06.14.13
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tPA Equally (In)Effective for Wake-Up Stroke


This is a, yet another, study in Stroke of folks claiming it is "safe" to use thrombolysis on patients who are found to have suffered a stroke while sleeping – the so-called "wake-up stroke" population.

The specific claim made is "This retrospective analysis of data in thrombolysed consecutive acute ischemic stroke patients shows no significant differences in mortality, functional outcomes, or bleeding rates between WUIS patients with no early ischemic change on CT and those treated within 4.5 hours of stroke onset."

...because their sample size is so small the absolute differences are still within the statistical variation expected by chance.  This is, unfortunately, a recurring theme I see in these stroke publications, many of which are retrospective registry reviews.  Their groups are statistically not different, but this is owing to failed statistical power in study design, as opposed to clinically meaningful equivalence.  This is a major difference between retrospective and prospective studies – in which prospective studies choose specific absolute differences necessary to define clinically meaningful equivalence, and then perform power and sample size calculations based on these constraints.

Their outcomes are, incidentally, also simply terrible.  They publish a figure comparing outcomes with their wake-up stroke population to their 0-4.5 hour thrombolysis reference group – a 326 patient reference group with 18% mRS 0-1 and a 26% mortality.  But then, they further break out the 197 patients from that group that received tPA within the ECASS III license criteria, showing that compliance with guidelines leads to 32% mRS 0-1 and 18% mortality.  This therefore implies the other 129 patients – the ones who received tPA outside the license criteria – had utterly dismal functional outcomes and frighteningly high mortality.

Someone needs to go down to King's College and check up on them and make sure all this off-label use isn't just costly killing fields.

"A Case-Controlled Comparison of Thrombolysis Outcomes Between Wake-Up and Known Time of Onset Ischemic Stroke Patients"
http://www.ncbi.nlm.nih.gov/pubmed/23723307
06.14.13
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Wann ein 12-Kanal EKG

Die Leitlinien der deutschen und auch europäischen kardiologischen Gesellschaften schlagen vor, dass Patienten mit Risiko für einen ST-Elevationsinfarkt innerhalb von 10min nach Eintreffen in einer Notaufnahme ein 12-Kanal EKG bekommen. Aber wer sind nun diese Patienten?

Üblicherweise wird vorgeschlagen, dass Patienten mit “Chest Pain”  innerhalb von 10 min das angeforderte EKG erhalten. Gleichzeitig wissen wir, dass bis zu 40% der Patienten mit Infarkt keine Thoraxschmerzen haben. Zusammenfassend möchten wir als ein Entscheidungskriterium bei der Triage in der Notaufnahme, wer das EKG nun tatsächlich sofort erhalten soll. Kennen Sie eine Lösung?

Hierzu gibt es ein spannendes Paper aus der Zeitschrift Crit Pathw Cardiol 2012. Sind nun die “Graff Kriterien” oder die “Glickman Kriterien” besser? Von 430 Herzkatheterlabor Aktivierungen wurden 418 Patienten durch die Graff Kriterien korrekt erkannt, die Anwendung der Glickman Kriterien identifiziert 2 weitere Patienten, ist aber deutlich weniger spezifisch. Die Autoren folgern deshalb daraus, dass auch zukünftig die Graff Kriterien bei der ZNA Triage verwendet werden sollen, um Patienten zu benennen, welche sofort ein 12-Kanal EKG erhalten sollen. Die Autoren folgern, dass weiterhin die Graff Kriterien verwendet werden sollen, um mit wenig Aufwand auf dem Boden von Hauptbeschwerden bei der Vorstellung die Patienten zu identifizieren, die sofort ein 12-Kanal (oder besser ein 15-Kanal EKG!!!!) erhalten sollten.

Deshalb noch kurz eine Zusammenfassung der Graff-Kriterien:

Patienten älter wie 30 Jahre:  

  • Leitsymptom “Chest Pain”

Patienten älter als 50 Jahre:

  • Leitsymptom “Chest Pain”
  • Leitsymptom “Synkope bzw. Beinahe-Synkope”
  • Leitsymptom “allgemeine Schwäche”
  • Leitsymptom “Palpitation bzw. schneller Herzschlag”
  • Leitsymptom “akute Atemnot bzw. Schwierigkeiten beim Atmen”

 

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Thematisch passende Beiträge

06.14.13
by

Make Your Audience the Hero

One of the biggest mistakes lecturers make is failing to connect with their audience.  Last week’s post on the “Dr. Fox Effect” generated a bit of controversy about whether or not presentation style can affect the audience’s ability to learn from the teacher.  While this certainly can be debated, one thing we do know is that emotion has a strong influence on learning and memory.1

Building an emotional connection is one of the most effective methods to keep an audience’s attention and persuade them that what you are teaching is important. One way to build this connection is by viewing your audience as a hero and incorporating the power of story into your lectures.

The classic hero’s journey involves:

  1. The Current State – represented by the current state of the world, and what the audience already knows and believes.
  2. The Journey – Represented by the internal conflict an audience will experience as they are taught something new, which may make them feel uncomfortable.
  3. The Resolution – The final destination that is reached as the audience accepts the teacher’s perspective and adopts it as their own.

In medical lectures, persuading an audience of physicians to change their behavior can prove to be challenging.  The teacher can expect an audience to be skeptical at first and initially unwilling to change – because the lesson will require the audience to let go of personal beliefs of what has been taught to be true for years.  But the facts stated within a lecture can be brought to life by regularly incorporating story and anecdote that support the teacher’s position.

Miyagi & Daniel

A common mistake made by educators is that they view themselves as the hero, and that their teaching will save an audience from everything they don’t know. Whether you are in the classroom or in the lecture hall, the role of the teacher is NOT to be the hero. The teacher must embrace the role of a mentor. You are not Daniel Larusso, you are Mr. Miyagi.

A mentor is selfless and has a primary goal of making sure the student succeeds. A good lecturer should embrace a stance of humility and place the interests of the learner first.  Their goal should be to act as a facilitator and guide the audience along their personal journey of change. Think of this as audience-centered teaching.  Take your audience on the Hero’s Journey – and they will not only remember your presentation, but will be able to take the tools you have provided them back to the bedside, and ultimately save a life.

Mr. Miyagi says:  “No such thing as bad student, only bad teacher”

Reference & Additional Reading

  • LaBar KS, Cabeza R. Cognitive neuroscience of emotional memory. Nat Rev Neurosci. 2006 Jan; 7(1):54-64.
  • Duarte, Nancy. Resonate: Present Visual Stories That Transform Audiences. Hoboken, NJ: Wiley, 2010.

Check out the Resonate Multi-Touch iBook, definitely a great read with lots of included multimedia.  https://itunes.apple.com/us/book/resonate/id517154732?mt=11#

The post Make Your Audience the Hero appeared first on iTeachEM.

06.14.13
by

JC: Time is brain…., calling #FOAMagitators. St.Emlyn’s

St Emlyns - Meducation in Virchester #FOAM

Streamlining of prehospital stroke management: the golden hour.

If you have been happily playing with #FOAM for the last year or two then you must have come across the many excellent articles on the use of thrombolysis in stroke.

Ed – what do you mean you’ve missed the debate!!

Seriously? Well I suppose it’s possible that you may have missed the superb contributions that have exposed the questions and concerns about the efficacy and fair reporting of trials looking at stroke thrombolysis. If you’ve missed the debate then I would strongly recommend that you have a look at the following…

There are many more out there and if you want to hear a fantastic review of all this then keep your eyes out for Domnhall’s talk from SMACC2013 when it is released. That was a fantastic summary and I hope it will make an appearance soon.

