Jun 01

Image of the Week – Massive PE

The Image of the Week comes to us from Drs. Kahra Nix, Ian Dodson, Darin Williams, and Jeremy Ackermann who used ultrasound to evaluate a 50 yo patient with COPD who presented with ROSC following PEA arrest.  Can you identify the finding below?

 

Thanks for all your great images this week. Happy Scanning!

===============================

Sierra Beck MD

Assistant Professor

Department of Emergency Medicine

Emory University SOM

Jun 01

Image of the Week – Traumatic Arrest After GSW

The Image of the Week comes to us from Drs. Almebash and Reynolds who performed a FAST exam in a patient who presented in traumatic arrest following a GSW. Can you identify the pathology present?

 

Thanks for all of your great images this week!

Happy Scanning!

===============================

Sierra Beck MD

Assistant Professor

Department of Emergency Medicine

Emory University SOM

May 19

Lit of the Week — 5/3/16

Linitis_plastica_2

Lit of the Week – 5/3/16

Glasgow Blatchford Bleeding Score

 

Blatchford O, Murray WR, Blatchford M. A risk score to predict need for

treatment for upper-gastrointestinal haemorrhage. Lancet. 2000 Oct

14;356(9238):1318-21. PubMed PMID: 11073021

 

 

Clinical question / background:

  • Can a risk score based on medical history, hemodynamic variables, and simple lab data risk stratify patients presenting with upper GI bleed to the emergency department?

 

Design:

  • Retrospective development of scoring system using logistic regression of objective data from large patient database followed by prospective validation using ROC curves compared to Rockall scoring and post-endoscopy scores
  • 1748 patients with UGIB in retrospective group
    • 19 hospitals in Scotland
  • 197 patients with UGIB in validation group
    • 2 hospitals in Scotland
  • Primary outcome: clinical intervention
    • Blood transfusion
    • Any operative or endoscopic procedure to control bleeding
    • Death, re-bleed, or substantial fall in hemoglobin after admission

 

Intervention:

  • Evaluation of Scoring system as detailed below
Glasgow-Blatchford Score
Admission risk marker Score component value
Blood Urea (mmol/L)
6.5-8.0 2
8.0-10.0 3
10.0-25 4
>25 6
Hemoglobin (g/L) for men
12.0-12.9 1
10.0-11.9 3
<10.0 6
Hemoglobin (g/L) for women
10.0-11.9 1
<10.0 6
Systolic blood pressure (mm Hg)
100–109 1
90–99 2
<90 3
Other markers
Pulse ≥100 (per min) 1
Presentation with melena 1
Presentation with syncope 2
Hepatic disease 2
Cardiac failure 2

Score

Score is equal to “0” if the following are all present:

 

Results:

  • area under the ROC curve of GB score was 0·92 (95% CI 0·88–0·95), which was significantly higher than that for Rockall admission (0·71 [0·64–0·78]) and the full postendoscopy scores (0·75 [0·67–0·83]
  • GB score more highly correlated with need for blood transfusion and hospital length of stay

 

Take-Home

  • In patients presenting with signs/sxs of acute UGIB, the GB score can be used to risk stratify them for need for further intervention

 

Strengths:

  • Easy to use based on common admission lab data
  • META-analysis found that score of 0 was associated with a low likelihood of the need for urgent endoscopic intervention (likelihood ratio 0.02, 95% confidence interval [CI] 0-0.05)

 

Limitations

  • Only applicable for acute UGIB
  • Score of 1 or greater indicates probable need for intervention limiting its use if patients with chronic anemia, renal disease

 

Real World

  • Score 0
    • Low risk for intervention
    • Reasonable to manage as outpatient
  • Score >0
    • Increased risk for intervention and inpatient management is recommended
    • However most cases <5 respond without significant intervention
  • Score >5
    • High risk for intervention

 

May 17

Lit of the Week- 5/17/16

“NEXUS Chest – Validation of a Decision Instrument for Selective Chest Imaging in Blunt Trauma”

http://www.ncbi.nlm.nih.gov/pubmed/23925583

Clinical question / background:

