Lab Case 34

A 35 year old female presents to your Emergency department with vaginal bleeding and low abdominal pain. Her last normal menstrual period was 6 weeks ago. She is prone to recurrent vaginal spotting. She looks anxious and distressed. Vitals: BP … Continue reading

EM Physicians Can Accurately Measure Systolic Function… Well Not Really

A guest post by Dr. Andrew Kirkpatrick (@AskEMdoc), an Emergency Medicine resident at the University of Texas Medical School at Houston.

With all of the recent advancement in the field of Emergency Department (ED) ultrasound, you may be tempted to think Emergency Physicians are masters of the bedside cardiac ultrasound and the assessment of systolic heart failure.  Despite the misleading title, the results of this article would suggest that is not the case.   

This is a prospective observational study to determine if E-point Septal Separation (EPSS) measurements made by emergency physicians correlated with calculated Left Ventricular Ejection Fraction (LVEF) measured by cardiologist using comprehensive Trans-Thoracic Echocardiography (TTE). Cardiac ultrasound and TTE were performed on 80 patients between the ages of 22 and 100 years old, of which 71 were included in the final analysis.  The study took place in the academic setting of Denver Health, conducted by 3 ultrasound fellows who had done at least 100 ultrasound scans.  They were given a 10 minute didactic presentation and supervised doing 3 EPSS measurements before they were set loose in the hospital to find patients who had undergone TTE in the last 24 hours. 

Based on their results, the authors conclude that  an EPSS of greater than 7mm is ideal for diagnosing severely reduced LVEF (<30%), with a sensitivity of 100% and a specificity of 51%.  This suggests EPSS is only useful in ruling out severe systolic heart failure – as values over 7mm were poor predictors of actual LVEF.  This inability to provide predictive information is well demonstrated by Figure 2, in which there are 3 patients with EPSS clearly in the range associated with severe systolic dysfunction- 20-22mm – and 2 of these 3 had normal ejection fraction on formal echocardiography.  Put another way, only 31 of the 63 patents with EPSS >7mm had moderate heart failure, calling into question the author’s suggestion the EPSS is a tool to accurately assess for LVEF.  In addition to the previous findings, the authors find that an EPSS of >8mm is a poor predictor of any systolic dysfunction with a sensitivity and specificity of 83.3% and 50.0%, respectively.  The authors also assessed the ability of emergency physicians to visually estimate ejection fraction, and found generally poor correlation with echocardiography and only fair interobserver observer reliability. 

There are several problems with this paper.  The sample size was small, and generalizability to Emergency Department patients may be limited because a majority of the population studied was inpatient.  More importantly, three ED ultrasound fellows performed all of the EPSS measurements.  These physicians having a special interest in ultrasound are likely more adept at wielding an ultrasound than the average emergency physician.  At best, this article makes a weak case for the clinical relevance of EPSS.  And, ultimately, subtle systolic dysfunction that may or may not be picked up by using a cutoff EPSS of >8 may not be as important as the ejection fraction that is so low it can be seen on the ultrasound screen from across the room. 

“E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction”

Papers I Want to Read ( #PIWTR)

Gday

I am introducing a new concept for the blog.  Here is how it goes.

I love reading the R&R In the Fast Lane – and contributing interesting papers when I see them.  But…..

When I do my research for the various topics we cover here at Broome Docs – I am often left searching for the ideal paper – the trail that would neatly answer the questions that we have in our day – to day practice.

Sometimes I even find myself staring longingly at a fresh PubMed search page, fantasising that somebody has published the “exact” paper I want to read in some archaic, obscure journal – and it had just passed us all by!

So here is what I will propose: “Papers I Want to Read”

I want to hear from you all – what questions do you want to have answered by a quality RCT or other trial?

Breaking it down:

(1) what is your question?

(2) How did you identify a “gap” in the literature – practice, reading, curiosity?

(3) What sort of trial, paper or design would answer that question?

(4) Nominate who you think should do it – maybe we can get in touch with them via the FOAM network and inspire some researcher to answer that question.

At worst it should be a fun exercise, at best we just might identify some gaps that we can plug.  Or maybe there are some folk out there who know the answer to your quandary and will let us know!

 

So, I know you are shy – I will go first.

I really want to see if dexamethasone on its own will give adequate symptom relief to kids with acute pharyngitis.

I have read a lot on this in recent weeks and found good data – but it is all tainted by combining ABs with Dex – so hard to define the effect.

It would be an ED or primary care RCT with 2 or 3 arms – dexamethasone, vs placebo +/- vs. usual care or ABs.  Primary endpoint has to patient-oriented eg. pain relief and satisfaction. [maybe parental sleep index??]

I would imagine that the group in the UK who are doing all the recent research into Strept throats in GP care – eg. PRISM trial etc would be a great crew to get this done.  After all the NHS has an enviable data set and organisation for collecting this stuff.

 

Now – over to you.  I will keep proposing trials from time to time as I find gaps, annoying questions in my practice that I cannot answer.

You can email me, comment or Tweet a question using the hashtag #PIWTR

Bring it on

Casey

 

Video: How to use the LUCAS 2

Last week we featured an instructional video describing how to use the Autopulse. At The Alfred we also have access to a LUCAS 2 mechanical CPR device, which is used preferentially for patients who have in-hospital arrests and need to be taken straight to the cath lab.

 

 

More information on instructions for use are available from the manufacturer’s website.

The post Video: How to use the LUCAS 2 appeared first on INTENSIVE.

Steve Bernard talks to EDECMO.org

Just released on EDECMO.org is a fascinating interview conducted by Joe Bellezzo and Zack Shinar with Prof Steve Bernard from The Alfred ICU. Steve shares insights into the development of the ECPR programme at The Alfred, the soon to be published preliminary results from the CHEER trial and the technical aspects of performing ECPR.

Listen to EDECMO Episode 14: ECPR with Steve Bernard now…. and look out for Part 2 coming soon.

The post Steve Bernard talks to EDECMO.org appeared first on INTENSIVE.