So, why am I talking about this if there has already been many questions in the #FOAM community already? Well, the Lancet has released a new article in the online first section that makes claims and suggests therapies that I would love my esteemed colleagues to review. The paper looks at streamlining prehospital care to deliver patients with stroke to a centre available to deliver thrombolysis as quickly as possible. This is analogous to the changes we have seen around cardiac care to deliver patients to thrombolysis, and no PCI as quickly as possible. In this study the argument for rapid transfer is predicated on the assumptions that thrombolysis is ‘state of the art’ and that the NNT for a positive outcome is 4.5 if thrombolysis is administered within 1.5 hours (NNT of 9 if 1.5-3 hours post symptom onset).

Now, just to redress the balance a little then you might also want to whizz over to EMCrit and listen to Scott’s podcast on the optimisation of processes for the delivery of stroke thrombolysis in hospital. To be fair Scott does not personally endorse it, but does say that if your institution decides to do this then do it well, and this is a way of delivering a slick door to needle time.

Does this matter? Well arguably yes. The proposals set out in the paper will require investment in time and money, and at a time of austerity we really do need to make sure that our health pounds are spent wisely.

So, if this area interests you then please do have a read, and if you feel the need it’s worth mentioning  that the Lancet has a quite vigorous correspondence section………

lancet stroke paper

 

 

 

 

 

 

 

 

Simon Carley

 

 

The post JC: Time is brain…., calling #FOAMagitators. St.Emlyn’s appeared first on St Emlyns.

06.14.13
by

SHOULD MEDICAL STUDENTS LEARN INTUBATION?? PHARM POLL SURVEY

Medical students being taught intubation by James DuCanto

Medical students being taught intubation by James DuCanto

First for background, here is a few minutes of reading from a Twitter debate

[View the story "Should medical students learn intubation ? " on Storify]

Now you can help settle the debate by giving us your opinion!

Click here to take survey


Filed under: airway, FOAMEd, Online critical airway training Tagged: intubation, medical, PHARM, poll, students
06.14.13
by

ECG of the Week – 17th June 2013

This ECG is from a 62 yr old male c/o chest pain for 2 hours




Click to enlarge

VAQ Corner

An 62 year old male presents to your urban district Emergency Department.
He c/o 2 hours of central chest pain.
Pst Hx hypertension & smoking.
BP 134/72 RR 21 Sats 98% RA T 36.4
His ECG is above.

a) Describe & interpret his ECG ? (100%)
06.13.13
by

Dr Brian Rowe on Getting Your Article Published

Screen Shot 2013-06-12 at 11.29.43 AM

I believe that Dr Rowe is pound-for-pound the best EM researcher in Canada. He completed the majority of  his research on a shoe-string budget while managing a formidable career. Now the  Associate Dean of Research at the University of Alberta, a Canadian Tier 1 Research Chair and former Senior Associate Editor CJEM, he came to share his experience as a clinical researcher. Through his familiar blue slides and jocular presentation style Brian dropped some important pearls about how to get published.

Brian’s published a book, 28 book chapters and over 385 peer-reviewed manuscripts. It goes without saying he has a wealth of experience that, he humbly admits, came with many failures along the way. He stressed perseverance and an ethical duty to publish as ultimately we’re doing it for the patients’ benefit.

The Decision to publish:

Why it’s important in EM

  1. Small studies in small centres is what the big studies are built on
  2. We need our own body of knowledge. Many of the questions that we need to answer cannot be answered by looking at our consultants’ practice
  3. There exists a significant Publication bias in EM [that needs to be corrected]
  • only 51% of RCT’s actually get published. In other fields only 44% get published after the abstract presented at a conference [Cochrane]. [In Aus this is 35%. In the UK - 57%]
  • positive results get published sooner and more frequently
  • main reasons Why? [Hartling et.al 2004]
    • Not enough time [56%]
    • Trouble with coauthors [28%]
    • Journal unlikely to accept [26%]

PUBLICATION BIAS INFLUENCES SYSTEMATIC REVIEWS and Systematic Reviews INFLUENCE PATIENT CARE

from http://doylepartners.com/

from http://doylepartners.com/

 Guidelines/Cochrane etc all base their advice on what’s out there. Ultimately the truth may not be revealed if we don’t publish – especially if the results are negative.

Sir Ian Chalmers ” It is unethical to conduct research and NOT to publish it”

Okay I’ve got you thinking that you actually want to conduct research. How do you go about it?

Brian’s Ten Steps to Getting Published:

Step #1:You Can’t Beat Quality

  • As clinicians, Brian suggests we always frame our questions in the PICO-D format (Population, Intervention, Control, Outcomes, Design)
  • If you are brave enough to tackle an RCT or Systematic Review, you need to follow the existing guidelines and frameworks:

Step # 2: Deciding on a Project

  • Passion:
    • You need to chose something that you’re passionate about. This will ensure that the project thrives to completion
  • Use Power of solid Planning:
    • If you have an idea, you probably aren’t the first.  Share your idea with colleagues, do extensive literature searches and read related articles.
    • Find similar papers or methodologies to give you methods ideas.
    • Make sure that your study will add something to our understanding of that particular disease or dilemma.
  • Question the conventional wisdom:
    • Look for ideas that are likely to result in counter-intuitive findings – These papers are novel for editors and are much likely to be picked up.

 Step #3: Get Some Friends

  • Collaborate with various co-investigators – the collaborations will enhance your project and make it more enjoyable:
    • Librarians will ‘help you avoid repetition and give you a sample of your competition’
    • Statisticians will help with methods, sample sizes and data analysis
    • Methodologists will help with methods and choosing the right outcome measurement(s)
    • Study coordinators have experience in the practical realities of data collection and timelines
    • Clinicians will give your project relevance -  ‘what is you paper going to add to our understanding of x?’
  • You might not have these people within your Division or Department, but you probably do at your institution (e.g., hospital, university, regional health authority).  A great team will make sure you have a great product.
  • Make sure to give them credit – acknowledge them with acknowledgements or [if they've done enough work] – with authorship.

“Every paper has a home. It’s your job to find the that home” Dr Brian Rowe

 Step #4: Have a research Philosophy

  • Every paper has a home. It’s your job to find the that home
  • Aim high – you’ll be surprised to see what happens [Brian shared an anecdote about getting rejected by one journal only to get accepted by a major one!]
  • Always match the topic to the Journal – use your Reference section. The journal you cite the most should be your first choice.

 Rule #5: Prepare a solid Manuscript

  • Editors are busy, and have a lot of papers to review – make their life easy.
  • Adhere to the “Instructions for authors”!
  • Use Reference Management Software [ I like Endnote]
  • Always get input from other authors [especially experienced writers]
  • Write succinctly and pay attention to spelling, grammar and language
  • Common Methods mistakes:
    • Poor Methodology
    • Not fully describing methods so that they may be replicated
  • Common Results Mistakes:
    • Stating, ‘there was a trend’ with a non-significant p-value.  Nobody cares about non-significant results
    • Not reporting all of the results in the results section.  New results should not show up in the discussion section
  • Statistics should be clean.
    • Justify sample sizes with power calculations, report p-values and confidence intervals.  Make sure you perform the appropriate analysis
  • Cover Letter:
    • Polite, concise.
    • Provide a compelling reason why they should pick your study

    Y0UR M1ND 15 R34D1NG 7H15 4U70M471C4LLY W17H0U7 3V3N 7H1NK1NG 4B0U7 17

Rule # 6: Write like Pro

  • If you suck at writing – Get training!
    • Use a template if you have to
  • Start writing the minute you have the idea
    • You can write most of it without any data
    • Writing early can help anticipate problems with the methods
  • Title and Abstract:
    • The title and abstract are far more important than authors recognize.
    • The title should be catchy and tell a bit of story
    • The introduction should be brief, and the last sentence should clearly outline the study objectives
    • The abstract should end with a finding, not just ‘more research needed’
  • Methods:
    • As mentioned above – use reporting guidelines for methods
  • Discussion:
    • Focus on the main finding:
      • Explain why it is an important finding
      • how does your finding relate to literature
    • Acknowledge your limitations:
      • but justify why your paper is still important despite them
      • DO NOT try to hide your paper’s limitations
  • Editing:
    • Don’t go over the word limit.  [Watson & Crick's paper on the double helix in the 1950's was 2 pages]
    • Have your co-authors review it and get input from other experienced authors
    • Take the time to sit and edit, don’t rush it. [I find it useful to read the entire document backwards so that you're mind isn't filling in the blanks]
    • Revise, revise, and re-revise

      ‘A good paper is like fine wine…it needs to age and mature a bit.’  Anonymous

Rule #7: Know how to Appease Decision Editors

Editors often make decisions about your paper in less than 5 minutes.  You can appease them by:

  • RIOT Criteria: Make sure that your work is …
  1. Relevant to readers
  2. Important or Interesting
  3. Original
  4. True – good methodology and plausibility of results
  • “Revise and Submit”
    • If they say “revise and re-submit” you’re ‘probably in’.
      • Do what they suggest [if reasonable]
      • Do it quickly
      • Respond specifically to every comment, and thank them for their helpful comments.