  • Low yield radiology is costly and exposes patients to unnecessary radiation. Can the previously described NEXUS Chest Imaging rules be validated for clinical use in cases of blunt chest trauma?
  • Very low risk for chest trauma if none of the following are met:
    • Older than 60 years old
    • Rapid deceleration mechanism (fall> 20ft, MVC > 40mph)
    • Chest Pain
    • Intoxication
    • Abnormal mental status
    • Distracting injury
    • Tenderness to chest wall palpation

Design:

  • Prospective, observational validation study
  • 9 US level I trauma centers
  • Blunt trauma patients >14 years old
  • Imaging studies ordered per individual physician (EP, Trauma). Prior to imaging results, MDs record presence or absense of NEXUS Chest 7 criteria.

Outcome:

  • Thoracic injury on chest imaging (TICI) defined as pneumothorax, hemothorax, aortic/great vessel injury, 2 or more rib fractures, ruptured diaphragm, sternal fracture, pulmonary contusion/laceration.
  • An expert panel was convened to determine which degree of injury clinically major, clinically minor and clinically insignificant injury.
  • Outcomes stratified by major, minor and insignificant

Results:

  • 9905 patients enrolled: 1478 with thoracic injury identified on chest imaging
  • Sensitivity 98.8% for any thoracic injury
  • Sensitivity 99.7% for injuries of major clinical significance.
  • Cohort of 200 patients without chest imaging followed up to determine rate of thoracic injury in patients without chest imaging. Zero missed injuries.

Discussion:

  • Clinical tool is validated for this patient population
  • Very poor specificity: this is a rule-out tool, not rule in

Apr 30

Image of the Week – Achilles Tendon Rupture

The Image of the Week comes to us from Drs Kahra Nix, Jose Rosa, and Jeremy Whitley & MS4s Eli and Rachel who used ultrasound to evaluate an athletic young man who experienced pain and a pop in his ankle whlle playing basketball. Can you identify the normal and abnormal structures below?

 

Thanks for all of your great images this week!

Happy Scanning!

===============================

Sierra Beck MD

Assistant Professor

Department of Emergency Medicine

Emory University SOM

Apr 29

Lit of the Week — Dopamine vs Norepinephrine in Treatment of Shock

Epinephrine-ampule

Lit of the Week – 4/26/16

SOAP II: Comparison of Dopamine and Norepinephrine in the Treatment of Shock

De Backer D, Biston P, Devriendt J, Madl C, Chochrad D, Aldecoa C, Brasseur A,

Defrance P, Gottignies P, Vincent JL; SOAP II Investigators. Comparison of

dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010 Mar

4;362(9):779-89. doi: 10.1056/NEJMoa0907118. PubMed PMID: 20200382

 

Clinical question / background:

  • Dopamine and norepinephrine are both first-line agents in the treatment of shock. Smaller studies had shown dopamine was independently associated with increased mortality.   In a large randomized clinical trial, how does dopamine compare to norepinephrine for prevention of all-cause mortality in the treatment of shock?

 

Design:

  • Randomized, double-blind, multi-center trial
  • 1679 patients with diagnosis of shock
    • 821 in norepinephrine group
    • 858 in dopamine group
  • Inclusion: Adults (> 18 y/o) with shock requiring a vasoactive agent
    • Shock definition:
      • MAP <70 mmHg or systolic BP <100 despite adequate fluids (1L crystalloid or 500mL colloids)
        • Unless CVP >12 or PCWP >14
      • Signs of tissue hypoperfusion: mottled skin, altered mental status, urine output < 0.5 cc/kg/hr, lactate > 2 mmol/L
  • Exclusion: < 18 y/o, already on vasopressor for > 4 hours, serious arrhythmia >160 bpm, brain dead patients
  • Primary outcome: all cause mortality at 28 days
  • Secondary outcomes: death in ICU, in hospital, 6-month mortality, 12-month mortality, number of days without need for organ support, time to attainment of hemodynamic stability, VS changes, adverse events

