Aktuelle FOAMed Infos rund um die klinische Notfallmedizin, Notfallmedizin und Intensivmedizin, auf den Spuren vom Skeptics Guide to emergency medicine

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Date: April 26th, 2017

Reference: Syed et al. Prospective validation of a clinical decision rule to identify patients presenting to the emergency department with chest pain who can safely be removed from cardiac monitoring. CMAJ Jan 2017

Guest Skeptics: Drs. Ryan Tam and Antony Robert are chief residents from the Royal College Emergency Medicine Program at McGill University.

* Ryan Tam’s academic interests include quality improvement, ultrasound and simulation. He is also involved with a start-up FOAMed site called EM-bites focused on providing point of care resources. When he is not working, he is an enthusiastic photographer, foodie and adventure traveler.

* Antony Robert’s academic interests include resuscitation, medical education, research, ultrasound and medical informatics. He is also the CEO of a new medical education start up, and is currently working on the first prototype. When he is not working, he is an avid runner and squash player.

I was invited to give Grand Rounds at McGill University. This was a three hour session that was broken up into three sections. The first section was a presentation on evidence based medicine, knowledge translation and social media. Here is a copy of the EBM/KT/SoMe slides.

The second section was medical myth busting with a Star Wars theme. It was called The Medical Myth Menace. I did a quick presentation of six recent SGEM episodes. There is a hand out for these two presentations that is available at this link.

The third section of Grand Rounds was a live recording of the SGEM Journal Club. The first SGEM-JC was done at McGill University in October of 2014 (SGEM#50). The question from that episode was: Does a vasopressin, epinephrine and corticosteroid (VSE) protocol for in-hospital cardiac arrest resuscitation improve survival with favourable neurological outcomes compared to epinephrine alone? Clink on the link to find out the answer.

It was Dr. William Osler who was credited for starting the first formal journal club at McGill University in 1875. The original purpose of his journal club was “for the purchase and distribution of periodicals to which he could ill afford to subscribe.”

Dr. Osler was ahead of his time. The purpose of his journal club seems to align with some of those from the FOAMed movement. The SGEM JC endeavours to combine Journal Club with FOAMed in order to cut the knowledge translation window down from over ten years to less than one year. The ultimate goal of the SGEM is to provide patients with the best care, based on the best evidence and to make the world a better place.

Five Rules of SGEM JC

Case: You are working during a busy shift with a bed blocked emergency department. A 52 year old gentleman known for coronary artery disease and hypertension presents with slightly suspicious chest pain. He is triaged and put in your monitored area. When you see him, he describes exertional retrosternal chest pain which is now resolved. His initial ECG shows non-specific t-wave changes.

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Date: April 20th, 2017

Reference: Motov et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med Dec 2016

Guest Skeptic: Dr. Ken Milne is a front line community emergency medicine physician passionate about skepticism, evidence based medicine and knowledge translation. He is also the moderator for Emergency Medical Abstracts, faculty member of Best Evidence in Emergency Medicine and creator of the Skeptics’ Guide to Emergency Medicine.

Case: A 37-year-old, presents to the emergency department with sudden onset right-sided flank pain, hematuria and vomiting. He rates his pain as 8/10 and is writhing around on the stretcher. He says it feels like his previous kidney stones. His vital signs are within normal limits.

You perform a quick bedside ultrasound, which reveals a normal aorta and mild right-sided hydronephrosis. You diagnose him with renal colic and he is requesting analgesia. He says morphine has made him nauseous in the past, but a shot of 30mg of ketorolac has helped. You decide to start by giving ketorolac and an anti-emetic. What dose of ketorolac do you give?

Background: Ketorolac is a commonly used non-steroidal anti-inflammatory drug (NSAID) used in the emergency department for treatment of moderate to severe acute pain (1)

Unlike opioid analgesics, NSAID dosing is limited by their “analgesic ceiling”, meaning there is a dose-analgesic response. Above certain doses, NSAIDs produce more side effects or harms, without providing additional analgesia (2). Previous literature suggests that the ketorolac analgesic ceiling dose is 10 mg, which is much lower than the doses of 30mg to 60 mg recommended in textbooks (3-7).

This is especially important as ketorolac has a greater gastrointestinal hemorrhage risk than other NSAIDs, and this appears to increase at higher doses (8) Furthermore, intramuscular doses of 15mg, 30mg and 60mg appear to increase post-operative bleeding (9-10).

Clinical Question: Does 10mg of ketorolac intravenously (IV) provide similar analgesic efficacy for treatment of acute pain compared to doses of 15mg or 30mg?

