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9 minutes | 2 days ago
REBEL Cast Ep96: Heroin OD – Is a 2-Hour Observation Protocol Long Enough?
Background: Opioid-related emergency department visits have been increasing over the past two decades in correlation with increasing rates of heroin use in the United States. Naloxone, which is used to reverse heroin overdose, has a half-life of approximately 60 to 90 minutes (2). A 4 to 6 hour observation period after naloxone reversal has typically been recommended to account for a duration of 5 half-lives of naloxone, and Goldfrank’s Toxicologic Emergencies recommends several hours of observation following naloxone reversal of heroin overdose (2). Systematic reviews have recommended as low as a 1-hour observation period (3). However, early discharge may be dangerous given both the short half-life of naloxone and the possibility that the purported heroin may have been adulterated or may have been another substance entirely, such as fentanyl analogs. This study attempted to determine the safety of a 2-hour observation period after naloxone administration for heroin overdose, which was chosen based on the half-life of naloxone. REBEL Cast Ep96: Heroin OD – Is a 2-Hour Observation Protocol Long Enough? Click here for Direct Download of Podcast Article: Heaton et al. Retrospective Review of Need for Delayed Naloxone or Oxygen in Emergency Department Patients Receiving Naloxone for Heroin Reversal. JEM 2019. PMID: 30961922 Clinical Question: What is the safety of a 2-hour observation period for heroin overdose patients who have received naloxone? What They Did: A single-center retrospective chart review of patients who presented to the emergency department for heroin overdose who received naloxone (n=806). The primary outcome was the rate of intervention, grouped by length of observation period at the time of intervention. Primary Outcome: Observed rate of intervention (i.e. repeat dose of naloxone or supplemental oxygen) 2 hours after the initial naloxone dose Inclusion: Patients who presented to the emergency department for heroin overdose between January 1, 2009 through December 31, 2014 who received naloxone Exclusion Criteria: If the chart did not indicate that heroin overdose was the cause of the presentation to the emergency department (e.g., if the chart noted opioids but did not specify the type of opioid or if the chart noted prescription opioid use) Missing prehospital or emergency department chart data (i.e. route, dosage, and time of initial naloxone dose) Results: 1384 patient visits were for heroin-related complaints, and only 844 patients received naloxone. For demographics, most patients were male, and the most common mode of transportation was by ambulance. Most patients in this cohort used heroin intravenously, 13% required 2 doses of naloxone, 2.5% required ≥3 doses of naloxone, and most patients received naloxone prehospitally (78%). Polysubstance use that included other opioids were excluded from the study, but other coingestants were common. Table: Demographics The median initial naloxone dose was 2.0 mg. For patient outcomes, 5 percent were intubated by the prehospital team and 2 percent were intubated by the emergency physician in the emergency department. 80 percent of patients were discharged home, 8 percent were admitted to the medicine floor, 3 percent were admitted to the ICU, 5 percent were admitted to psychiatry, and 2 percent left against medical advice. 0.62% (5 patients) died as a result of heroin. 7 patients experienced pulmonary edema, and 6 of 7 of the cases of pulmonary edema were identified before 2 hours of observation. 37 patients (4.6% of patients) required an intervention, either supplemental oxygen or repeat naloxone dosing, greater than 2 hours after the observation period began. 15 patients (1.9% of patients) required either supplemental oxygen or repeat naloxone dosing greater than 3 hours after the observation period began. 7 patients (0.9% of patients) required either supplemental oxygen or repeat naloxone dosing greater than 4 hours after the observation period began. Table: Patients who required repeat naloxone or supplemental oxygen, hours after observation period began 56% (n=458) of patients were found to have polysubstance use, as determined by self-report and toxicological testing (urine or serum testing). Depressant use (e.g., barbiturates, benzodiazepines, or antipsychotics) was correlated with the use of repeat naloxone doses (p < 0.01). Strengths: This study provides further evidence for a topic that is controversial in emergency medicine and toxicology literature, and heroin overdose is frequently encountered in the emergency department Limitations: This study was only for patients presenting with reported heroin overdose and does not apply to other opioids; however, both in this study and in practice it is often difficult to determine what substance was used Routes of administration of heroin may affect the pharmacokinetics Intranasal naloxone has different pharmacokinetics than intravenous or intramuscular naloxone, with persistence of plasma concentrations for a longer duration of time (5) The outcome of requiring supplemental oxygen or repeat naloxone dosing are influenced by individual physician practice, and perhaps a more objective primary outcome would have been better (i.e. the reason for supplemental O2 was not present for every patient) Repeat naloxone administration is a surrogate for recurrent opioid toxicity. It is unclear whether