If you simply cannot do revisions required [for example if it would compromise the intended objective] – try another journal. Make sure to use the comments that they gave you in the next submission.

“I’ve been rejected more times than a pimple-ridden teenager” Brian Rowe

Rule #8 Approaches to rejection

In the world of journal submissions, rejections are common.  You are not alone.  High quality journals like CMAJ only accepts 5-7% of submitted manuscripts [NEJM 2%]

  • Try and have a thick skin. Don’t take it personally
  • Don’t give up.  [really important]
  • Take a break, and then use the criticisms to make your paper better

Rule #9 Learn along the way

  • Serve as a reviewer
    • First and foremost, it’s your duty to contribute to our profession.
    • Second, you’ll learn a ton about what constitutes a good paper.
    • Third, you may be asked to write an editorial (which is a publication).
  • Becoming a good researcher – just like a good presenter – takes time. Work at it. Write write write [get feedback from colleagues]

 Step #10: Build your success:

  • Savour your success – you’ve done what 99% don’t achieve. You’ve contributed to better care for patients.
  • Look for opportunities to publish more. Answer a “Call for Authors” from Journals as they as seldom turn you down.
  • Provide mentorship to someone who is trying to publish.
  • Collaborate with others [use national conferences to network and offer to participate as a local site] – you don’t have to be First author all the time!

I’d like to acknowledge my friend and brilliant colleague Rob Woods for his edits. As always, comments are welcome.

The post Dr Brian Rowe on Getting Your Article Published appeared first on ERMentor.

06.13.13
by

Hyperkalemia and ST Segment Elevation, Post 1


A male in his 60's presented with weakness.  Here is his initial ECG.  He had no chest pain:

Probable junctional rhythm, with wide QRS (162 ms) and peaked T-waves.  Obvious hyperkalemia.  But there is also ST elevation in III and aVF, with reciprocal ST depression in I and aVL, and ST depression in V2 and V3.  Is there also an infero-posterior STEMI?

The K returned at 9.4 mEq/L.  He was treated with 5 g of calcium gluconate, 20 units of insulin and 100 ml of 50% dextrose.  Here is the second ECG 60 minutes later, with a concurrent K of 9.0 mEq/L:
Sinus rhythm with a normal QRS at 94 ms, with hardly any change in the serum potassium.  All the difference is in calcium administration.  The ST elevation is gone.

The troponin was normal.  All ST elevation was due to hyperkalemia.




A woman in her 40's was found down:

Sinus rhythm with wide QRS at 133 ms and obvious Peaked T-waves with obvious hyperkalemia.  But there is also significant ST elevation in V1-V3.  Is there anterior STEMI?


The K = 8.1.

After treatment with 3 g of calcium gluconate, 10 units of insulin, and 50mL of 8.4% bicarbonate (at 100 minutes), the K was measured again and was 6.5 mEq/L and this ECG was recorded:
QRS = 88 ms and ST elevation is now normal, not excessive.   

 The troponin was normal.


Lesson:

Hyperkalemia can cause ST segment shifts that mimic STEMI.  Here is a post with two more cases.  



My next post will be a similar dramatic presentation in which the diagnosis is a mystery.
06.13.13
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Rapid correction of severe acute hypernatremia caused by soy sauce ingestion

kikkomans3.5 out of 5 stars

Survival of Acute Hypernatremia Due to Massive Soy Sauce Ingestion. Carlberg DJ et al. J Emerg Med 2013 Jun1 [Epub ahead of print]

Abstract

This fascinating case report from the University of Virginia Medical Center describes a 19-year-old male who — apparently on a dare — ingested a quart of soy sauce (17-18% sodium chloride).

When brought to the emergency department 2 hours later he unresponsive (GCS = 3) and had possible seizure activity. His pulse rate was 147 bpm. Head CT was unremarkable. Labs were significant for a sodium of 177 mmol/L and glucose of 384 mg/dL. Four-and-a-half hours after ingestion his sodium was 191 mmol/L.

At that point, the treating physicians reasoned that since a sodium level this high has been strongly associated with fatality and the development of hypernatremia in this case was quite rapid, it would be reasonable to correct the electrolyte abnormality quickly.

The patient received 6 liters of 5% dextrose (D5W) over 30 minutes, followed by free water at a slower rate. His mental status gradually improved, and 32 hours after ingestion his sodium level was 145 mmol/L. At follow-up one month after the admission his mental status was reported as normal and he was “performing well on college examinations.”

The authors state that, to their knowledge, the corrected sodium level of 196 mmol/L is the highest ever reported from acute salt ingestion in a patient who survived.

Chronic hypernatremia should be corrected slowly, since the brain adapts over time to a high sodium level by producing idiogenic osmoles. In this situation, reversing hypernatremia too rapidly can cause cerebral edema, seizures, or herniation. In the case reported here, the sodium level increased so acutely there was no time for this adaptive mechanism to occur.

There are many videos on YouTube of adolescents and young adults taking the so-called “soy sauce challenge.” This seems even less wise than enduring the “cinnamon challenge,” which TPR has reported on before.

Tip o’ the hat to @ToxTalk, who alerted me to this article.

 

 

06.13.13
by

The Lactate “Debate” with Dr Seth Trueger

Gday,

I was lucky enough to record a new podcast with Dr Seth Trueger – inspired by the recent online discussions around lactate, or more specifically lactate-clearance as a marker, or a goal of therapy in the treatment of septic patients.

This is a topic my team will be covering at the ACEM Winter Symposium here in Broome this weekend.  It has been a weird preparation for our discussion in front of a whole bunch of ED Specialists – everytime I sit down to plan the talk I see another FOAMed resource or opinion which changes the landscape.

This podcast needs a bit of background in order for the whole conversation to make a bit of sense.

Lactate Clearance has been around for 10 years or so as a therapeutic goal – or at least of a marker of “winning” when we are resuscitating septic patients.

Nguyen, Rivers and co popularised lactate clearance as a marker of improvement in 2004 – a few years after the original EGDT trials by Rivers.

Then in 2009 Jones et al did a comparison between SvcO2 and lactate as markers to guide therapy in sepsis resuscitation – they showed they both worked equally as well.  Jones et al showed it was “non-inferior” to SvCO2 to guide resuscitation.

Then in March this year Prof. Paul Marik and Dr Renaldo Bellomo wrote a review article titled “Lactate clearance as a target of therapy in sepsis: a flawed paradigm.”  In this paper they utilise a lot of pathophysiology and common sense to show why the traditional concept of lactate as a marker of anaerobic metabolism was a flawed concept.

This provoked a short sharp retort from Dr Scott Weingart on his Emcrit podcast (much shorter than our longish dissection!)  Have a listen to his thoughts then carry on to our discussion.

I was supposed to be taking the position that lactate clearance is a flawed concept – and Seth was taking the pro stance.  But we pretty much ended up agreeing on everything!