Reference: Motov et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med Dec 2016

* Population: Adults aged 18 to 64 years of age presenting to the emergency department with acute flank, abdominal, back, musculoskeletal, headache or dental pain with an intensity of ≥5 on a numerical rating scale (NRS) going from zero to ten.

* Exclusion criteria: Age ≥65, pregnancy or breastfeeding, active peptic ulcer disease, acute GI hemorrhage, known history of renal or hepatic insufficiency, allergy to NSAIDs, unstable vital signs (SBP < 90 or >180; heart rate < 50 or >150)

* Intervention: 10mg, 15mg or 30mg of ketorolac intravenously

* Control: None

* Outcome:

* Primary Outcome: Reduction in numeric rating scale scores at 30 minutes

* Secondary Outcomes: Adverse events and rescue analgesia

Dr. Sergey Motov is the lead author of this paper. He is an Emergency Physician in the  Department of Emergency Medicine, Maimonides Medical Center in New York City.

Authors’ Conclusions: “Ketorolac has similar analgesic efficacy at intravenous doses of 10, 15, and 30 mg, showing that intravenous ketorolac administered at the analgesic ceiling dose (10 mg) provided effective pain relief to ED patients with moderate to severe ...

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Date: April 6th, 2017

Reference: Marik et al. Hydrocortisone, Vitamin C and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest Dec 2016

Guest Skeptic: Dr. Jeremy Faust is an attending emergency physician at Brigham and Women’s Hospital in Boston Massachusetts and an instructor at Harvard Medical School. He’s the co-host of FOAMcast with co-host Dr. Lauren Westafer and he’s written about sepsis in the Annals of Emergency Medicine, EM Clinics of North America, and for mainstream audiences in Slate. 

Case: A 60 year-old man is admitted to the ICU with severe sepsis from pneumonia. He has a history of hypertension and diabetes. You are providing him with intravenous fluids and appropriate antibiotics. When speaking with the family his son asks about a vitamin C cure he just read about?

Background: We have covered sepsis many times on the SGEM (#44, 69, 90, 92 and 113). Most recently we covered the HYPRESS Trial on SGEM#168. The primary outcome was that hydrocortisone did not prevent the development of septic shock. The secondary outcomes also showed no difference in mortality.

There has been a huge buzz in the media about a vitamin C cocktail (vitamin C, hydrocortisone and thiamine) as a possible cure for sepsis. Many FOAMed sites have joined the conversation:

* The Bottom Line: An Orange a Day Keeps Sepsis at Bay?

* EMLit of Note: Vitamin C for Sepsis

* EMCrit: Paul Marik on the Metabolic Resuscitation of Sepsis

* Pharmacy Joe: Vitamin C, Hydrocortisone, and Thiamine for Severe Sepsis and Septic Shock

* Everyday EBM: Vitamin C in Sepsis – Splashes in the Popular Press

* St. Emlyn’s: Vitamin SCepTiC?

* REBEL EM: The Marik Protocol: Have We Found a “Cure” for Severe Sepsis and Septic Shock?

* ZdoggMD: Vitamin C Cures Sepsis and other fake news?

For the scientific rationale why vitamin C therapy may help septic patients check out Josh Farkas’ post on PulmCrit.

People have searched and people have failed to find an effective treatment for sepsis (DC Angus JAMA 2011). A classic example is the story of recombinant activated protein C (ADDRESS NEJM 2005 and FDA).

Date: April 7th, 2017

Superstar Nurse Brenda Palsa and I had a wonderful time presenting at Talk Trauma 2017 this week in London, Ontario. It is a one day conference for nurses, allied health & EMS professionals involved in providing care for adult and paediatric trauma patients. Talk Trauma is put on by the London Health Science Centre (LHSC). We were honoured to return for a second year in a row to talk about managing trauma patients in the periphery.

 

Our idea was to demonstrate that you could provide excellent evidence based care before transferring patients to the trauma centre (LHSC). This resulted in Episode II – Tales from the Outer Rim (Talk Trauma Intro Trailer). I was inspired by ZdoggMD and dress up as Doc Vader while Brenda became Nurse Leia.

 

The entrance went well as we came on stage to the Imperial March with lightsabers drawn (Nurse Leia and Doc Vader). Our presentation consisted of defining evidence based medicine (EBM) followed by six critical reviews of recent papers. The goal was to cut the knowledge translation down to less than ten years and ensure trauma patients get the best care, based on the best evidence no matter where they present.

