Conference Follow Up: September 4th 2013

Dr. Gatton's Trauma lecture:

1 - Hypothermia in trauma? We discussed how although we always learn that hypothermia is bad for trauma ... it is part of the deadly triad. However, there are some theories that it could improve outcomes, particularly in head trauma. See this cochrane review on hypothermia in head trauma. Although limited in study quality, and finding no statistically significant improved outcome, there was a trend toward mortality benefit. Take a look at it yourself.

"The review authors found that fewer people died or became severely disabled if they were treated with hypothermia, but this finding may be due to chance. It was also found that patients given hypothermia were more likely to develop pneumonia, and some patients died from pneumonia, but the increased risk of pneumonia could also be due to chance. "

2- Hyperventilation in ICH. We discussed the role of hyperventilation to decrease ICP and improv CPP in intracranial hemorrhage/trauma. Below are some resources on this debated topic.

Here is a great review article in CHEST. 

AHA Intracranial Hemorrhage GUIDELINES:

"Hyperventilation
Hyperventilation is one of the most effective methods available for the rapid reduction of ICP. The CO₂ reactivity of intracerebral vessels is one of the normal mechanisms involved in the regulation of CBF. Experimental studies using a pial window technique have clearly demonstrated that the action of CO₂ on cerebral vessels is exerted via changes in extracellular fluid pH.⁷⁴ Molecular CO₂ and bicarbonate ions do not have independent vasoactivity on these vessels. As a result, hyperventilation consistently lowers ICP. Despite the effectiveness of hyperventilation in lowering ICP, broad and aggressive use of this treatment modality to substantially lower PCO₂ levels has fallen out of favor, primarily because of the simultaneous effect on lowering CBF. Another characteristic of hyperventilation that limits its usefulness as a treatment modality for intracranial hypertension is the transient nature of its effect. Because the extracellular space of the brain rapidly accommodates to the pH change induced by hyperventilation, the effects on CBF and on ICP are short-lived. In fact, after a patient has been hyperventilated for >6 hours, rapid normalization of arterial PCO₂ can cause a significant rebound increase in ICP. The target levels of CO₂ for hyperventilation are 30 to 35 mm Hg. Lower levels of CO₂ are not recommended.^75"

Bites:

1- Study on primary vs secondary closure of dog bite wounds: Great discussion of dog bites. Study showed significant cosmetic improvement with early closure with no statistically significant change in infection rate.

2- Link on how and when to report animal bites to the NYC.gov health department.

Oncologic Emergencies

1- Attached are two awesome Evidence Based Medicine articles from 2010 on Oncologic Emergencies. 

2- We discussed the early ultrasonographic signs of pericardial tamponade. We can all easily see effusions, but which ones are resulting in tamponade physiology require some advanced echo techniques that we can all learn. This will make us rock stars when presenting the patient with greater urgency to our Cardiothoracic colleagues. See the below links for studies and tips.

 Probably the best ARTICLE on US Findings in Tamponade

Here is a fantastic review from Stanford's ICU with great diagrams, images and figures to explain the physiology. 

NEJM Review Article on Tamponade: 

n the absence of my- ocardial disease or injury, echocardiography dem- onstrates the usually circumferential fluid layer and compressed chambers with high ventricular ejection fractions.24 Doppler study discloses marked respiratory variations in transvalvular flows. One mechanism of pulsus paradoxus is visible: on inspi- ration, both the ventricular and atrial septa move sharply leftward, reversing on expiration1; in other words, each side of the heart fills at the expense of the other, owing to the fixed intrapericardial volume. The inferior vena cava is dilated, with little or no change on respiration.Among echocardiographic signs, the most char- acteristic, although they are not entirely specific, are chamber collapses, which are nearly always of the right atrium and ventricle. During early diastole, the right ventricular free wall invaginates, and at end di- astole, the right atrial wall invaginates.25 Right ven- tricular collapse is a less sensitive but more specific finding for tamponade, whereas right atrial col- lapse is more specific if inward movement lasts for at least 30 percent of the cardiac cycle. Right atrial collapse may be seen in patients with hypo- volemia who do not have tamponade. In about 25 percent of patients, the left atrium also collapses, and this finding is highly specific for tamponade. Left ventricular collapse usually occurs under spe- cial conditions such as localized postsurgical tam- ponade. These wall changes occur when respective chamber pressures temporarily fall below the peri- cardial pressure.24,25 

Should we be ok letting the GI specialist sleep?