OK.  Onto the podcast.  Love to hear you comments  Play below or DOWNLOAD Direct here

Casey

06.13.13
by

TechTool Thursday 031

TechTool review of CT Scanning in Critical and Emergency Care by Frasford Pty Ltd on iPad   

Website: – iTunes - Website

CT Scanning in Critical and Emergency Care aims to teach ED health professionals to better understand CT scans and pick up common abnormalities.  It contains tutorials that work through CT interpretation cases

Design and User Interface

The app looks great and is so simple and pleasant to use.  The screens are all clear and the actual scan graphics and accompanying audio are faultless.  What more could you ask for?

ipad1

ipad2

ipad3

[DDET CT Scanning on iPad 4]

ipad4

[/DDET]

Clinical Content

There is a lot of great educational content in here.  There are over 60 cases which include a clinical scenario and a CT scan.  For each case, you can:

  • Read the case history
  • Look through the scan series
  • Listen to an audio track explaining the findings (with clear directions on where on the scans the abnormalities are)
  • Read through a text based tutorial on understanding the scan and related common abnormal findings

Cost

  • $9.49 – it’s not cheap for an app but it does have a decent volume of content

Room for Improvement

  • Getting it on the iPhone would be a great asset
  • It’s a bit heavy on the self-promotion – all the buttons on the bottom take you to more of their products.  It’s like being beaten over the head with a promotional baseball bat.  A simple ‘About Us’ page would do the job
  • Some paediatric CTs would have made me a very happy Paeds ED trainee

Overall

  • I really enjoyed using this app and it has advanced my adult CT interpretation ability by leaps and bounds.
  • It’s an excellent way of providing CT education, and has common ED presentations that ED docs should be expected to recognise.
  • A great use of mobile app technology to deliver effective medical education

The post TechTool Thursday 031 appeared first on Life in the Fast Lane medical education blog.

06.13.13
by

Briefs: Special K is not just for breakfast

Simultaneously in your ED you encounter;

  • A 2 year old male with a complex facial laceration
  • A 9 year old female gymnast you decided to do a back handspring, and in the process fractured her right radius and ulna
  • A 4 year old boy with a screw embedded in his left foot

 

You have fentanyl, midazolam and ketamine in your pharmacy. Propofol is nowhere to be found. Of the three drugs, which would you use, all by itself, to provide procedural sedation for these patients?

  • Which do I choose?

    Ketamine

Ketamine is an excellent choice for moderate/procedural  sedation in the pediatric ED because it has a short durtauion of action, fast onset and low risk of side effects. Its street drug cousin is PCP – but I don’t usually see kids ripping the doors off of cop cars after getting it. The drug is either effective, or it isn’t and via the binding of MDMA receptors it produces a “lights are on but nobody’s home” or trance-like state. It provides;

  • Sedation
  • Analgesia
  • Amnesia

 

It doesn’t mess with;

  • Upper airway muscle tone and protective reflexes
  • Breathing

 

The initial IV dose is 1 to 1.5 mg/kg.with repeat doses of  0.5 to 1 mg/kg given q5-10 minutes as needed. If you are also giving Propofol, you can give 0.5 mg/kg. The IM dose is 4 to 5 mg/kg with a repeated IM dose of 2 to 4 mg/kg after 10 minutes if needed. IM dosing takes longer and has a higher risk of side effects, so I prefer IV. More on that later.

Upon administration, which is generally given over 2 minutes,  you will see;

  • Effect/onset withn 60 seconds after initial dose is fully given and IV is flushed
  • Onset 3-4 minutes after IM dose administration
  • Staring off into the distance
  • Horizontal nystagmus
  • Increased salivation
  • Incoherent rambling/moaning
  • Mild increase in blood pressure

The duration of action of a single IV dose is 5-10 minutes, whereas IM doses can last 30 minutes on average.

Adverse Effects

Overall the risk of adverse effects is low (<4%) and may be associated with age <2 years of >13 years, initial dose in excess of 2.5mg/kg, total dose >5mg/kg and coadmihstration with midazolam, atropine/glycopyrrolate. The three most common are;

Vomiting

This is the most common, and is the basis for making sure that patients are NPO for at least a little bit. The issue of how long to fast before ED procedures is complicated – and I’ll address it in a future post. But suffice it to say I believe that 2 hours after clears, and 4 hours after solids is fine – though others may disagree. IM increases the risk 26% vs 12% according to a RCT by Roback et al. Alhough I don’t always give it, studies have shown that premedication with ondansetron reduces the risk of vomiting with a number needed to treat of 13. The overall frequency is roughly 8% and peaks around age 12.

Hallucinations

More common in children older than 15, and in those with a prior history of psychosis. Severe cases can resemble Godzilla rising from the ocean. MIdazolam does not decrease the risk of emergence reactions, and may increase the risk of other side effects. Therefore I do not routinely administer it with my patients, unless I have exceeded 4mg/kg of ketamine.

Apnea or laryngospasm

Very rare (1/5,000-10,000) and responds to positive pressure ventilartion with a bag valve mask, as the pressure will “pop” open the vocal cords. This appears to be an idiosynchratic reaction. With effective PPV it generally resolves in 1-2 minutes. In a single observational study the IM route was associated with an increased risk of laryngospasm OR 5.2; 95% CI 2.3-11.9. The aforementioned study by Roback did not show a significant difference in the rates of laryngospasm however.

Contraindications

  • Younger than 3 months
  • History of psychosis
  • Closed head injury
  • Conditions associated with elevated intracranial pressure (hydrocephalus)
  • Glaucoma or other conditions associated with increased intraocular pressure an/or eye injuries – though at most the pressure increases only 1 mmHg

The post Briefs: Special K is not just for breakfast appeared first on PEM Blog.

06.13.13
by

Ist der Arzt ein Schriftsteller?

Das ist natürlich eine komische Frage. Ich glaube, man kann sicherlich sagen, dass man von einem Arzt keine schriftstellerischen Fähigkeiten erwartet. Man erwartet aber, dass Textstücke, Bestätigungen und natürlich auch Arztbriefe grammatikalisch einwandfrei und konzise geschrieben sind. Dass sie inhaltlich natürlich auch korrekt sein müssen, versteht sich von selbst. Und dann gibt es ja noch die “Beschwerdeschreiben” und natürlich auch noch die Kommunikationen innerhalb des Kollegenkreises.Vielleicht sollten Sie sich verinnerlichen, dass jedes verfasste Schriftsstück ein “Spiegel” des eigenen ichs ist. Und so findet auch eine Beurteilung von anderen statt.

Wer wissenschaftlich aktiv sein will bzw. seine Doktorarbeit (oder sogar Habilschrift) verfassen will, für den ist es umso wichtiger, ein paar Leitsätze zu kennen, wie ein Text zu erstellen ist. Und das ist zu erlernen und eigentlich keine Hexerei.

Wie schaut es in der Realität aus? Nun …. will dazu nicht viel sagen. Vielleicht nur die kurze Bemerkung: Es gibt immer Möglichkeiten, den eigenen Stil zu verbessern.

In der “Die Zeit” war vor nicht allzu langer Zeit ein von Autoren zusammengestellte “Stilkunde” im Deutschen. Ich finde diese Artikel sehr sehr gut und auf den Punkt geschrieben. Nehmen Sie sich doch mal Zeit, Ihre eigenen Textentwürfe “laut” vorzulesen …. es hilft! Also, viel Spass dabei ;-)

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06.13.13
by

NADİR BİR GÖĞÜS AĞRISI VAKASI

Bilindiği gibi acil servis hekimleri hastalardaki semptomları değerlendirirken öncelikle en kötü ve en acil olan seçenekleri eleyerek işe başlar. Örneğin göğüs ağrısı, bir acil hekimi için ekarte edilene kadar enfarktüs, aort diseksiyonu, pnömotoraks ve benzeri mortal tanılardır. Bu tanıları ekarte ederken bir takım algoritmalar kullanılır. Bugün sizinle paylaşacağım vakayı ise itiraf etmeliyim ki bu algoritmalar içine oturtamadım. Bazı soruların aklıma takılması üzerine kısa bir literatür taraması yapıp sonuçları sizlerle paylaşmak istedim.

