Saturday, January 4, 2014

Sux in Head Injury

The confirmation Ive been looking for!

US Diagnosis of Intraperitoneal Air

Very cool, from this study. Id be curious if this reverb artifact exists without significant free fluid?

This demonstrated free intraperitoneal fluid in Morison’s pouch (Video Clip S1). Upon attempting views of the pelvis, distinct hyperechoic foci with reverberation artifacts were visualized within the free fluid, suggesting associated free intraperitoneal air (Video Clip S2). 

A new syncope rule? The Anatolian Syncope Rule (Turkey)

Check out this Turkish paper which has developed a syncope rule VERY sensitive for adverse events. Makes me rethink butting heads with medicine when they ask for orthostatics (as this syncope rule finds orthostasis highly correlating with adverse events). It is yet to be validated by anyone outside of Turkey.

Of important note the rule is, as they state: 
The newly proposed ASR performed with higher sensitivity but lower specificity when predicting mortality

Read the paper here.

Below are the 6 parameters with high predictive value for adverse events:
Inline image 1

Im not sure how to interpret the "precipitating cause" (maybe someone -Melville or Amisha?), from their results section they state:

 Precipitating factors were drugs, diabetes and neurologic disorders in patients with orthostatic syncope (40% of the known precipitating group). Fever, dehydratation, fasting and long standing were the precipitating factors in vasovagal syncope (45% of the known precipitating group). The other 15% were due to arrhythmia and cardiogenic causes.

Wednesday, January 1, 2014

Why do we discharge, and can we predict bounce back?

Fascinating paper on discharge decision making. They analyzed why the physician discharged.

Most physicians (even these Canadians who we often perceive as being more algorithmic) stated they used clinical judgement (nearly70%) compared to evidence-based reasoning.

Also, the adverse event rate in 366 discharges was low. 10. With only one death. HOWEVER, upon review by 3 trained ED physicians almost all of these were deemed to be PREVENTABLE.

Its a provocative paper and offers and interesting discussion on discharge decision making which is one of the heaviest tasks we have.

Here is the Paper.

Tuesday, December 17, 2013

Champagne Lit Review: Sgarbossa in Ventricular Pacing

Sgarbossa in Ventricular Pacing

Slightly off conference topic, we had a case in the department where a patient with active chest pain had Sgarbossa criteria in the presence of ventricular pacing. Cardiology did not consider it  STEMI. There was delayed PCI, which later showed 100% LAD occlusion. I decided to pursue the literature:

Mattu seems convinced. The literature however is not very robust. Theoretically, right sided endocardial paced rhythms should have similar electrical patterns to LBBB and thus reflect the same obscuration during ischemia. The high specificities in the studies below gives confidence that we are looking at STEMI equivalents, but there aren't huge numbers (like the tens of thousands in the LBBB Gusto group) enough to change protocols or to convince lazy cardiologists to treat these as STEMIs.

Still seems like the right thing to do, with good but limited evidence in its support. I'd call these STEMI codes and let the cardiologists decide. Especially if the patient looks sick and vomits on your pants.

94%/88%/82% specificity for the three criteria

Sgarbossa Sensitivity in V-Paced: validation study of Sgarbossa GUSTO Ventricular paced date (n=57)
high SPECIFICITY for concordant depression V1-3 and Excessive discordance

     -makes no mention of analyzing ventricular paced ECGs
     -V-Paced not included in definition of LBBB

Monday, October 28, 2013

Conference Follow Up: 10/23/13

As usual, here is a brief supplementary email for this week's conference:

Each week I send a post conference email I'm gonna add 2 new musicians I think you should check out (lemme know what you think of the idea):


Now to the Medicine:

Chest Tube Placement:

Video on procedure (skip to the 4 minute mark!)

Some people were asking about Clamshell Thoracotomy, here is a fantastic overview with graphic images from the atlas.

Troponin (nice grand rounds Joe):

Here is a great overview and simplification of the very complicated discussion regarding HIGH SENSITIVITY TROPONIN, from Academic Life in EM.

Inline image 3

Some of the most interesting bullet points from this review were these:
  • High sensitivity Tn requires only 2 to 3 hours between time of initial lab and repeat Tn to see a conclusive increase to rule in AMI [1]
  • A normal hsTn at 3 hours has a NPV of 99% in excluding AMI [2] 
Here are the references for those bullets:
  1.  V.S. Mahajan, and P. Jarolim, "How to interpret elevated cardiac troponin levels.", Circulation, 2011.
  2.  A.S.V. Shah, D.E. Newby, and N.L. Mills, "High sensitivity cardiac troponin in patients with chest pain.", BMJ (Clinical research ed.), 2013.

The Overtesting/Overscreening Phenomenon (as discussed by Dr. Jahnes):

Here is a link to the pubmed search results for ALL of Dr. V Prasad's papers. (Dr. Jahnes' new hero)

This one was my favorite, it was a literature review on contradictory data regarding medical therapies. 

This is a BMJ article on the evidence for over diagnosis of PE:
Inline image 2

Submassive Pulmonary Embolism Journal Club

Here is a great summary of the management of submassive PE

Perhaps this discussion will clarify some of the words that were incapable of leaving my mouth this morning (hah), it is a podcast summarizing the submassive PE thrombolysis trials. Keep in mind the bias as the two physicians talking are prominent authors and Stavros is the MAPPET lead investigator. (grain of salt required).

Inline image 1

Tuesday, October 22, 2013