whats happening in the EM world

the educators' blog: 

an online journal of whats impotant in emergency medicine, specifically as it relates to our local practice in the Hunter New England Area. please post comments via the 'post new entry' and upload any files into the appropriate folder under 'files'. 

 **please note this blog is available to the general public and anyone using it, in any fashion, is deemed in agreeance with our "terms of use" as described under our disclaimer 

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Thursday
Jun192014

website re-design

I am contemplating on re-designing the website a little to make it more 'user-friendly' on the front and back end, especialy on mobile devices.  Unfortunately, that means there would be a few changes in the ways we can access the website. 'User-friendly' usually means complex programs and software running in the background, all of which do not play nice with the arachiac versions of windows Internet Explorer, the web browser of choice on all HNEH computers.   Before I bite the bullet and go ahead, I am interested to hear many of your opinions on the matter and whether there is anything more or less you would like on our department website.  PLEASE, fill out this short survey and/or comment to this post.

 

Create your free online surveys with SurveyMonkey , the world's leading questionnaire tool.

 

Wednesday
Jun182014

Journal club: Transfusion strategies for acute upper GI bleeding

The study: in 921 patients with severe acute upper GI bleeeding, 461 were randomally assigned to a restrictive strategy (transfusion when Hb < 7 g/dL) & 460 were randomally assigned to a liberal strategy (transfusion when Hb < 9g/dL).

 

Result: In patients with severe acute upper gastrointestinal bleeding the outcomes were significantly improved with a restrictive transfusion strategy (Threshold < 7 g/dL). The restrictive group received significantly less transfusions. This resulted in a reduction in cost & use of blood. The restrictive group had a lower mortality, rebleeding & complication rate.

 

BOTTOM LINE: Having a transfusion threshold of < 7g/dL appears to have increased benefit, reduced harms & reduced costs. It appears to be a safe option for managing haemdynamically stable patients with upper GIH who are not exsanguinating. (It is important to note that patients with acute coronary syndrome, transient ischaemic attack, stroke and symptomatic peripheral vasculopathy were excluded from this study & therefore need to be considered for a more liberal transfusion strategy.)

 

Link to the full article

 

Link to the full review

Friday
May302014

Journal club: ARDS NET trial

As part of the project for our educational term, Mick Sales and I are going to be putting some regular journal article reviews on the site.

We will be using the CASP UK critical appraisal skill proforma to help us analyse these articles…but neither of us are EBM experts and so if you disagree with our review please post in the comments and let us know!

Most of the articles will be taken from the 52 landmark article post in ALiEM previously bought up by Tim Cowan.

The first study I have reviewed is the ARDS NET study of low tidal volume ventilation.

The link to the article and the appraisal tools used are listed here.

The ARDs NET ventilator protocol is here.

For those interested in the full review the link is here

Bottom line:

Lower tidal volume ventilation has a mortality benefit in patients with ARDS (8%), with a NNT of 12.5.

This has led to changes in ventilator strategies for all patients with TV of 6-8mls/kg recommended.

As a result of this study a protocolised ventilator protocol to meet oxygenation goals by titrating FiO2 and PEEP in ARDS patients has also been widely adopted.

Massive article!

Cheers - Dave

Thursday
May292014

Serotonin syndrome/toxicity and NMS

Dear All,

Further to my talk this morning a couple of links :

A very good review of serotonin syndrome/toxicity here

A 'Practice' article from early 2014 in BMJ here

The original study deriving the Hunter criteria for serotonin toxicity here

Monograph on serotonin syndrome including comparison with neuroleptic malignant syndrome here

thanks

Michael

Thursday
May152014

Cardiac catastrophe

Challenging case that I was previously involved with.....

Gentleman in his 40’s, referred from local ECHO provider due to severe cardiac failure and tachy-arrhythmia.

On initial assessment the patient is noted to be markedly diaphoretic, tachypneic (RR 28) and tachycardic (172bpm) with a marginal blood pressure (100/60).

He is saturating well on room air, does not feel SOB at present but notes a markedly limited exercise tolerance and has pedal oedema to his knees with a delayed capillary refill (4 secs).

A brief history is taken while IV access/ECG’s are obtained which reveals that the patient had been previously well, with no significant past medical history or regular medications.

His issue had began a few months ago when he had developed a persistent cough which was worse at night without any infective features.