VAKA

 

28 yaşında erkek hasta acil servise göğüs ağrısı ile başvuruyor. Yaklaşık olarak on gündür retrosternal bölgede huzursuz edici bir ağrı anlatıyor. Ağrıyı azaltan artıran bir şey yok. Kardiyak risk faktörleri yok. Nefes darlığı şikayeti yok. Son iki gündür acil servis başvurusu olan hastaya miyalji tanısı konulmuş ve iki gündür ağrı kesici kullanıyor.

Tansiyon basıncı 110/80 mmHg Nb: 100/dk SO2 : %99 SS: 20/dk Ateş:37,1oC. Fizik muayenede patolojik bulgu saptanmadı. Çekilen EKG’si tamamen normal olan hastanın kardiyak değerleri de normal sınırlarda geldi. Wells skoru düşük olan hastanın D-dimer’i normal olarak geldi. Çekilen akciğer grafisi normaldi.

Bu noktadan sonra hastaya toraks tomografisi çekildi. (Açıkça söylemeliyim ki gözden kaçabilecek küçük bir spontan pnömotoraks haricinde belirli bir ön tanım yoktu. Bu vakada hastanın ısrarlı başvurusu olmasa tomografi çekmeyebilirdim.)

Hastanın Tomografisi

SPM-2SPM-1

Not: Büyütmek için BT görüntüsünü tıklayın

Hastada spontan pnömomediastinum (SPM) tanısı konulması üzerine göğüs cerrahisine yatırıldı. 5 gün oral beslenmesi kesilen ve yatak istirahatına alınan hastanın şikayetlerinin gerilemesi üzerine taburculuğu yapıldı.

1-      Böyle bir hastada çok kolaylıkla non-spesifik göğüs ağrısı tanısı konulabilir. Bir acil hekimi hangi durumlarda SPM ön tanısı düşünüp toraks tomografisi istemelidir?

2-      Bu hastalara tanı konulamazsa ciddi bir mortalite ve morbitide ile karşılaşılır mı?

Tetikleyebilecek herhangi bir hastalığı olmayan kişilerde mediastinumda serbest hava görünmesi olarak tanımlanan SPM ilk kez 1939 yılında Hamman tarafından tanımlanmış.(1) (Kendi ismiyle anılan bulgusu da var. Hamman bulgusu:  Kalp oskültasyonunda  kalp atımlarıyla beraber duyulan çıtırtı-krepitasyon sesi.) Literatürde yakın yıllarda birisi 2007 yılında diğeri ise 2012 yılında yayınlanan iki tane SPM olgularından oluşan vaka serileri yayınlanmış.

Macia ve arkadaşlarının 2007 yılında yayınladığı retrospektif çalışmada 1990 ve 2006 yılında başvuran 41 SPM’li hasta incelenmiş. Vakaların %82,9 erkek iken %17,1’i bayan hastaymış. %85’inde göğüs ağrısı semptomu mevcutken %49’unda nefes darlığı %44’ünde boyun ağrısı mevcutmuş. Yine boyun bölgesinde cilt altı amfizem %66 vakada mevcutken sadece %29 hastada göğüs duvarı üzerinde cilt altı amfizem saptanmış. %12 hastada Hamman bulgusu mevcutmuş. Önemli bir veri ise hastaların %78’ine semptomları ve akciğer grafisi ile tanı konulabilmiş. Diğer 7 hastaya ise toraks BT ile tanı konulmuş. Hastaların %41,7’sinde lökositoz saptanmış.(2)

Tüm vakalar hastaneye yatırılmış. %85,4’üne analjezi verilirken %68,3’üne yatak istirahatı %29,3’üne ise oksijen desteği sağlanmış. Ek olarak 10 hastaya bronkodilatör tedavi verilirken 5 vakaya antibiyotik tedavisi eklenmiş. Hiçbir hastada ciddi bir komplikasyon gelişmemiş.(2)

Dr. Ji-Yoon Ryoo ise 1999 ile 2012 yıllarında başvuran 32 SPM olgusunu retrospektif olarak inceleyip 2012 yılında yayınlamış. Vakaların %78,1 erkek hastayken %21,9’u bayan hastaymış. Sadece hastaların %6’sı 30 yaş üstüymüş. Bu seride de %51,2 ile göğüs ağrısı en sık semptom iken boyun ağrısı %23,3 ile en sık ikinci semptom, %14 ile nefes darlığı ise üçüncü sık semptom olarak belirtilmiş. 32 vakanın 27’sine (%84,3’ü yazar yüzdeliği kendi belirtmemiş) sadece akciğer grafisi ile tanı konulurken geri kalan hastalara boyun grafisi ve toraks BT ile tanı konulmuş. 14 hastanın (%43) lökositozu mevcutken bunların sadece 4 tanesi 15.000/μL değerinin üzerinde saptanmış.(3)

25 vaka hastaneye yatırılırken yatak istirahatı ve oksijen desteği sağlanmış. Paralitik ileus gelişen tek hastada intravenöz sıvı desteği sağlanmış. Antibiyotik tedavisi uygulanmamış. Ciddi bir komplikasyon bildirilmemiş.(3)

 

ÖNEMLİ NOT: Bu noktadan sonra yazılanlar yukarıdaki makaleler ışığında yazarın sesli düşüncüleridir. Herhangi bir bağlayıcılığı yoktur. Yazar yorumlarınızı beklemektedir.

 

Bu veriler ışığında aslında SPM vakalarının çoğunun dikkatli bir muayene ve basit akciğer grafisiyle tanı alabileceğini görüyoruz. Tanı alamayan ama klinik bulgulardan özellikle boyun ağrısı ve cilt altı krepitasyonu olan hastalarda tomografi ile SPM tanısının üstüne gidilebileceği görülmekte. Yukarıda sunulan hastada olduğu gibi sadece göğüs ağrısı olan bir hastada ise bu tanının kolaylıkla atlanabileceğini düşünmekteyim. Ancak atlanılması durumunda bile yukarıdaki olgu serilerinin sonlanmaları düşünüldüğünde ciddi bir mortalite ya da morbitide ile karşılaşılmayacağı görülmektedir.

Kaynakça;

1. Hamman L. Spontaneous mediastinal emphysema. Bull Johns Hopkins Hosp 1939;64:1-21.

2. Macia I, Moya J, Ramos R, Morera R, Escobar I, Saumench J, et al. Spontaneous pneumomediastinum: 41 cases. Eur J Cardiothorac Surg 2007;31:1110-4.

3. Ryoo JY. Clinical analysis of spontaneous pneumomediastinum. Tuberc Respir Dis (Seoul). 2012 Sep;73(3):169-73. Epub 2012 Sep 28.

Dr.Şeref Kerem ÇORBACIOĞLU

Diğer Yazılar

  • Travmada direk grafi mi? Pan-CT mi?29/05/2013 -- Travmada direk grafi mi? Pan-CT mi? (0)
      Son iki ay içerisinde karşıma çıkan iki vaka multitravma hastalarında PAN-CT (Tüm Vücut Tomografisi) uygulaması üzerine biraz düşünmeme ve yakın yılları kapsayan kısa bir literatür ta...
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    Acilde trombolitik tedavi uyguluyor musunuz? Akut koroner sendromda koroner yoğun bakıma hastayı yatırıyorsunuz ve orada uygulanıyor, iskemik inmede nörologları zorluyorsunuz ve birkaç hastaya zorl...
  • Resüsitasyon Odasında BT24/01/2013 -- Resüsitasyon Odasında BT (0)
    Resüsitasyon odasında bulunması gerekenlere ek “Bilgisayarlı Tomografi” Hepinizin malumu Acil Servislerde hayat kurtarıcı girişimlerin yapıldığı, gerçek acillere en faydalı olduğumuz alandır resüs...
  • Etomidat efsanesi bitti mi?04/02/2013 -- Etomidat efsanesi bitti mi? (0)
    Bugün biraz etomidattan bahsedeceğiz. Etomidat, hızlı ardışık entübasyon kavramıyla karşılaşmamı takiben en sık kullandığım sedatif ilaçlardan biriydi. Bu yazıyı yazma nedenlerimden biri de aslında...