We promised the attendees that all the information would be made available. Here is a copy of our slides (Tales from the Outer Rim Slides). You will also find the links to the six SGEM critical reviews and the ZdoggMD videos that were shown.

Evidence Based Medicine: “The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” (Dr. David Sackett)

Six SGEM Critical Reviews:

* CPR Man or Machine: Mechanical chest compression devices do not appear superior to manual chest compression for out of hospital cardiac arrest. SGEM#136

* Hypertonic Saline for TBI: Hypertonic saline as a first line treatment for patients with severe traumatic brain injury cannot be recommended at this time. SGEM#150

* Isolated Sternal Fractures: Patients discharged home with isolated sternal fractures have a 12.5% risk of delayed hemothorax. These are painful injuries and patients should be provided with adequate analgesia and follow-up. SGEM#161

* Chest Tube Placement: Put the tube on the correct side, within the triangle of safety, and within the pleural space. SGEM#129 (Featuring Dr. Rick Malthaner from LHSC)

* Ketamine for RSI: Ketamine seems to be a reasonable alternative induction agent for undifferentiated patients requiring RSI in the emergency department. SGEM#93

* Massive Transfusion Strategy: A 1:1:1 transfusion strategy is a reasonable approach to adult patients who require a massive transfusion. SGEM#109

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Date: March 21st, 2017

Reference: Friedman BW et al. Diazepam is no better than placebo when added to naproxen for acute low back pain. Ann Emerg Med 2017.

Guest Skeptic: Dr. Anand Swaninathan is an Assistant Professor of EM at NYU/Bellevue Hospital in the Department of Emergency Medicine. He is also part of REBEL EM, The Teaching Course and Core EM.

Case: A 43-year-old woman who presents with an acute onset of back pain. She states she was carrying some heavy boxes when she slipped and although she didn’t fall, she felt her back wrench. There are no back pain “red flags” on your history and physical examination and after some treatment with a non-steroidal anti-inflammatory (NSAID) and a dose of morphine, the patient is improved. She still has pain and you notice that she’s got difficulty walking and bending due to continued discomfort, but she says she’s late and wants to get home. You consider whether you should discharge her home with a short course of diazepam to improve her functionality.

Background: Low back pain is an extremely common presentation to US Emergency Departments  representing 2.4% or 2.7 million visits annually. The vast majority of presentations are benign in etiology but can be time consuming and frustrating for both patients and physicians.

Physician frustrations with managing acute non-traumatic low back pain are multifaceted – preoccupation for finding the rare dangerous back pain patient (epidural abscesses, osteomyelitis, pathological fractures, etc), patients demanding imaging, difficulty in relieving pain and concern for secondary gain (i.e. opiate abuse or diversion).

There are multiple “Red Flag” lists to help identify patients at risk for more serious causes of their back pain. No list is comprehensive. A simple red flag list from our friend Salim Razaie (@srrezaie) at REBEL EM is called TUNA FISH.

Other things to consider would be immunocompromised patients besides just those on steroids (patients with HIV, diabetes, alcoholics or taking biologic agents) who are at risk for spinal epidural abscess, discitis, or osteomyelitis.

When it comes to patient demands for imagine, Choose Wisely from ACEP and CAEP encourages emergency physicians to avoid ordering lumbar spine imaging in patients without serious underlying conditions (red flags).

* ACEP: Avoid lumbar spine imaging in the emergency department for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equina syndrome, or cancer with bony metastasis).

*  CAEP: Don’t order lumbosacral (low back) spinal imaging in patients with non- traumatic low back pain who have no red flags/pathologic indicators.

Many different treatment modalities have been tried to treat low back pain with limited success. Williams et al (Lancet 2014) showed acetaminophen did not affect recovery time compared with placebo in low-back pain. However, these were not patients recruited from the emergency department.

Friedman et al (JAMA 2015) showed that adding a muscle relaxant (cyclobenzaprine) or oxycodone/acetaminophen to an NSAID (naproxen) alone did not improve functional outcomes or pain one week after emergency department presentation.

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Date: March 23rd, 2017

Guest Skeptic: Dr. Manrique Umaña: Specialist in Emergency Medicine (ME), working as an assistant at San Juan de Dios Hospital and Hospital Cima, in San José, Costa Rica. He is the current National Coordinator and Professor of the Postgraduate Emergency Medicine (University of Costa Rica). He is also Professor of the Chair of Internal Medicine (UCIMED), member of the Costa Rican Association of Emergency Physicians (ASOCOME) and International member of ACEP and IFEM. Additionally, he is very active in the use of social networks (@umanamd) and writes in a Spanish ME blog called ViamedEM.