repeat doses were given due to hypoxia, altered mental status, or other reasons If naloxone was given by EMS en route to the hospital, the time at presentation to the emergency department was listed as the time naloxone was administered. It is important to note that this study was therefore testing for the duration of the observation period and not the time from naloxone administration in all cases The number of patients with polysubstance use and preexisting conditions was too small for analysis of these subgroups The true rate of polysubstance use is most likely underestimated in this trial as self-reporting was used instead of toxicology screens on every patient. Although toxicology testing can confirm a particular substance it does not necessarily indicate intoxication at the time the test was performed Discussion: This study found that 4.6% of patients required an intervention of either repeat naloxone dosing or supplemental oxygen after 2 hours of observation. This study provides evidence against the 1-hour observation period (4). Also, although this study was not designed specifically for prehospital medicine, it provides evidence against non-transportation of patients after treatment with naloxone. The majority of patients (60%) who required interventions after 2 hrs received naloxone dosages ≥2mg and 90% received naloxone dosages ≥1mg. Additionally all but one case of pulmonary edema (6 out of 7) and aspiration pneumonia (16 of 17) were evident within 2hrs of ED arrival. An observation period of 3 hours would have identified all but 2 of these cases (1 for each adverse event). We have discussed the HOUR protocol before on REBEL EM (Link is HERE) looking at a 1-hour observation protocol and felt it was too focused on throughput and missed too many complications. In that cohort only 1 patient required an additional dose of naloxone after the 1 hour mark. However, if the patients in this trial were used, a one-hour observation period would have missed significantly more complications (i.e. repeat naloxone dosing or O2 administration). Authors’ Conclusions: “A 2-h ED observation period for heroin overdose patients reversed with naloxone resulted in a delayed intervention rate of 5%. Clinicians may consider a 3-h observation period, with extra scrutiny in polysubstance abuse.” Clinical Take-Home Point: A 1-hour observation period after naloxone administration for suspected heroin overdose is too short a period of observation. Consider at least a 3-hour observation period and perhaps longer if the patients have consumed coingestants. References: Heaton et al. Retrospective Review of Need for Delayed Naloxone or Oxygen in Emergency Department Patients Receiving Naloxone for Heroin Reversal. JEM 2019. PMID: 30961922 Nelson L, Lewin N, Howland MA, Hoffman R, Goldfrank L, Flomenbaum N. Goldfrank’s Toxicologic Emergencies. 9th ed. New York, NY: McGraw-Hill Medical; 2015. Willman MW et al. Do Heroin Overdose Patients Require Observation After Receiving Naloxone? Clin Toxicol 2017. PMID: 27849133 Clemency BM et al. Hospital Observation Upon Reversal (HOUR) with Naloxone: A Prospective Clinical Prediction Rule Validation Study. Acad Emerg Med 2019. PMID: 30592101 McDonald R et al. Pharmacokinetics of Concentrated Naloxone Nasal Spray for Opioid Overdose Reversal: Phase I Healthy Volunteer Study. Addiction. 2018. PMID: 29143400 For More on This Topic Checkout: REBEL EM: The HOUR Trial – Clinical Decision Rule for Opioid OVerdose Patients in the Emergency Department Tox and Hound: Great! Naloxone Worked! Now What? Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie) The post REBEL Cast Ep96: Heroin OD – Is a 2-Hour Observation Protocol Long Enough? appeared first on REBEL EM - Emergency Medicine Blog.
6 minutes | 2 days ago
REBEL Core Cast 50.0 – Superficial Venous Thrombosis
Take Home Points SVT >5cm or <3 cm from the SFJ should be treated with anti-coagulation. The rate of concurrent DVT and PE in patients with SVT is 25% and 5%, respectively. REBEL Core Cast 50.0 – Superficial Venous Thrombosis Click here for Direct Download of Podcast Definition: The presence of a clot in a superficial vein. Epidemiology: Although large prospective trials are lacking, superficial venous thrombosis (SVT) has been reported occur at a rate of 4 in 1000 per year in the US (Blumenberg 1998, Coon 1973) As a comparison, the incidence of venous thromboembolism (VTE) is estimated to occur in 1 in 1000 per year. (White 2003) The most common locations of SVT of the lower extremity are: (Cosmi 2015) Long saphenous vein – 50-60% Short saphenous vein – 11-15% Tributaries of the long/short saphenous – 30-40% Pathophysiology, causes and risk factors: Vascular clots are caused by a combination of venous stasis, endothelial injury and hypercoagulability. Risk factors for the development of SVT are similar to those of VTE. (Cosmi 2015) Risk factors of complications of SVT (such as propagation of clot into deep veins) include male gender, history of VTE, cancer, SVT in a non-varicose vein, large SVT >5 cm, or SVT involving the sapheno-femoral junction (SFJ). (Bauersachs 2013) Clinical Significance SVT previously thought to be a benign disease entity (Cosmi 2015) However, subsequent studies have demonstrated that in patients with lower extremity SVT concomitant DVT and PE was seen in approximately 25% and 5% respectively. (Frappe 2014, Cosmi 2015) Half of the DVTs seen in SVT are non-contiguous and 17% of DVTs are seen in the contralateral limb. (Cosmi 2015) Signs + Symptoms: Pain