Author information

Şeref Kerem Çorbacıoğlu
Şeref Kerem Çorbacıoğlu
Yazar ; Görev Yeri: Antakya DH
Antakya Devlet Hastanesi'nde 2012'den beri acil tıp uzmanı olarak çalışmaktadır. Bulunduğu hastane ve o bölgenin güncel durumdan dolayı travma konularında ayrıca ilgili ve tecrübeli olup aslen Acil tıbbın her alanına ayırt etmeksizin ilgi duymaktadır. Acilci.net'in büyüyen yazar kadrosuna güç katan yazarlarımızdandır.
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The post NADİR BİR GÖĞÜS AĞRISI VAKASI appeared first on acilci.net.

06.13.13
by

Mattu: AV Bloklar – Türkçe Altyazılı (27 Mayıs 2013)

Altyazılar: Dr. Can Özen & Video İşleme ve Yayın: Dr. Haldun Akoğlu

Amal Mattu; Maryland Üniversitesi Acil Tıp AD Profesörü, Emergency Medicine Clinics of North America Editörü, EKG gurusu ve sayısız Acil Tıp kitabının yazar ve editörüdür. #FOAMed hareketini daha adı konmadan Joe Lex ile beraber başlatan kişilerden biri, bir Acil Tıp fenomenidir. Haftalık EKG vaka serilerini vodcast olarak yıllardır yayınlamaktadır. Bu serileri acilci.net üzerinden paylaşmakta olup yakında Türkçe altyazılarıyla sizlerle birlikte olacaktır. Acilci.Net Uluslararası Editöryal Danışma Kurulu Üyesidir.

Author information

Haldun Akoğlu
Acilci.Net Kurucusu ve Sahibi ; Görev Yeri: Marmara Üniversitesi
Marmara Üniversitesi'nde Öğretim Üyesi olarak çalışmaktadır. Türkiye Acil Tıp Dergisi Editör Yardımcısı ve Sosyal Medya sorumlusudur. İnternet, istatistik, tüplü dalış, fringe, castle, nikonD90 ve civilization5 oyunu özel ilgi alanları içerisindedir. Uluslararası FOAMed internet eğitimi devrimi saflarına Twitter ile katılan ilk Türk'tür. Türkçe, İnternet üzerinden Bilimsel, Açık Erişimli, Acil Tıp Eğitimini Güvenilir ve Editörlü bir siteden yayınlama fikriyle Twitter üzerinde #FOAMedTr hashtagini yaratarak paylaşımlara başlamıştır. Yeni isimleri acilci.net kervanına katmaktan doymak bilmeyen büyük haz duymaktadır.
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The post Mattu: AV Bloklar – Türkçe Altyazılı (27 Mayıs 2013) appeared first on acilci.net.

06.13.13
by

Bedside Critical Care 2013

A quick heads up about this year’s not-for-profit Bedside Critical Care conference in Cairns.

Last year’s conference was great — I got to invite people to come join the FOAM party using one of my favourite medical stories (together with plenty of slides of phallic vegetables, of course), as well have give a heap of tox talks and workshops over 5 days. Sadly, I won’t be there this year, but there will be even better people there instead!

This is what is happening in Cairns, north Queensland from September 23rd to 27th 2014 at Shangri La on the marina:

  • high impact clinical update talks are mixed with hands on, interactive clinical workshops
  • day 1 is a free registrars’ day — trainees would be stupid not to go!
  • it is the most family friendly academic meeting there is, it doesn’t use up a weekend, the days are short (so you’ll actually have a chance to remember stuff!) and it is during the school holidays

This year’s themes include:

  • Critical Care Radiology
  • Simulation
  • Resuscitation
  • Airway Emergencies
  • Advanced Hemodynamic Monitoring & support
  • Renal Replacement Therapy
  • Ultrasound / Echo
  • Microbiology

Check out the program here, it is packed with good stuff. Register here. The whole thing is organised by my SMACC co-conspirator Roger Harris and backed up by the IntensivecareNetwork.com. If you’re planning to go, remember to book early so you don’t miss out accommodation during the holidays.

Have fun getting meducated!

The post Bedside Critical Care 2013 appeared first on Life in the Fast Lane medical education blog.

06.12.13
by

Bedside Critical Care 2013

BCC4 back

The Critical Care Conference with a difference is back and is booking up fast!

Why should you go?

  • Strong critical care academic program
  • Short, digestable clinical updates on topics that are genuinely relevant
  • Small group workshops on practical skills you want and need to practice
  • Incredible venue on the marina in Cairns
  • During school holidays, perfect for the familiy, and not eating up another weekend
  • Social program and optional activities like no other conference
  • FREE registrar day on the Monday - LIMITED places though!

REGISTER NOW

06.12.13
by

Capnografia e sedazione procedurale

E’ mattina, e al cambio turno ci viene detto” c’è poi il sig Alberto, è stato fatto tornare oggi per una fibrillazione atriale insorta ieri mattina, purtroppo è ancora in FA e penso che dovrai procedere con la cardioversione elettrica…” Uno degli specializzandi, da poco arrivato in pronto soccorso,  argomenta:” cosa usate per il monitoraggio [...]

The post Capnografia e sedazione procedurale appeared first on EM Pills.

06.12.13
by

This is NOT Gambling Advice

Subtitle: "Why You Can Stop a Trial Early for Harm but not Benefit"

This builds on a recent Twitter discussion with Jeremy Faust, David Marcus, and CKB.

It sounds odd when you first hear about it, but EBM experts say that you should stop a study if it shows sufficient harm early on, but stopping a study early because it showed great results is shady.

Why? Well, it's tough to explain, so here's an analogy I came up with*:
Stopping a trial early for benefit is like winning money gambling at a casino. If you've ever won money, why aren't you there right now, winning more?
Take any of the big games where you play against the House: slot machines, blackjack, or craps. I like craps -- it's fun, when you win everybody wins (except the one guy sitting next to the dealer betting wrong), and I hear that it's the best odds in a casino, other than counting cards at blackjack or cheating.

Now I know that the odds are stacked against me. The House has an edge, something like 51%. As the cliche goes, casinos are not built for me to make money.

But I know that the 51% House advantage is an average over time -- there are fluctuations around it. I saw a great video comparing it to walking a dog on a leash: the person walks in a straight line (overall trend) but the dog walks a little this way and a little that way (variation) but overall still follows the same path.** I'm hoping to catch a little variation in my favor, and quit playing before the game regresses back to the mean. And so is the drug company.

I know that overall, I am more likely to lose than win (the drug doesn't work). Now if I win some money in the first hour or two (early benefit) I know it's probably a fluke and not loaded dice (drug that ). I can take my money and walk away (stop trial) or I can keep playing. If I stopped with a few extra dollars in my pocket, would I conclude that I can win at craps (blockbuster drug!)? No -- I know that I just caught a little variation in the overall pattern, but in the long run, craps will cost me money.

What about if I lose money (harm)? Maybe I can win it back, should I keep playing? The problem is that eventually, if I keep losing money (drug doesn't work), large men will come after my family (drug is really harmful), and I don't want that.
Do not want.

Of course, in a clinical trial, we don't actually know whether or not the therapy works. Clinical trials start from a position of equipoise: we don't think the drug is harmful, but it might benefit patients, and the risk of harm vs risk of benefit is balanced. But if we show harm early, we lose that equipoise, and we have stop the trial before we harm the study subjects too much (before burly men show up at my house), knowing that we may have given up on a worthwhile drug but that it was just too risky. While it seems that the two are symmetric, beneficence vs maleficence is not a symmetric equation.

