C (rhAPC)

A history of the evolution of SSC recommendations as to rhAPC (no longer available) is provided.

O. Mechanical Ventilation of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)

1. Target a tidal volume of 6 mL/kg predicted body weight in patients with sepsis-induced ARDS (grade 1A vs. 12 mL/kg).
2. Plateau pressures be measured in patients with ARDS and initial upper limit goal for plateau pressures in a passively inflated lung be ≤30 cm H2O (grade 1B).
3. Positive end-expiratory pressure (PEEP) be applied to avoid alveolar collapse at end expiration (atelectotrauma) (grade 1B).
4. Strategies based on higher rather than lower levels of PEEP be used for patients with sepsis- induced moderate or severe ARDS (grade 2C).
5. Recruitment maneuvers be used in sepsis patients with severe refractory hypoxemia (grade 2C).
6. Prone positioning be used in sepsis-induced ARDS patients with a Pao2/Fio2 ratio ≤ 100 mm Hg in facilities that have experience with such practices (grade 2B).
7. That mechanically ventilated sepsis patients be maintained with the head of the bed elevated to 30–45 degrees to limit aspiration risk and to prevent the development of ventilator-associated pneumonia (grade 1B).
8. That noninvasive mask ventilation (NIV) be used in that minority of sepsis-induced ARDS patients in whom the benefits of NIV have been carefully considered and are thought to outweigh the risks (grade 2B).
9. That a weaning protocol be in place and that mechanically ventilated patients with severe sepsis undergo spontaneous breathing trials regularly to evaluate the ability to discontinue mechanical ventilation when they satisfy the following criteria: a) arousable; b) hemodynamically stable (without vasopressor agents); c) no new potentially serious conditions; d) low ventilatory and end-expiratory pressure requirements; and e) low Fio2 requirements which can be met safely delivered with a face mask or nasal cannula. If the spontaneous breathing trial is successful, consideration should be given for extubation (grade 1A).
10. Against the routine use of the pulmonary artery catheter for patients with sepsis-induced ARDS (grade 1A).
11. A conservative rather than liberal fluid strategy for patients with established sepsis-induced ARDS who do not have evidence of tissue hypoperfusion (grade 1C).
12. In the absence of specific indications such as bronchospasm, not using beta 2-agonists for treatment of sepsis-induced ARDS (grade 1B).

P. Sedation, Analgesia, and Neuromuscular Blockade in Sepsis

1. Continuous or intermittent sedation be minimized in mechanically ventilated sepsis patients, targeting specific titration endpoints (grade 1B).
2. Neuromuscular blocking agents (NMBAs) be avoided if possible in the septic patient without ARDS due to the risk of prolonged neuromuscular blockade following discontinuation. If NMBAs must be maintained, either intermittent bolus as required or continuous infusion with train-of-four monitoring of the depth of blockade should be used (grade 1C).
3. A short course of NMBA of not greater than 48 hours for patients with early sepsis-induced ARDS and a Pao2/Fio2 < 150 mm Hg (grade 2C).

Q. Glucose Control

1. A protocolized approach to blood glucose management in ICU patients with severe sepsis commencing insulin dosing when 2 consecutive blood glucose levels are >180 mg/dL. This protocolized approach should target an upper blood glucose ≤180 mg/dL rather than an upper target blood glucose ≤ 110 mg/dL (grade 1A).
2. Blood glucose values be monitored every 1–2 hrs until glucose values and insulin infusion rates are stable and then every 4 hrs thereafter (grade 1C).
3. Glucose levels obtained with point-of-care testing of capillary blood be interpreted with caution, as such measurements may not accurately estimate arterial blood or plasma glucose values (UG).

R. Renal Replacement Therapy

1. Continuous renal replacement therapies and intermittent hemodialysis are equivalent in patients with severe sepsis and acute renal failure (grade 2B).
2. Use continuous therapies to facilitate management of fluid balance in hemodynamically unstable septic patients (grade 2D).

S. Bicarbonate Therapy

1. Not using sodium bicarbonate therapy for the purpose of improving hemodynamics or reducing vasopressor requirements in patients with hypoperfusion-induced lactic acidemia with pH ≥7.15 (grade 2B).

T. Deep Vein Thrombosis Prophylaxis

1. Patients with severe sepsis receive daily pharmacoprophylaxis against venous thromboembolism (VTE) (grade 1B). This should be accomplished with daily subcutaneous low-molecular weight heparin (LMWH) (grade 1B versus twice daily UFH, grade 2C versus three times daily UFH). If creatinine clearance is <30 mL/min, use dalteparin (grade 1A) or another form of LMWH that has a low degree of renal metabolism (grade 2C) or UFH (grade 1A).
2. Patients with severe sepsis be treated with a combination of pharmacologic therapy and intermittent pneumatic compression devices whenever possible (grade 2C).
3. Septic patients who have a contraindication for heparin use (eg, thrombocytopenia, severe coagulopathy, active bleeding, recent intracerebral hemorrhage) not receive pharmacoprophylaxis (grade 1B), but receive mechanical prophylactic treatment, such as graduated compression stockings or intermittent compression devices (grade 2C), unless contraindicated. When the risk decreases start pharmacoprophylaxis (grade 2C).