 

Intervention:

  • Enrolled patients received either dopamine or norepinephrine titrated to maximum doses of 20 mcg/kg/min for dopamine or 0.19mcg/kg/min for norepinephrine to maintain MAP > 65 mm Hg
  • If additional pressor required, open-label norepinephrine was used
  • Dopamine not allowed to be used as open-label
  • Inotropes as needed for supplementary support
  • Stress dose steroids and other ICU interventions per treating physician preference

 

Results:

  • Shock Subtypes
    • Septic shock 62%
    • Cardiogenic shock 17%
    • Hypovolemic shock 16%
  • All-cause mortality at 28 days
    • Dopamine 52.5% vs. Norepinephrine 48.5% (OR 1.17; 95% CI 0.97-1.42; P=0.10)
  • ICU death
    • Dopamine 50.2% vs. Norepinephrine 45.9% (OR 1.19; 95% CI 0.98-1.44; P=0.07)
  • Inpatient mortality
    • Dopamine 59.4% vs. Norepinephrine 56.6% (OR 1.12; 95% CI 0.92-1.37; P=0.24)
  • 6-month mortality
    • Dopamine 63.8% vs. Norepinephrine 62.9% (OR 1.06; 95% CI 0.86-1.31; P=0.71)
  • 12-month mortality
    • Dopamine 65.9% vs. Norepinephrine 64.0% (OR 1.15; 95% 0.91-1.46; P=0.34)
  • 28-day mortality among patients with cardiogenic shock increased in dopamine group compared with norepinephrine (P=0.03)
  • No significant difference in mortality among those with septic and hypovolemic shock
  • Arrhythmia
    • Dopamine 24.1% vs. Norepinephrine 12.4% (P<0.001; NNH 9)

 

Take-home:

  • In the treatment of shock, norepinephrine and dopamine compare similarly with respect to 28-day mortality, but dopamine is associated with an increased risk of arrhythmias
  • In cardiogenic shock, dopamine is associated with higher mortality
  • Higher heart rate with dopamine may contribute to ischemic events

 

Strengths:

  • Well-designed, large trial
  • Broad inclusion criteria
  • Powered to detect difference for primary outcome

Limitations

  • Open label norepinephrine was given if maximum dose of dopamine or norepinephrine was used which may have confounded results
  • Unclear if the underlying cause of shock was treated appropriately
  • Unclear how frequent supportive interventions (eg, intraaortic balloon pumps) were used

 

Real-World

  • Norepinephrine first-line vasopressor therapy for treatment of septic shock
  • Dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia)

Apr 21

Image of the Week – Aortic Dissection

The Image of the Week comes to us from Drs. Kahra Nix, David Zhou, and Shikha Kapil who used ultrasound to evaluate a patient who presented after clinic visit  for cough and an abnormal CXR prompted further work up. Can you interpret the image below that was obtained when the patient arrived in the ED?

 

Thanks for all of your great images this week!

Happy Scanning!

===============================

Sierra Beck MD

Assistant Professor

Department of Emergency Medicine

Emory University SOM

Apr 20

FOAM of the Week – Pediatric Abdominal Pain, Abdominal Trauma, Cirrhotic Patients, GI Bleeds

I’ve got some stuff from both last week and this week’s lectures. Enjoy.
 
 
 
 
 
 

Apr 19

Lit of the Week – 4/19/16 – TMP-SMX vs Placebo in the treatment of uncomplicated skin abscesses

Lit of the Week – 4/19/16

Talan DA, Mower WR, Krishnadasan A, Abrahamian FM, Lovecchio F, Karras DJ,Steele MT, Rothman RE, Hoagland R, Moran GJ. Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. N Engl J Med. 2016 Mar 3;374(9):823-32. doi: 10.1056/NEJMoa1507476. PubMed PMID: 26962903.

 

Clinical question / background:

  • Compared to placebo, does administration trimethoprim-sulfamethoxazole improve cure rates of non-complicated cutaneous abscesses drained in the ED?

