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:

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.

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.

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.

 

Mattu Lecture on Sgarbossa in Pacemaker

Original Sgarbossa GUSTO V-Paced Subset data (n=17)

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

The original NEJM Sgarbossa GUSTO-1 paper

     -makes no mention of analyzing ventricular paced ECGs

     -V-Paced not included in definition of LBBB

Paper excluding 5mm excessive discordance as STEMI criteria

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):

MUSIC

#1 Canadian indie rock band based out of montreal

#2 Cool Icelandic composer/mixes w/ electronic

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 trauma.org 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.

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. http://www.ncbi.nlm.nih.gov/pubmed/22105197
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. http://www.ncbi.nlm.nih.gov/pubmed/2387815

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:

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).

ACEP Clinical Policy on PE Management:

Journal Club Articles

Here is a nice general overview of the topic if you're interested in reading before you get to the individual studies. 

http://circ.ahajournals.org/content/123/16/1788.full

Articles:

http://www.nejm.org/doi/pdf/10.1056/NEJMoa021274

http://journal.publications.chestnet.org/article.aspx?articleid=1090134

Abstract: (article to come in full form from the library) http://www.ncbi.nlm.nih.gov/pubmed/23102885

9/11/13 Post Conference Summary

This is the second post-conference email. Hope it helps.

Vasopressors in Shock (Lecture by Dr. Keshava)

This is a GREAT SUMMARY of the updates in the surviving sepsis guidelines of 2012.

-30cc/kg bolus (1A)

-albumin if using high volumes (2B)

-NOT providing steroids if fluids work

• Authors strongly recommend norepinephrine (Levophed) as the first choice for vasopressor therapy (Grade 1B). Vasopressin 0.03 units / minute is an alternative to norepinephrine, or may be added to it (Grade 2A).
• When a second agent is needed, epinephrine is their weakly-recommended vasopressor choice (Grade 2B).

Pediatric LP/Septic Workups (Lecture by Kirsten Malone):

Good Video of infant LP

-attached to this email is the uptodate.com summary of the three major infant fever protocols

-there is a lot of controversy regarding continuing to follow these protocols, this is because the protocols were developed in the 90's before true herd effect of H.flu, '88 pneumococcal vaccine, and the updated 2000 pneumococcal vaccine. 

-Some people believe prevalance has dramatically decreased, which significantly decreases pre-test (pre-septic workup) probability

CPC: Cases: 

Aortic Dissection: Attached to this email is the IRAD study which is retrospective analysis of clinical features of  confirmed Ao Dissection.

Also, this study is a validation study of a prediction tool developed by AHA used IRAD data. 

Asthmatic: 

Continuous Bladder Irrigation:

-funny how the resident was making recommendations for us to NOT perform this in the ED. Thanks to Melville for pointing out that the Uro attendings more often than not are the ones who ask us to perform this.

-not sure if anyone heard me belly laugh when he commented that "if the pt needs CBI, it probably needs a Urologist to urgently evaluate the patient". HAHA. I can count on one hand the times ive seen a uro attending in the ED. We manage their patients, including procedural complications, bleeding, obstruction, etc. I find it funny that the thought is that we should be waiting for them to evaluate these pts.

- Ok enough ranting. Here is some info:

-CBI Procedure Video

-Foley Irrigation Video (skip to minute 3, this is an old school vid)

-Cool lecture on Obstruction

FAST

-Check out Sonospot.com and go to the Sono Studies or Sono Tutorial on the right side menu and find E-FAST

Attached is a lecture I gave on the EVIDENCE FOR FAST EXAM

Studies:  in blunt trauma

Pediatric Sepsis Management:

-as Dr. Melville pointed out, rule #1 is DO NOT SIT AND INTELLECTUALIZE while the kid is dying.

-aside from that , here are some guidelines.

Ultrasound Competition WINNER for AUGUST

Dr. Laura Melville  AND Dr. Mike McMahon

Youngish F hx thombophilia, DVT, PE s/p IVC placement presenting to the ID for suprapubic pain sudden, back pain for a week and arrived hypotensive, diaphoretic and tachycardic.

Vitals 70systolic, HR 120s. sat 99%.

In ED bedside echo showed massively dilated >1:1 RV:LV and PSS showed D sign. This essentially diagnosed PE.

Arrival to ED. pt got intubated, pressors, recieved tPA in ED. She was admitted to the ICU and found to have bilateral PE's with RLL infarction.

Update:

4 days later:  Discharged. Placed on Xarelto. Pt extubated, off pressors, ECHO shows normal LV EF 62%, RV pressure = 50