This is an SGEM Xtra in support of the 7th Inter American Emergency Medicine Conference (IAEMC) being held in San Jose, Costa Rica May 22nd to 26th, 2017. My FOAMed friend Manrique reached out to me and asked if I would do something to support this conference.  My answer was…of course, people let’s do a podcast?

Manrique and I met at an ACEP Scientific Assembly a few years ago where he gave me some wonderful Costa Rican coffee. We then did a podcast together (SGEM #107: Can’t Touch This – Hands on Defibrillation) that we recorded in Costa Rica at an Emergency Medicine and Acute Care conference.

Manrique and his colleagues are also part of the SGEMGlobal Team translating the SGEM into Spanish. The goal of SGEMGlobal is to cut the knowledge translation window down from over ten years to less than one year in multiple languages.

Here are the Top Five Reasons to Attend #IAEMC17:

* Big Names in the Emergency Medicine are Speaking

* Amazing Keynote Speakers

* Great pre-conference Workshops

* Network with Emergency Medicine People from the Whole Continent

* Pura Vida Life in Costa Rica

There is still time to register and we hope to see many of our FOAMed friends in Costa Rica this May.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

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Date: March 21st, 2017

Reference: Qureshi et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. NEJM June 2016

Guest Skeptic: Chip Lange is an Emergency Medicine Physician Assistant working primarily in rural Missouri in community hospitals. He has international experience in critical care and emergency medicine. He hosts a blog and podcast called TOTAL EM, which stands for Tools Of the Trade and Academic Learning in Emergency Medicine. Although Chip’s focus is to educate those working in rural and remote settings, his goal has been to help others provide total care everywhere.

Case: A 68 year-old female arrives via EMS for left sided weakness starting two hours prior to arrival in the emergency department. She does not take blood thinners and has lived independently prior to her complaint today. Her head CT without contrast demonstrates a bleed of the right parietal region that measures 52cm3 in size. On arrival her blood pressure is 220/140, which was also found by EMS. The patient’s nurse asks you what blood pressure target you want to aim for given her bleed.

Background: Bleeding in the brain can be bad and can result in morbidity and mortality. There is limited data about the target for systolic blood pressure when treating acute hypertensive response in patients with intracerebral hemorrhage (ICH).

Prior to this study there was the INTERACT-2 trial by Anderson et al that randomized almost three thousand patients with ICH within six hours of symptom onset to either intensive treatment (target systolic blood pressure <140 mm Hg) or control group (target systolic blood pressure <180 mm Hg). Overall, that study found no statistical significance in their primary endpoints of death and disability at 90 days or safety.

There were a number of problems with INTERACT-2 that were discussed on SGEM#73 (How Low Can You Go). One of the main controversies was the secondary ordinal analysis showing a significantly lower modified Rankin Scale (mRS) with intensive treatment OR 0.87 (95% CI 0.77 to 1.00; P = 0.04).

Overall, the evidence for lowing blood pressure in patients with acute ICH is limited.

Clinical Question: In patients with an acute intracerebral hemorrhage, does intensive blood pressure lowering to a systolic blood pressure target of 110-139 mm Hg result in a lower rate of death or disability than a systolic blood pressure target of a 140-179 mm Hg?

Reference: Qureshi et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. NEJM June 2016

* Population: Patients with intracerebral hemorrhage (ICH) that are at least 18 years old with clinical signs consistent with a stroke, GCS of five or greater on arrival, INR <1.5, intraparenchymal hematoma of less than 60cm3 on initial CT scan, and at least one systolic blood pressure reading of 180 mmHg or more between symptom onset and initiation of intravenous antihypertensive treatment.

* Exclusion Criteria: Systolic blood pressure reduced to <150 mm Hg before randomization or randomization occurred 4.5 hours after symptom onset. Patients with ICH due to previously known neoplasms, AVM, or aneurysms or those with ICH from trauma, ICH located in infratentorial regions such as pons or cerebellum, intraventricular hemorrhage associated with intraparenchymal hemorrhage and blood completely fills one lateral ventricle or more than half of both ventricles, patient to receive immediate surgical evacuation, current pregnancy (or parturition within previous 30 days...

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Date: February 27th, 2017

Reference: Gomez et al. Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants. Pediatrics 2016.

Guest Skeptic: Dr. Anthony Crocco is a Pediatric Emergency Physician and is the Medical Director & Division Head of the Division of Pediatric Emergency at McMaster’s Children’s Hospital. He is also the creator of SketchyEBM.