Had been subsequently treated with multiple courses of antibiotics and steroids for a presumed infective exacerbation of previously undiagnosed COPD, and in the last week had deteriorated markedly to the extent where he was unable to walk more than a few metres.

An ECHO had been booked on the day of presentation which showed severe global hypokinesis of both R and LV with a LVEF of 10%

His initial investigations are listed below:

-       ECG

-        CXR

-        Venous gas

A review of his previous notes found an old ECG with a pre-existing LBBB.

How would you want to manage this patient?!

Will post next week with the patients progress…

Tuesday
May132014

ACEM Vimeo channel

Worth a look:

http://vimeo.com/user16826920

Thursday
May082014

HS Troponin follow up

So I was following up recently on my patient with the elevated troponin and it looks like I may have made a mistake.

On review of Auslab, it appears that the result of 160 that I thought came from the patients 2nd test was actually the lab re-spinning the initial sample.

His actual retest result was <9.

Oops…..

By the time I learnt all this though, the case had really spiked my curiosity in HS troponin, and in particular how I should be dealing with it on the floor.

So what I thought I’d do in this post, is give a brief summary of the article that JP attached for those who hadn’t had a chance to read it, and then outline the best resource I’ve found so far as to how we should be using the HS troponin in ED.

 JP’s article: Reference 1

Methods: Study was part of the APACE trial, and >2000 patients presenting to ED with chest pain (onset or peak in the last 6-12 hours) were consecutively enrolled.

Based on my (very limited) ability in literature appraisal, it appeared to be a pretty good study with generalizable results.

Patients had standard troponin measurements taken as well as HS troponins measured at 1/2/3 and 6hrs post arrival.

The patients were deemed to have ACS if they had elevated troponins, rise or fall in the troponin level (using 30% of the reference range) combined with signs of ischaemia (ECG/history)

The final diagnosis was made by cardiologist who had access to all the patients’ investigations during the next 90 days (including Angio/EST/ECHO etc.)

 The interesting thing about the study was that it tested results and calculated the Sn/Sp for the four main HS troponin assays and so I will focus on talking about the assay that we use locally (Abbott)

 Sensitivities/specificities (and NPV/PPV) for the Abbott assay were:

-          Presenting >6hrs post symptoms: Sn 84%/NPV 96. Sp 90 and PPV 76% (table 2)

-          <3 hours: Sn 50%/NPV 89. Sp 97% and PPV of 85

One of the real interesting things about this study (and the big change in the diagnostic guidelines for ACS) was that a one off elevated troponin is not enough to rule in or out ACS. You need to do serial sampling on all patients.

The European Society of Cardiology has published a review article about this which I found very helpful in terms of using HS troponin, and in particular when describing the delta (the change in troponin levels) of troponin required to diagnose ACS.

Please see the link here.

The big points from this article were:

  1. Diagnosis of ACS requires:

-          Troponin above the reference range coupled with a significant delta

-          Signs of ischaemia (ECG or history)

The flow chart they recommended for the diagnosis of ACS is below

 

  1. Diagnose myocardial necrosis with either

-          Initial troponin >upper reference limit (URL) with a subsequent increase of >20% of initial value

-          Initial troponin below the URL when the repeat test is >the URL due to an increase of >50% URL

To describe that using our URL for males (26) a positive result could occur with either:

-          Initial troponin of 30 with repeat testing of >36

-          Initial troponin of 20 with repeat levels at >33 (Increase of >13 which is >50% URL)

 I couldn't find any reference here to fall in troponin levels but as per JP's comments in the previous post that is also talked about in the literature.

 2. History or ECG that is suggestive of ischaemia then = ACS

 

Bottom Line:

-          One off HS troponin results are not sufficient to rule in ACS

-          Need to check the delta in all patients where ACS is suspected

-          HS troponin is very specific for myocardial necrosis but not for ACS

-          The Sensitivity and specificity of our local assay are not as good as I would have thought.

 

Anyone else’s heads a bit sore?!

Cheers

 

References:

  1. Hoeller R et al, 2013, ‘Normal presenting levels of high-sensitivity troponin and myocardial infarction’, Heart, 0:1-6
  2. Thygesen K et al, 2012, ‘How to use high sensitivity cardiac troponins in acute cardiac care, European Heart Journal, 33, 2252-2257
Tuesday
Apr222014

Are you sure you want me to see this patient?!