Are there times when we should stop a trial early for a huge, obvious benefit? I think so, but only if the study is adequately powered at that point, which it's very unlikely to be, because studies are designed to be powered at the end of the study, not midway through.

Back to the casino: if I walk into a casino, drop a quarter into a slot machine, and on my first try win $1 million, would I conclude that the machine is a winner? What if I win $10,000 on 3 of my first 5? It would take a combination of a big enough benefit over a big enough sample to demonstrate the power needed to end the study early, and that is rare.

At what point do I decide that the machine might be mis-calibrated (the drug works), and I should tell my parents to cash out their 401k and spend it all playing on this machine before the casino catches on (FDA approval)?


*I would guess that others have had the same idea before, like Newton & Leibniz simultaneously discovering the calculus, and the creation of the term "FOAMites"

**I tried and failed to find the video. Sorry. 
06.12.13
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The 7th DutchNorthSea Emergency Medicine Conference

 Vorige week was het weer zover, het jaarlijkse NVSHA congres in Egmond aan Zee. Zoals altijd was het weer erg gezellig en leerzaam om de collega SEH-artsen uit Nederland te ontmoeten. De kwaliteit van het congres wordt echt met het jaar beter en dat is een compliment aan de congrescommissie! De CAT walk en abstracts […]
06.12.13
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Özhasenekler: ATLS 9. baskı çıktı

Değerli arkadaşımız Dr. Ayhan Özhasenekler yeni bir şeyler okumuş, acilci.net takipçileri ile paylaşmak istemiş, bize de buyursunlar demek düşer. İyi okumalar…

Yusuf Ali Altuncı

Travma sezonu açıldı! Bu iş sezonluk mu demeyin, ülkemiz genelinde trafik kazalarının ön planda olduğu bahar ve yaz ayları herkesin bildiği gibi travma sezonudur. Bölgemizde özellikle yüksekten düşme ve ateşli silah yaralanmaları da trafik kazaları ile aynı klasmanda fakat farklı kulvarlarda yarış halindeler. Her yılın sonunda birinci değişebiliyor, fakat genel gözlemimiz at başı yarışta oldukları…

Hazır sezon açılmışken, bir de IX. Ulusal Acil Tıp Kongresinde (ATUDER 2013) “Sistem Travmalarında Güncellemeler” adlı nazik bir sunu daveti geldi. Konu travma olunca en önemli kaynağın ATLS (Advanced Trauma Life Support) olabileceğini düşündüm. Araştırmaya başladım ve The ATLS Subcommittee, American College of Surgeons’ Committee on Trauma and the International ATLS working group tarafından özel rapor olarak kaleme alınan “Advanced trauma life support (ATLS®): The ninth edition” adlı yazıya J Trauma Acute Care Surg dergisinde rastladım. Herkes hatırlar; ATLS en son 2008 yılında 8. baskı olarak güncellenmişti. Yukarıda adı geçen makalede; ATLS 9. baskının 2012 yılı Ekim ayında güncellendiğini ve bu baskıdaki değişiklikleri gördüm.

ATLS 9. baskıdaki yeni güncellemelerde özellikle üç değişiklik dikkatimi çekti;

1. Havayolu bölümünde; video laringoskopinin, potansiyel olarak zor hava yolu olan hastalarda yardımcı olarak kullanılabileceği kanıt düzeyi 1-3 olarak,

2. Pediatrik havayolu bölümünde; <1 yaş altı infantlar dışındaki tüm çocuklarda kaflı endotrakeal tüplerin kullanılması gerektiği kanıt düzeyi 1-2 olarak,

3. Başlangıç değerlendirilmesi ve şok bölümlerinde; agresif resüsitasyon teriminin kaldırıldığı, kanama kontrol altına alınmadan önce ılımlı hipotansiyonu içeren dengeli resüsitasyon yapılmasının daha doğru olacağı ve bununla ilişkili olarak şok durumunda başlangıçta verilen 2 lt kristaloid yerine 1 lt kristaloid verilmesi gerektiği, tahmini kan kaybının önemli miktarda olduğu veya masif transfüzyon gerektiren hastalarda trombosit ve plazma solüsyonlarının (herhangi bir oranı zorunlu kılmayan) erken dönemde kullanılması gerektiği kanıt düzeyi 1-4 olarak belirtiliyordu.

 

Yazıda ayrıca ATLS kursu içerisindeki sorular ile senaryolarda yapılan değişikliklerden söz edilmekte ve “myATLS” adlı uygulamanın da akıllı telefonlarınıza indire bileceğinizden bahsedilmekte

Demiştim ya sezon açıldı! Bu değişikliklerden haberdar olmak ve yeni sezona bu değişikliklerle girmek biz Acil Tıpçıların asil görevi.
Paylaşmak istedim, travmasız günler diliyorum…
Bilgiyi paylaşmak dileğiyle….

Daha fazlası için;
Advanced trauma life support (ATLS®): the ninth edition. ATLS Subcommittee; American College of Surgeons’ Committee on Trauma; International ATLS working group J Trauma Acute Care Surg. 2013;74(5):1363-6.

Dr Ayhan ÖZHASENEKLER
Dicle Üniversitesi Tıp Fakültesi
Acil Tıp AD Öğretim Üyesi
ATU, Yrd Doç
Diyarbakır
drhasenek@hotmail.com

Diğer Yazılar

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06.12.13
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Date raping drugs – Facts und Fantasy

Notaufnahmen und auch Intensivstationen sind immer wieder mit bewusstlosen jungen Menschen konfrontiert, bei denen der Verdacht auf k.o. Tropfen Verabreichung diskutiert werden muss bzw. wird.

Wer kann sich nicht an eine vor vielen Jahren im Münchner “Donisl” Geschichte erinnern, bei der ein paar Kriminelle k.o. Tropfen ins Getränk gemischt haben und anschließend die “Gäste” ausgeraubt haben. Auch auch St. Pauli gibt es ähnliche Geschichten. Und diese Drogen stehen immer wieder in Verdacht, auch eingesetzt zu werden, um junge Frauen zu vergewaltigen. Insbesondere “liquid ecstasy” (gamma-Hydroxy Buttersäure) steht hier unter großem Verdacht. Aber ist dem wirklich so?

Liquid Ecstasy ist eine Substanz mit kurzer Halbwertszeit und somit schnellem Wirkeintritt und rascher Abflutung der Wirkung. Zunächst wirkt sie stimulierend, euphorisierend, öffnend und offensichtlich auch sexuell stimulierend. Bei höheren Dosierungen wird eine Sedierung erreicht bis zum Koma. Aufgrund der nur teilweise vorhandenen Analysemöglichkeiten (Gaschromatographie) und der kurzen Halbwertszeit wird diese Substanz nur selten toxikologisch erfasst. Aber wird sie tatsächlich zum “Date Raping” eingesetzt?

Nun, ich hätte vermutet: Ja, Klaro! Doch wenn man die Literatur durchschaut, ist man erstaunt. Meist wird Liquid Ecstasy selbst verabreicht, bei Date Raping spielt Alkohol und andere Drogen wie Cannabis oder Heroin die deutlich überwiegende Rolle. Kriminalstatistiken gehen von einer verschwindend geringen Anzahl von Patienten aus, die mittels k.o. Tropfen für sexuelle Vergehen gefügig gemacht werden. 

Im Deutschen Ärzteblatt ist 2009 ein äußerst interessanter Artikel zu dieser Problematik publiziert worden, und weitere Details ermöglicht auch der Blick in Wikipedia (Liquid Ecstasy, k.o. Tropfen).

Welche Aspekte müssen nun bei Patienten mit entsprechenden Symptomen berücksichtigt werden? Ich finde, dass die im Ärzteblatt publizierte Tabelle einen sehr guten Überblick gibt!