U. Stress Ulcer Prophylaxis

1. Stress ulcer prophylaxis using H2 blocker or proton pump inhibitor be given to patients with severe sepsis/septic shock who have bleeding risk factors (grade 1B).
2. When stress ulcer prophylaxis is used, proton pump inhibitors rather than H2RA (grade 2D)
3. Patients without risk factors do not receive prophylaxis (grade 2B).

V. Nutrition

1. Administer oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hours after a diagnosis of severe sepsis/septic shock (grade 2C).
2. Avoid mandatory full caloric feeding in the first week but rather suggest low dose feeding (eg, up to 500 calories per day), advancing only as tolerated (grade 2B).
3. Use intravenous glucose and enteral nutrition rather than total parenteral nutrition (TPN) alone or parenteral nutrition in conjunction with enteral feeding in the first 7 days after a diagnosis of severe sepsis/septic shock (grade 2B).
4. Use nutrition with no specific immunomodulating supplementation rather than nutrition providing specific immunomodulating supplementation in patients with severe sepsis (grade 2C).

W. Setting Goals of Care

1. Discuss goals of care and prognosis with patients and families (grade 1B).
2. Incorporate goals of care into treatment and end-of-life care planning, utilizing palliative care principles where appropriate (grade 1B).
3. Address goals of care as early as feasible, but no later than within 72 hours of ICU admission (grade 2C).

What is EMCrit Drinking?

Cascade Brewing’s Kriek Ale

Now on to the Podcast…

The post Episode 10 – Surviving Sepsis Campaign (SSC) Guidelines 2012 appeared first on Practical Evidence.

Screening for by cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma 73:(5) Supplement 4, S301-S306, 2012.

Michael McGonigal has a great summary of the BCI guidelines on his Trauma Professional’s Blog

The post Episode 9 – Blunt Cardiac Injury from EAST appeared first on Practical Evidence.

Should we be prescribing opioids from the ED? This question is explored in the recent ACEP Clinical Policy on ED Opioid Prescriptions.

The post Episode 8 – ACEP Opioid Prescription Policy appeared first on Practical Evidence.

The difference between screening, rule-out, and risk prediction criteria.

The post Episode 7 – Rule-Out Criteria and Screening appeared first on Practical Evidence.

From American College of Chest Physicians

Antithrombotic Therapy and Prevention of Thrombosis, 9th ed Guidelines

Chest 2012;141:7S-47S (Executive Summary)

For outpatient treatment, start 10 mg daily for the first 2 days followed by INR measurements

Give 1 day of LMWH or UFH before initiation, if treating VTE

If the patient is on VKAs, avoid NSAIDs and certain ABX (table 8 from full guidelines)

Avoid anti-plt agents unless clinical condition warrants

Normal goal is 2-3, including antiphospholipid

No need to taper when d/cing

Heparin - 80/18 for VTE, 70/15 for cardiac or stroke patients

For outpatients with VTE treated with SC UFH, they suggest weight-adjusted dosing (first dose 333 units/kg, then 250 units/kg) without monitoring rather than fixed or weight-adjusted dosing with monitoring

High INRs

4.5-10, no bleeding: no vitamin K necessary

> 10, no bleeding: Oral Vitamin K

If anticoagulant related major bleeding: 4-factor PCC and Vitamin K Slow IV Injection

See Michelle Lin's Paucis Verbis on the same

Critically Ill Patients

Recommend against routine screening

Use LMWH or LDUH in all patients unless contra-indicated

For travelers at risk of VTE, use graded compression stockings; do not prescribe aspirin or anticoagulants

Diagnosis of DVT

Low Risk

moderate sens d-dimer, high sens d-dimer, or CUS of proximal veins only. D-dimers are preferred

If d-dimer is positive, get Compression Ultrasound (CUS) of proximal veins

Moderate Risk

Use High sens d-dimer, CUS of prox, or CUS of whole leg

Can stop if high-sens D-dimer is negative

If no d-dimer or d-dimer postive, need a second CUS 1 week later if only prox CUS done

If whole leg CUS is negative, you are done

High Risk

Prox CUS or Whole Leg CUS

If prox CUS and d-dimer negative as well, done

If d-dimer positive or only prox CUS, get 1 week f/u CUS

If whole leg CUS is negative, you are done

Recurrent

In patients with past DVT, recommend high-sens d-dimer, if positive get Prox CUS and 1 week Prox CUS

If negative, get just one Prox CUS

If the old CUS is not available, confirm with venography if positive CUS

Upper Ext

Go right to Doppler CUS for upper extremity dvt suspicion

Treatment of DVT

Start with IV or SQ UFH, LMWH, or fondaparinux (Latter two preferred)

If high pretest, start heparin immediately; If moderate, start heparin only if diagnostic tests are expected to be > 4 hours delayed

Isolated distal DVT-serial CUS rather than treatment unless severe symptoms or risk factors for extension (see full text)