The case:

52 year old man presenting with a 5/7 history of diffuse lower abdominal pain

He had been febrile for 3/7, had some nausea and vomiting and had not opened his bowels for 5/7.

He was otherwise well with no regular medications or past medical history

On examination he was febrile to 39 degrees celcius, tachycardic at 108 bpm with a peritonitic abdomen.

Surgeons were consulted and a CT scan organised.

Bloods had been taken before I reviewed the patient and were pending.

Prior to the CT scan the surgical registrar arrived to review the patient and had a look at the bloods which included a high sensitivity troponin (?!)

Unfortunately, this was elevated at 461, prompting the question above.

I was quite surprised by this reading and went back to reassess the patient.

He denied any chest pain, and was very fit and active with a good exercise tolerance and no risk factors.

Serial ECG's were performed (normal) and a repeat troponin was taken which was still elevated at 161.

The on call cardiologist was then consulted who advised that this was a false positive test and that we should disregard the troponin.

Like most of us I am still trying to get my head around the new HS troponin assays.

I was lucky enough to attend the SMACC conference this year and heard Louise Cullen and Rick Body speak on this issue.

They were both of the opinion that the HS troponin is very specific for heart damage (and shouldn't be raised at all if the heart is not affected) and if there were elevations it was due to an insult of some sort (though not necessarily ischaemia).

Based on that logic it would seem that the patient must have had a type 2 myocardial infarction....but I'm still quite sceptical that this occured in the patient given how fit and healthy he normally was.

Would be very keen to hear others thoughts and in particular if they had any information on this issue!

The patient subsequently had a CT that showed a perforated appendiceal abscess and went to OT where he was found to have 4 quadrant peritonitis with multiple adhesions.

He was discharged 6 days later and has been fine since.

Tuesday
Feb112014

TAPNA 2014

G'day All,

On April 30th till 3rd May Newcastle will once again host the Toxicology And Poisons Network Australasia, TAPNA, scientific meeting. The plenary sessions will include talks on marine poisoning, the latest in redback envenoming following the RAVE II trial and a session on addiction medicine. Go to www.tapna.net for information. 

On Saturday 3rd May we will be running a one day Toxicology workshop aimed at ED/acute care trainees, final programme will be on the website within the next week. Early bird price is $250.00 Hoping a few of you can make it. This is the weekend of the fellowship clinicals so obviously those involved in that won't be coming but everyone else !!!

Finally, the slideshare website through which I put up some of last year's talks as well as Sam Vidler's presentation from last year, is going to discontinue the slidecast service soon. This means that after April you won't be able to access any of the audio-visual presentations. I am hoping to have these (and some more talks) up on a different platform soon.

thanks

Michael

Tuesday
Feb042014

neonatal urine collection

.....just wondering if anyone has tried tapping out a babies urine?...

Amy

 

(post on AliEM)

http://academiclifeinem.com/trick-of-the-trade-urine-collection-in-neonates/

 

The Case: A 8-day-old, uncircumcised male is brought to the ED with fever, irritability, and decreased urination.
 
The Problem: Getting a clean catch urine in a timely, non-invasive manner
 
The Solution?

 Trick of the Trade

  1. Provide oral intake to the neonate
  2. 25 minutes after feeding, clean genitals with soap and water; dry with sterile gauze
  3. Give non-pharmacologic analgesia (Pacifier or 2% sucrose syrup)
  4. One person holds neonate under the axilla with feet dangling
  5. Another person starts bladder stimulation with gentle tapping of the suprapubic area (100 taps/min) and stimulation of lumbar paravertebral zone (light circular massage)
  6. Perform steps 4 and 5 for 30 secs at a time, as many times as needed
  7. Catch midstream urine sample in a sterile collection container

Study Publication [1]

  • Study methodology:
    • Prospective feasibility and safety study
    • Single center in Madrid
    • 80 neonates (31 girls and 49 boys)
    • Mean ages: 6.66 day old boys and 6.23 day old girls
  • Results:
    • 86% success rate in obtaining urine in
    • Mean time for sample collection: 57 sec
    • Mean time spent collecting samples in males: 60.48 sec
    • Mean time spent collecting samples in females: 52.04 sec
  • Limitation: Lack of control group
  • Conclusion: Based on a previous study using a vibrating bladder stimulator [2], this manual method to obtain midstream urine in newborns is safe, quick, and effective.
Screen Shot 2013-04-17 at 11.00.35 PM copy
 

BOTTOM LINE

Urine collection in neonates is a time-consuming and unpredictable task that requires time and attention. Although a small study, this new technique does not cause discomfort or waste time as is typically the case with catheterized urines and bag collection methods, respectively.