 

Design:

  • Randomized, double-blind, placebo-controlled trial at 5 North American emergency departments
  • 1265 patients randomized
    • 636 TMP-SMX group
    • 629 placebo group
  • Inclusion: Patients (> 12 y/o) with uncomplicated cutaneous abscess diagnosed on physical or ultrasonographic exam that had been present <1 week and had a diameter of at least 2 cm with purulent discharge on drainage
  • Exclusion: Suspected osteomyelitis or septic arthritis, diabetic foot decubitus, or ischemic ulcer, mammalian bite, IVDU, long-term care residence, incarceration, immunodeficiency (i.e. ANC <500/mm3), iommunosuppressive drugs, active chemotherapy, known AIDS, creatinine clearance <50mL/min, taking warfarin, phenytoin, or methotrexate, pregnant or lactating
  • Analysis groups:
  • Modified Intention-to-Treat: Participants who took at least one dose of the active drug or placebo and had an in-person or telephone assessment through the test-of-cure visit, as well as those who withdrew from the trial, were lost to follow-up before final classification, or had missing or unassigned outcomes
  • Per-Protocol: Participants who either took ≥75% of the total doses of study drug or placebo during first 5 days and had an in-person test-of-cure or were determined to have had clinical failure before the test-of-cure visit and received ≥75% of the doses provided during the first 48 hours of the treatment period

Primary outcome: Clinical Cure of Abscess (Test-of-cure Visit = 7 – 14d after treatment period, Extended Follow–up Visit = 42 – 56d after treatment period)

 

  • Secondary outcomes: Composite cure (i.e. resolution of all symptoms and signs of infection, or improvement such that no additional antibiotic therapy or surgical drainage procedure was necessary), surgical drainage procedures, changes in erythema size, invasive infections (sepsis, bacteremia, endocarditis, osteomyelitis, septic arthritis, necrotizing fasciitis, or pneumonia), skin infections at the same site and at a different site, hospitalizations, similar infection in household contacts, days missed from normal activities, days missed from work or school, days analgesics were used

 

Intervention:

  • TMP-SMX
  • 320mg of TMP and 1600mg of SMX BID for 7 days

Control:

  • 4 pills containing microcrystalline cellulose BID for 7 days

 

Results:

  • Significant increase in cure rates in patients who received TMP-SMX compared to patients who received placebo in both analysis groups
  • Clinical Cure of Abscess in Modified Intention-to-Treat Population:
  • TMP-SMX: 507/630 patients (80.5%) vs Placebo: 454/617 patients (73.6%)
  • Absolute Difference: 6.9% (2.1 – 11.7%), NNT = 14

 

  • Clinical Cure of Abscess in Per-Protocol Population:
  • TMP-SMX: 487/524 patients (92.9%) vs placebo: 457/533 patients (85.7%)
  • Absolute Difference: 7.2% (3.2 – 11.2%), NNT = 14
  • No difference between groups in secondary outcomes

 

 

Take-home:

  • Patients with uncomplicated cutaneous abscesses had improved cure rates with a 7 day course of TMP-SMX compared to patients who received only a placebo

 

Strengths:

  • Multicenter, double-blinded, randomized clinical trial
  • Before initiation of trial, trial personnel underwent standardized training on the general technique and trial-specific procedures for I&D
  • 4% of the MRSA isolates tested were susceptible to trimethoprim-sulfamethoxazole

 

Limitations:

  • There was a moderate degree of nonadherence with only 64.7% of the study population determined to be 100% adherent and another 17.2% were 76 – 99% adherent. But this is probably what happens in everyday practice. This could bias the results against trimethoprim-sulfamethoxazole.
  • This study provided a power of 90% to detect a between-group difference of 7.5%, which was not met by this study in any of its trial populations. The key to understanding this issue is to recall the difference between a superiority study and a non-inferiority study. This was a superiority study and hence a statistical difference can be found even if the observed delta is less than the delta used to power the study. Because the 95% CI did not cross zero, statistical significance was found. One has to determine, however, what is clinically significant as the threshold for clinical significance was not defined. Because the effect size was not huge, Dr. Talan and co-authors suggest that collaborative decision making with the patient should be used.