Variceal bleeding is a frightening condition seen infrequently in the ED, but when it shows its face it sparks high anxiety. It is one of the most rapid type of not compressible bleeding (unless you consider the blakemore), in my eyes it is comparable to intraperitoneal traumatic bleeding.  Can we as EP's simply rely on medical management and stabilization or is our gut right when we say, "where is G.I. , they've got to come in for this?" This is a debate, seemingly more one-sided as most of the literature on it is from gastroenterology journals and may be skewed toward our colleagues' opinion (our 'Annals' does not have a single paper with "esophageal varices" or "variceal" in the abstract or title). What is the right thing to do for our patients?

You can imagine, a "cushy" subspecialty like gastroenterology having private conversations amongst
each other at national conferences, discussing how they could convince the world that they need not speed over to the hospital at 4am for an emergent endoscopy.  Their desire to never be awoken from their slumber however has given birth to a hubris of new extremes.  With a massive review paper published in the Canadian Journal of Gastroenterology titled, "Emergency management of bleeding esophageal varices: Drugs, bands or sleep?"  they have comfortably convinced themselves that because the jury is still out, they will continue to sleep. 

In conclusion of this extensive study they authors state:

"Timing of definitive endoscopic treatment has not been clearly defined. Delaying endoscopic treatment may make it easier to perform in a clear, bloodless field, especially for band ligation. Current data suggest no difference in control of hemorrhage or mortality in the setting of pharmacological therapy if endoscopic treatment is delayed up to 48 h. Therefore, to the probable delight of gastroenterologists on call, we recommend that emergency endoscopic treatment (less than 6 h from presentation) be reserved for continuing bleeding resistant to initial pharmacological treatment."

The interesting thing is that they confidently make a very serious, consequence-heavy "recommendation" to delay emergent endoscopy several paragraphs after this one (within their limitations section) :

"Excellent meta-analyses are available for octreotide, terlipressin and comparisons with sclerotherapy; however, pharmacological treatment and band ligation have not been directly compared. Therefore, while band ligation may appear to be superior to other methods of treatment, this conclusion is still premature."

As well as, and perhaps more strikingly after this one:

"The only study to directly address timing was by Shemesh et al (35), who analyzed whether emergency sclerotherapy was more effective than stabilization and elective sclerotherapy ... Emergency therapy stopped all acute bleeding and resulted in decreased rebleeding in hospital (4.7% versus 17.1%, P=0.027) and by one year (7.0% versus 17.1%, P=0.027). There was an insignificant trend showing improved mortality in hospital and at one, three and five years after follow-up in the emergency sclerotherapy group."

The above was within their "can or should we wait" section. Aside from the casual mention of the ONLY study that EVER addressed emergency endoscopic intervention (scleropathy in the study) vs. stabilization and waiting, they also appear to believe that "band ligation may appear to be superior to other methods." This was clearly pointed out in their mention of a meta-analysis by Gross et al (Endoscopy. 2001 Sep; 33(9):737-46) showing banding more successful than pharmacologic treatment (without timing directly compared). 

Shockingly (phh), they have a small section of the review boasting combined pharmacologic and endoscopic therapy as improving mortality and "initial control of bleeding" (once again without specified timing). This was from a meta-analysis in Hepatology. (Hepatology. 2002 Mar; 35(3):609-15)

It appears their main reasoning for recommending delayed endoscopic therapy is the lack of evidence to the contrary at the moment. They point to various end-point, inclusion criterion, timing, and dosing differences amongst the studies they used. One study they use to demonstrate "no difference in bleeding or mortality" between emergent and delayed endoscopy firstly used scleropathy (which they deem inferior to ligation) and secondly although it had no statistically significant differences in end points it does have some trends that are notable. (Lancet. 1993 Sep 11; 342(8872):637-41)
Of note, scleropathy now has been almost entirely abandoned as "standard of care" as Villanueva et al demonstrate in this study from 2008.


What's new:

New literature appears to support our "gut" that waiting and watching these variceal bleeders decompensate in our ED is not ideal management:

(2012 Paper:) A prospective cohort study published in 2012 revealed statistically significantly differences in bleeding and mortality.  "In hematemesis patients, 6-week re-bleeding rate (18.9% vs. 38.9%, p=0.028) and mortality (27% vs. 52.8%, p=0.031) were lower in those with early (≤ 12 h) than delayed (>12h) endoscopy."

(2005 and 2010 Papers):  Consensus papers from the international expert "Baveno" consensus group which has standardized the methodology of studying variceal hemorrhage recommends performing endoscopy "as soon as possible."