 

KO Tropfen

 

Und nicht vergessen: Die betroffenen Patienten sind vital gefährdet! Sicherung der Atemwege und enge Observation sind obligat!

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Thematisch passende Beiträge

06.12.13
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Beware Observational Conclusions


"High achieved SBP after standardized antihypertensive therapy in hyperacute intracerebral hemorrhage was independently associated with poor clinical outcomes. Aggressive antihypertensive treatment may ameliorate clinical outcomes."

Jerry Hoffman has mentioned the exercise to, while reading, expand any instance of the word "may" to "may or may not" – to help erase the positive bias of speculative conclusions.  And, this is one of those perfect circumstances where the lukewarm endorsement from this abstract conclusion ought to be predicated with a pound of cautionary conditionality.

These authors call their study SAMURAI-ICH, and it's a prospective, observational study regarding the safety of early blood pressure reduction in intracerebral hemorrhage.  What this really means is they thought aggressive BP lowering was going to be awesome – despite only having various bits of inconclusive evidence – so they made wholesale practice changes, and then started a registry to monitor outcomes.  So, you can see the bias already.

And, verily, there is an association between their ability to lower blood pressure in ICH and favorable outcomes.  Now, their "favorable outcomes" cohort was also young, less disabled at baseline, and had smaller ICH hematoma volume.  Through the magic of statistical models, they attempt to control for all the various prognostic catastrophes, and thusly they arrive at their significant association.

But, finally, this observation doesn't in the slightest explain whether the blood pressure control improved outcomes – or whether it was simply easier to lower blood pressure in patients whose cerebrovascular physiology was less deranged by smaller insults, and who went on to have good outcomes.  Aggressive antihypertensive treatment "may or may not" ameliorate clinical outcomes, indeed.

Beware observational conclusions!

"Systolic Blood Pressure After Intravenous Antihypertensive Treatment and Clinical Outcomes in Hyperacute Intracerebral Hemorrhage : The Stroke Acute Management With Urgent Risk-Factor Assessment and Improvement-Intracerebral Hemorrhage Study"
www.ncbi.nlm.nih.gov/pubmed/23704107

06.12.13
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PREGNANCY AND CARDIOPULMONARY ARREST

A bit of literature:   J.Soar et al, Resuscitation 81(2010)1400-1433   Resuscitation guidelines for pregnancy largely based on case series, extrapolation, manikin studies and expert opinion.   Maternal death associated with: -       cardiac disease -       pulmonary embolism -       psychiatric disorders -       hypertensive disorders of pregnancy -       sepsis -       haemorrhage -       amniotic-fluid embolism -       ectopic pregnancy […]
06.12.13
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Site internet sur les calculs rénaux

Capture d’écran 2013-06-12 à 07.56.03

Cliquer sur l’image pour accéder au site internet ou sur la vidéo pour la faire démarrer

Voici un excellent site internet sur les calculs rénaux (en anglais) , d’où j’ai tiré cette vidéo. On vous explique les différents types de calculs rénaux, les symptômes, les causes et on vous donne des recommandations diététiques. Tout est en anglais, désolé…

Comme il est dit dans l’introduction, le calcul rénal est une affection douloureuse et fréquente qui touche plus de 5% de tous les adultes aux USA. On estime que près de 2  millions de personnes consultent leur médecin ou les urgences pour un calcul rénal chaque année.

Si vous avez vécu un épisode de calcul rénal, vous savez à quel point c’est désagréable et douloureux. Il est donc important de comprendre non seulement comment les calculs se forment, mais aussi ce que vous pouvez faire pour prévenir la formation de nouveaux calculs. Les calculs rénaux ont un taux élevé de récidive. Quelqu’un ayant fait un calcul a un risque de 30 à 50% d’un refaire un dans les 5 prochaines années.

Il faut suivre les recommandations de votre médecin, qui s’adaptent au type de calcul que vous avez fait (il en existe 5 types). Ce site internet – en anglais – vous donne quelques conseils simples et pratiques.

Voir aussi

Anomalies biologiques retrouvées lors d’un bilan de lithiase urinaire

Calcul rénal d’oxalate de calcium

Guide pour la prophylaxie de la lithiase urinaire

Source

http://www.stonedisease.org

http://www.kidney.org/atoz/content/kidneystones.cfm


StoneDisease.org
06.12.13
by

ECG of the Week – 10th June 2013 – Interpretation


This ECG is from an 84 year old male.
Presents complaining of general lethargy, nausea, several episodes of diarrhea, and dizziness.
Past history of atrial fibrillation, diabetes, and hypertension.
Medications include aspirin, ACE inhibitor, statin, sulphonylurea, and digoxin.
He is conscious, vague but orientated, and his BP is 112 systolic.


Click to enlarge
Rate:
  • 36
Rhythm:
  • Regular
  • Nil p waves visualised
Axis:
  • RAD (~160 deg)
Intervals:
  • PR - nil p waves
  • QRS - Prolonged (120-130ms)
  • QT - 550ms
Segments:

  • Wandering baseline makes assessment difficult
    • ? Minor ST depression III, aVF, V5-6

Additional:

  • U waves 
    • Best visualised lead II
    • Secondary to digoxin toxicity

Interpretation:
  • "Regularised AF"
    • Escape rhythm - likely junctional as QRS morphology similar post Tx
    • Atrial fibrillation
    • 3rd Degree AV block
  • Conduction delay

What happened ?

Our patient is on digoxin with clinical features that whilst non-specific are often associated with chronic digoxin toxicity. As the comments section suggests digoxin toxicity should rate high on our list of likely diagnosis with associated electrolyte abnormalities.

Urgent electrolytes and digoxin levels were performed and this patient had a digoxin level of 5.4 ng/ml and a potassium > 9.0 !

He was treated with digoxin immune Fab, following which a repeat ECG was performed.


Click to enlarge
The ECG following treatment shows rate controlled atrial fibrillation (~66bpm), normalisation of QRS width (80-100ms), and decreased prominence of the U waves.

Chronic Digoxin Toxicity

Digoxin toxicity seems to have featured heavily in the FOAM world this last month. 
Two highlights are:



You can read more about the general management of digoxin toxicity in the following resources:
I like to just focus on ECGs with this blog but I thought we'd just touch on one of the  unique features of chronic digoxin toxicity which is hyperkalaemia and "stone heart".

Hyperkalaemia, digoxin toxicity, and calcium therapy - 'Stone Heart'

Stone heart refers to life-threatening cardiac tetany due to the use of i.v. calcium to treat hyperkalaemia in the setting of digoxin toxicity. 
The theory being:

  • Digoxin works by inhibiting cardiac sodium-potassium ATPase pump
  • This increases intracellular sodium and calcium in the cardiac myocyte
  • Increased intracellular calcium = increased contractility and automaticity
  • In toxic setting more calcium = cardiac tetany = irreversible contraction = death

First line treatment in chronic digoxin toxicity is Digoxin Immune Fab, a recommended empirical dose is 2 ampoules if features of toxicity, and 5 ampoules in the setting of cardiac arrest in which chronic digoxin toxicity is suspected. In the absence of Fab or as adjuncts to treat hyperkalaemia options include sodium bicarb, insulin / dextrose, and magnesium sulphate.

The Toxicology Handbook, which is a must own textbook for anyone doing Emergency Medicine and certainly the most useful EM book I own, states calcium is contraindicated in treating hyperkalaemia in the setting of digoxin toxicity. This is echoed by a number of other sources such as, this letter in the EMJ, and the eMedicine review of the emergency management of digoxin toxicity. 

There is certainly an amount of debate as to the existence of the 'Stone Heart' and the danger of using calcium in the setting of digoxin related hyperkalaemia. I'm not going to go through this here as a number of other people have covered the topic more eloquently than I could, I will just link to some further readings below:


References / Further Reading

Life in the Fast Lane
  • ECG in Digoxin Toxicity here
  • Digoxin Toxicity Overview here
Textbook