Case: A 25-day-old girl presents with fever. There is no history of congestion, cough, vomiting, diarrhea, shortness of breath or any other focus for her infection. She looks well on exam and her vitals are normal except for a rectal temperature of 38.3C. She is less than 28 days old and you wonder how much of a work up to do (full septic workup, intravenous antibioticsadmission to hospital, blood and urine tests)?

Background: Fever without source in infants less than three months old represents a significant diagnostic dilemma for clinicians. Several criteria had been developed previously, including the Rochester (Jaskiewicz et al 1994), Boston (Baskin et al 1992) and Philadelphia (Baker et al 1993) criteria to help clinicians stratify the risk of significant bacterial infections.

These criteria, however, are out-dated in our current era of vaccinations, but to date, have represented our best option. A new algorithm has been developed by a European group of pediatric emergency physicians called the “Step-by-Step” approach.

Mintegi et al did a retrospective study of this “Step-by-Step” approach in 2014. They concluded: A sequential approach to young febrile infants based on clinical and laboratory parameters, including procalcitonin, identifies better patients more suitable for outpatient management. (EMJ 2014).

Clinical Question: In infants 90 days or younger of age with fever without focus, how does the “Step-by-Step” approach compare to using the Rochester criteria or using the “Lab-score” method in identifying patients at low risk of invasive bacterial infections (IBI)?

Reference: Gomez et al. Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants. Pediatrics 2016.

* Population: Infants 90 days old or younger with fever without source (FWS)

* FWS was defined as a temperature measured at home or at the Pediatric Emergency Department ≥38°C, in patients with a normal physical examination and no respiratory signs/symptoms or a diarrheal process.

* Excluded if clear source of fever identified after history and physical examination, no fever on arrival and fever that had only been subjectively assessed by parents, absence of one or more of the mandatory ancillary tests, and refusal of the caregivers or parents to participate.

* Intervention: Use of the “Step-by-Step” approach

* Comparison: Use of the Rochester criteria and the “Lab-score” method

* Outcome: Performance metrics to identify patients at low risk of invasive bacterial infection (defined as positive blood culture or CSF culture). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood (LR+) and negative likelihood ratio (LR-).

Author’s Conclusions: “The Step-by-Step approach revealed a high sensitivity, being more accurate than the Rochester criteria and the Lab...

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Date: March 2nd, 2017

Reference: Stiell et al. Prospective and Explicit Clinical Validation of the Ottawa Heart Failure Risk Scale, With and Without Use of Quantitative NT-proBNP. AEM March 2017

Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the Director of Simulation Education at Markham Stouffville Hospital in Ontario. He is the author of the excellent #FOAMed blog called First10EM.com and is an associate editor of Emergency Medicine Cases.

Case: A 68-year-old woman with a history of congestive heart failure, hypertension, and hyperlipidemia presents to the emergency department with a three-day history of shortness of breath on exertion, orthopnea and mild leg edema, but with normal vital signs. Her renal function is normal and troponin is negative. Her ECG is normal. After a dose of intravenous furosemide, she says she feels a lot better and would like to go home.

Background: Heart failure is a serious condition that often presents to the emergency department. Guidelines exist to help physicians on the diagnosis and treatment of heart failure but none offer recommendations on who to admit (Yancy et al, Arnold et al, McMurray et al, and McKelvic et al).

Heart failure patients often have other co-morbid conditions increasing their rate of hospitalization (Blecker et al).  In addition, patients hospitalized for heart failure have a high risk of readmission to hospital after discharge (McAlister et al, Richter et al, and Yeung et al).

Patients in Canada are more often treated in the emergency department and discharged home compared to the U.S. (Stiell et al, Pang et al, Collins et al, and Schrader et al). This difference in admission rates is similar to what is seen in patients diagnosed with pulmonary embolism. We have discussed this issue on SGEM#51.

So who can go home and who needs to come in to hospital is a question faced regularly by emergency physicians. There are published risk-stratification tools to predict mortality in patients with acute heart failure but they are limited in their ability to inform the emergency physician in deciding disposition (admit or discharge home). See reference #19-28 in Dr. Stiell’s Hot Off the Press publication in AEM for these risk-stratification tools.

Clinical Question: Can the Ottawa Heart Failure Risk Scale (OHFRS) help make disposition decisions by accurately predicting the 30-day rate of serious adverse events in patients with acute heart failure?

Reference: Stiell et al. Prospective and Explicit Clinical Validation of the Ottawa Heart Failure Risk Scale, With and Without Use of Quantitative NT-proBNP.