References

  1. M.L. Herreros Fernández, N. González Merino, A. Tagarro García, B. Pérez Seoane, M. de la Serna Martínez, M.T. Contreras Abad, and A. García-Pose, "A new technique for fast and safe collection of urine in newborns.", Archives of disease in childhood, 2012. http://www.ncbi.nlm.nih.gov/pubmed/23172785
  2. P. Davies, R. Greenwood, and J. Benger, "Randomised trial of a vibrating bladder stimulator--the time to pee study.", Archives of disease in childhood, 2008. http://www.ncbi.nlm.nih.gov/pubmed/18192318
Friday
Dec202013

ED drinks

Hi everyone,
It has been a while since we had end of term drinks in ED. It is always tricky to get everyone there at once of course with shift work, exams, kids and life in general. But what about we give it a try in 2014?? A few people will be leaving hne or leaving ED next year and I thought it wd be nice to meet up before next term.
What about drinks on Friday 31/01/14??? I am afraid I can't really recommend a good drinking spot though. I will leave that decision to the more experienced drinkers...
Have a safe and happy Christmas and New Year!!!
Adeline. 

Sent from my iPhone

 

Thursday
Dec192013

Anaphylaxis 4

This is the fourth and last instalment of Simon Brown's anaphylaxis workshop from TAPNA 2013. It covers treatment so the most clinically relevant. Goes for about 20 minutes. 

Click here

Monday
Dec162013

Latest Critical Care research - Practice changing?

Gajendragadkar and colleagues undertook a multicentre, prospective, covert observational study, examing the survival times of chocolates (n=258), both Quality Street (Nestlé) and Roses (Cadbury), on four UK wards, and found:

  1. 191 out of 258 (74%) chocolates were observed being eaten
  2. mean total observation period was 254 minutes (95% CI 179 to 329)
  3. median survival time of a chocolate was 51 minutes (39 to 63)
  4. chocolate consumption was non-linear, with an initial rapid rate of consumption that slowed with time
    • an exponential decay model best fitted these findings (model R2=0.844, P<0.001)
  5. survival half life (time taken for 50% of the chocolates to be eaten) was 99 minutes.
  6. mean time taken to open a box of chocolates from first appearance on the ward was 12 minutes (95% CI 0 to 24)
  7. Quality Street chocolates survived longer than Roses chocolates (hazard ratio for survival of Roses vs. Quality Street 0.70, 95% CI 0.53 to 0.93; P=0.014)
  8. percentages of chocolates consumed were by
    • healthcare assistants (28%) 
    • nurses (28%)
    • doctors (15%)

Full Text:  Gajendragadkar. The survival time of chocolates on hospital wards: covert observational study. BMJ 2013;347:f7198

Saturday
Dec072013

THIS is the point I was trying to make...

for those of you who were present at thursday teaching session, I gave a talk on using the FOAMed resources more then wasting your time attempting to critique articles and used the TTM trial published recently as an example....  leave it to someone from NZ to make the point much more succint then I?   see below.  but you should get in and be a part of the discussion, say, at next thursday M&M journal club where the TTM trial is going to be discussed... cheers.scott

great quote:

For the new docs I (this is heresy) recommend you don’t spend too much time reading original research.  You have too much to learn, and you need to get the big picture and not get lost in the detail.

http://emtutorials.com/2013/12/eminence-evidence-based-medicine/

here is my talk and resources used: click here

Wednesday
Nov272013

52 articles in 52 weeks: Landmark EM articles

In case you didn't see this on ALiEM, nice that someone has collated them. Not necessarily all relevant to our day to day practice but maybe worth picking out a few to be familiar with. I like the 'one a week' concept, makes it seem more manageable. 

http://academiclifeinem.com/52-articles-in-52-weeks-landmark-em-articles-2013/