Likely adding to the G.I. chatter in support of staying in bed:

(2009 Paper): Cheung et al conclude no clinical difference in bleeding or mortality in 4 vs. 8 vs 12 hour endoscopy. However, these were all hemodynamically stable bleeders. No patient with unstable hemodynamics was included.
Of note, this study is listed as being cited in 24 other peer reviewed articles. We always have to keep in mind the inclusion criteria. I think this study can essentially be written off, as the debate we are having is whether the sickest, most unstable (requiring crystalloid and blood resuscitation, and medications) should be getting emergent endoscopy.


Also interesting: 

The NNT review for Octreotide is pretty sobering as well. No mortality benefit from their perspective.


I believe that yes, this is still a controversy. Until a well done, multi-centered RCT is performed comparing apples and apples, with timing being the only variant, we may not ever have a solid answer. Until then, I think that there is plenty of good science as well as expert consensus recommending emergent, "as soon as possible" endoscopic therapy of acute variceal bleeders. I will continue to fight for this, for my patient in the ED exanguinating from above and below while awaiting midnight consultation.

Changing the Mistake Culture

Read the Article here.

Tell me something like this won't happen to EACH of us, if it has not already.

"This ER was always busy, and the administration had been pressuring us to move patients through more quickly. I examined Claire briefly and saw no worrisome signs. X-rays of her neck showed nothing wrong; I assumed she had slept wrong or pulled a muscle. So I discharged her with some pain medication and picked up the next chart in the bottomless stack.

The next morning we received a call from an ambulance transporting a female who had suffered cardiac arrest. She was brought into the resuscitation room, where we continued CPR. I didn’t recognize her at first, but then I noticed a familiar-looking son and daughter sobbing in the hallway. I looked at the lifeless patient and almost broke into tears myself. In my rush the day before, I hadn’t listened carefully to Claire’s complaint of severe headache. Now it seemed clear to me that I’d overlooked a symptom of an impending stroke."

We Need A Mechanical CPR Device!!!

Category: Cardiology

Title: Mechanical vs. Manual Chest Compressions

Posted: 7/21/2013 by Semhar Tewelde, MD
Click here to contact Semhar Tewelde, MD

• A recent meta–analysis of 12 studies (6,538 patients with 1,824 ROSC) assessed the quality of cardiopulmonary resuscitation (CPR) using either manual vs. mechanical (load-distributing or piston-driven) compressions in out-of-hospital cardiac arrest
• Compared w/manual CPR, load-distributing band CPR had significantly greater odds of ROSC (odds ratio, 1.62 and p<0.001)
• The treatment effect for piston-driven CPR was similar to manual CPR
• The difference in percentages of ROSC rates from CPR was 8.3% for load-distributing band CPR and 5.2% for piston-driven CPR
• Compared with manual CPR, combining both mechanical CPR devices produced a significant treatment effect in favor of higher odds of ROSC with mechanical CPR devices (odds ratio, 1.53 and p<0.001)

References

Westfall M, Krantz S, Mullin C, Kaufman C. Mechanical versus manual chest compressions in out-of-hospital cardiac arrest. Crit Care Med 2013 Jul; 41(7):1782-9

LINK to Study

Television Distorts CPR and Death Realities

http://www.nejm.org/doi/full/10.1056/NEJM199606133342406#t=articleMethods

"Rates of long-term survival after cardiac arrest as reported in the medical literature vary from 2 percent to 30 percent for arrests outside a hospital, and from 6.5 percent to 15 percent for arrests that take place inside a hospital.6-19 For average elderly patients, the rate of long-term survival after cardiac arrest outside a hospital is probably no better than 5 percent. For arrests due to trauma, the reported survival rates vary from 0 to 30 percent.22-25 Clearly, the rates on television are significantly higher than even the most favorable data reported in the literature."

Ultrasound Competition: July WINNER

Ryan Giorgetti for the following case:

Older male w PMHx of PUD came in w abdominal pain w n/v.  On arrival was tacky with HR 140, BP 98/70.  Exam significant for rigid abdomen.  CXR showed free air.  FAST exam showed significant free complex fluid.  Found to have perforated duodenal ulcer in the OR.

Approaching the "Altered Mental Status"

Dr. Lin @ UCSF puts together a great blog with up to date resources. She is famous for her info cards for EM called "Paucis Verbis."  Check those out HERE.

This blog is a great refresher and review of how to approach the elderly patient with "Altered Mental Status" which is one of the most vague, yet common chief complaints we see. It is the essence of emergency medicine, as it is a complex and concerning complaint and the most "undifferentiated" patient presentation you can get. Take a look at the blog HERE.