Apr 19

Lit of the Week — Amiodarone, Lidocaine, or Placebo in out-of-hospital cardiac arrest

040421-N-8090G-001 Atlantic Ocean (Apr. 21, 2004) - Hospital Corpsman 3rd Class Flowers administers chest compressions to a simulated cardiac arrest victim during drills aboard the conventional powered aircraft carrier USS John F. Kennedy (CV 67). Kennedy is completing final Carrier Qualifications (CQ) prior to her upcoming scheduled deployment. U.S. Navy photo by Photographer's Mate Airman Apprentice Nicholas Garrett. (RELEASED)

Lit of the Week – 4/12/16

Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B,

Vaillancourt C, Wittwer L, Callaway CW, Christenson J, Egan D, Ornato JP,

Weisfeldt ML, Stiell IG, Idris AH, Aufderheide TP, Dunford JV, Colella MR, Vilke

GM, Brienza AM, Desvigne-Nickens P, Gray PC, Gray R, Seals N, Straight R, Dorian

P; Resuscitation Outcomes Consortium Investigators. Amiodarone, Lidocaine, or

Placebo in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2016 Apr 4. [Epub ahead

of print] PubMed PMID: 27043165.

 

Clinical question / background:

  • Compared to placebo, does administration of amiodarone or lidocaine improve mortality or neurologic outcome in patient’s with out-of-hospital cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia?

 

Design:

  • Randomized, double-blind, placebo-controlled trial at 10 North American centers
  • 3026 patients with out-of-hospital cardiac arrest
    • 974 amiodarone group
    • 993 lidocaine group
    • 1059 placebo group
  • Inclusion: Adults (> 18 y/o) with non-traumatic, shock-refractory VFib or pulseless VTach + IV or IO access
    • Shock refractory = delivered 1 or more shock during resuscitation
  • Exclusion: already received Amiodarone or Lidocaine OR known hypersensitivity to these drugs
  • Normal pre-hospital cardiac arrest care + administration of study drugs or placebo
  • Primary outcome: survival to hospital discharge
  • Secondary outcomes: survival with favorable neurologic status at discharge defined as MRS < 3 (conduct ADLS independently or with minimal assistance)

 

Intervention:

  • Lidocaine IV
    • Initial dose of 120 mg IV (60 mg if patient less than 100 lb)
    • Second dose of 60 mg IV if first dose unsuccessful
  • Amiodarone IV
    • Initial dose 300 mg IV (150 mg if patient < 100 lb)
    • Second dose of 150 mg IV if first dose unsuccessful

 

Control:

  • Normal saline administration

 

Results:

  • No significant demographic differences between three groups
  • No significant difference in survival to hospital discharge for Amiodarone vs Placebo (24.4% vs 21%), Lidocaine vs Placebo ( 23.7% vs 21%), or Amiodarone vs Lidocaine (24.4% vs 23.7%)
    • Absolute risk difference between each groups also not significant
  • No significant difference in survival with favorable neurologic status for amiodarone vs placebo (18.8% vs 16.6%), lidocaine vs placebo (17.5% vs 16.6%), and amiodarone vs lidocaine (18.8% vs 17.5%)
  • Witnessed arrest à rate of survival to hospital discharge was significantly higher with amiodarone (27.7%) or lidocaine (27.8%) than with placebo (22.7%) — a clinically important difference of 5 percentage points

 

 

Take-home:

  • neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia
  • Consider administration of Amiodarone or Lidocaine in witnessed arrests
  • Bystander CPR still offers best outcomes regardless of drug used

 

Strengths:

  • Well-designed, double-blinded large trial
  • Although not primary outcomes: trial observed the following
    • Fewer shocks administered after study drugs given
    • Fewer patents required rhythm-control medications during hospitalization in study groups
    • Fewer patients required CPR during hospitalization if they had ROSC

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