Ambulate DVTs, no bed rest

In patients with hypotension (SBP) < 90 and PE, give systemic thrombolytics (through peripheral, rather than PA cath)

Atrial Fib

Chads 0 - nothing

Chads 1/2 - VKA/oral anti-coag; Dabi is preferred

If a-fib > 48 hours; give 3 weeks of VKA/dabi before cardioversion. Or get TEE with LMWH. Follow with 1 month of Vka/oral anti-coag

If a-fib < 48 hours; Start LMWH and then VKA for 4 weeks

If hemodynamically unstable, treat with anticoagulation ASAP preferably before cardioversion and then continue for 4 weeks

Treat a-flutter like a-fib for all of the above

Stroke

If hemorrhagic, can start heparin between days 2-4, LMWH preferred

What is EMCrit Drinking?

A White IPA-Boulevard # 2

The post Episode 6 – ACCP Antithrombotics and VTE Guidelines appeared first on Practical Evidence.

National Institute for Health and Clinical Excellence:

Acute upper GI bleeding: NICE guideline
http://guidance.nice.org.uk/CG141/NICEGuidance/pdf/English

Great Britain's National Health Service has a group called the National Institute for Health and Clinical Excellence (NICE); this group has recently put out guidelines for the management of Upper GI Bleeds. Thanks to my friend, Cliff Reid, for bringing these guidelines to my attention.

The Guidelines

Before endoscopy, calculate a Blatchford Score consider discharge if the score is zero.

After endoscopy, calculate a Rockall Score, this helps determine disposition

Transfuse massively bleeding patients as per local protocols, realizing that both under- and over-transfusion are bad

Do not give platelets if the patient is not bleeding. If they are bleeding, give plts for count < 50,000.

Offer FFP to pts with fibrinogen < 1 g/L or INR > 1.5

Use PCC for patients taking warfarin and are actively bleeding

Do not use Factor VIIa until other methods have failed

Offer endoscopy for severe acute bleeding immediately after resuscitation

Do not offer PPI to patients with non-variceal upper GI bleeding unless endoscopy reveals an ulcer

Offer them if the patient has stigmata of recent hemorrhage on endoscopy

If patient still bleeding after intial endocscopy or rebleeds after repeat endoscopy, go to IR, then to surgery

In variceal bleed, they recommend terlipressin until definitive haemostasis or for 5 days

GIVE PROPH ABX for suspected variceal bleeds

Go to TIPS if endoscopic treatment is unsuccessful

What is EMCrit drinking?

Rodenbach, an amazing Flemish Sour Ale

Now on to the Podcast...

The post Episode 5 – Upper GI Bleed Guidelines appeared first on Practical Evidence.

The Recs:

1. Use Hunt & Hess or WFN Scores
2. Risk of early rebleeding is high - be quick and decisive in getting the aneurysm secured
3. Still recommending LP if negative CT
4. Get CTA if CT or LP is positive
5. MRI may be useful if negative CT, but if negative you still need a LP
6. Keep SBP < 160 until clip/coil
7. If delay until clip/coil, use aminocaproic acid or TXA
8. Give nimodipine to prevent delayed cerebral ischemia
9. Need CSF drainage if acute, symptomatic hydrocephalus
10. Consider anti-convulsants in acute SAH management
11. Use isotonic fluids, keep fluid balance positive
12. Keep patient Normothermic
13. Control Hyperglycemia

from:
Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage
doi: 10.1161/?STR.0b013e3182587839

What is EMCrit drinking?

An insanely good aged sour ale: Rodenbach 2009 Vintage

The post Episode 4 – Subarachnoid Hemorrhage Guidelines appeared first on Practical Evidence.

The original ACEP guidelines can be found here.

This table from (Annals of Emergency Medicine  Volume 58, Issue 1, July 2011, Pages 12-20) shows the IUPs eventually discovered on f/u vs. what was seen in the ED at various thresholds of bHCGs.

 What is EMCrit drinking?

Rare Vos by Omegang

Now on to the Podcast:

The post Episode 3 - ACEP 2012 Management of Early Pregnancy appeared first on Practical Evidence.

Welcome to the second episode of Practical Evidence, a podcast about the evidence you NEED to know but may not have time to read.

This month we discuss the American College of Emergency Physicians' Pulmonary Embolism Clinical Policy(2011)

What's EMCrit Drinking?

This month, I'm drinking a Dreamweaver by Troeg Brewery

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The post Episode 2 - ACEP 2011 Clinical Policy on Pulmonary Embolism (PE) appeared first on Practical Evidence.

Welcome to the first episode of Practical Evidence, a podcast about the evidence you NEED to know but may not have time to read.

This month we discuss the Eastern Association for the Surgery of Trauma's (EAST) guidelines on the management of penetrating trauma.

What's EMCrit Drinking?

This month, I'm drinking a Mary's Maple Porter from Brooklyn Brewery

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Please check out our bandwidth sponsor EB Medicine for great offers exclusively for our listeners.

The post Episode 1 - Penetrating Neck Trauma Guidelines appeared first on Practical Evidence.