and redness to an area in the distribution of a superficial vein. Tendernesss of the vein may precede redness. Diagnosis Clinical diagnosis involves visualizing an area of redness and swelling and palpating a painful cord along the path of a vein. However, the clinical diagnosis of SVT can be unreliable and the extent of the SVT is often underestimated clinically. (Bauersachs 2013) Additionally, many other dermatologic conditions may mimic SVT (Cosmi 2015) The current objective test of choice is ultrasound demonstrating a non-compressible superficial vein, with or without echogenic thrombus inside of the vein. Management: Due to the lack of large clinical trials evaluating the treatment of SVT, much of the literature relies heavily on expert consensus. Traditional treatment involves NSAIDS and stockings. This treatment is still recommended by most for SVT’s <5cm in length and >3cm from the SFJ. (Cosmi 2015) 2012 ACCP guidelines suggest that patients with SVT > 5 cm can be treated with prophylactic dose of fondaparinux or LMWH for 45 days. (Guyatt 2012) This recommendation was largely based on the CALISTO trial, which randomized 3002 patients with SVT to get either fondaparinux or placebo and reported that the rate of PE or DVT was 85% lower in the fondaparinux group (Decousus 2010) SVT within 3 cm of SaphenoFemoralJunction is considered by some to be equivalent to DVT and can be treated as such (Cosmi 2015) Topical NSAIDS may help symptoms and can be used at the same time as anticoagulation (Kearon 2012) There is no literature supporting or refuting using the same treatment in the evaluation of upper extremity SVT. If an SVT is uncovered in the lower extremity, a bilateral duplex ultrasound evaluating the deep venous system should be considered. Take Home Points SVT >5cm or <3 cm from the SFJ should be treated with anti-coagulation. The rate of concurrent DVT and PE in patients with SVT is 25% and 5%, respectively. References: Frappe P, et al the STEPH Study Group. Annual diagnosis rate of superficial-vein thrombosis of the lower limbs: the STEPH community-based study. J Thromb Haemost 2014; 12: 831–8. PMID: 24679145 White RH. The epidemiology of venous thromboembolism. Circulation 2003; 107: I4–8. PMID: 12814979 Blumenberg RM, et al.: Occult deep venous thrombosis complicating superficial thrombophlebitis. J Vasc Surg 1998, 27:338– 343. PMID: 9510288 Coon WW et al. Venous thromboembolism and other venous disease in the Tecumseh Community Health Study. Circulation 1973;48:839–846. PMID: 4744789 Cosmi B. Management of superficial vein thrombosis. Journal of thrombosis and haemostasis : JTH. 13(7):1175-83. 2015. PMID: 25903684 Guyatt GH et al. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 141(2 Suppl):7S-47S. 2012. PMID: 22315257 Decousus H et al. Fondaparinux for the treatment of superficial-vein thrombosis in the legs. The New England journal of medicine. 363(13):1222-32. 2010. PMID: 20860504 Bauersachs RM. Diagnosis and treatment of superficial vein thrombosis. Hämostaseologie. 33(3):232-40. 2013. PMID: 23757000 Kearon C, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 141(2 Suppl):e419S-94S. 2012. PMID: 22315268 Post Created By: Jacob Avila (Twitter: @coreultrasound) Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie) The post REBEL Core Cast 50.0 – Superficial Venous Thrombosis appeared first on REBEL EM - Emergency Medicine Blog.
18 minutes | 14 days ago
REBEL Cast Ep95: Colchicine in COVID (COLCORONA)? Don’t Believe the Hype.
Background: Science by press release. Not the way any of us would choose to operate but, the COVID pandemic has made this a reality. It’s vital that we understand that while pharmaceutical companies have a responsibility to release this information, we as clinicians should not be practicing medicine based on press releases. Of course, these press releases don’t only originate from pharma. On January 22nd, 2021, the Montreal Heart Institute released a statement about the results from the COLCORONA study investigating the use of colchicine in COVID-19. The press release painted a very positive picture but, does the pre-peer reviewed publication stand up? REBEL Cast Ep95: Colchicine in COVID (COLCORONA)? Don’t Believe the Hype. Click here for Direct Download of Podcast Paper: Tardif JC et al. Efficacy of Colchicine in Non-Hospitalized Patients with COVID-19. MedRxiv 2021[Link is HERE] ClinicalTrials.gov Clinical Question: Does colchicine reduce the risk of hospitalization or death in outpatients with COVID-19 who are at high-risk for decompensation? Population: Patients ≥ 40 years of age with a diagnosis of COVID-19 who could be enrolled within 24 hours of diagnosis, were not currently hospitalized and not under immediate consideration for hospitalization. All patients had to have at least one of the following high-risk criteria: Age > 70 Obesity (BMI > 30 kg/m2) Diabetes Uncontrolled hypertension (SBP > 150 mm Hg) Known respiratory disease Known heart failure Known coronary artery disease Fever > 38.4 C within the last 48 hours Dyspnea at the time of presentation Bicytopenia Pancytopenia Combination of high neutrophil and low lymphocyte count Intervention: Colchicine 0.5 mg Q12 X 3 days followed by 0.5 mg Q24 X 27 days Control: Placebo Outcome (Primary): Composite endpoint of death or hospitalization due to COVID-19 within 30 days following randomization (intention to treat analysis) Outcomes (Secondary): Components of the composite primary endpoint (death or hospitalization within 30 days), mechanical ventilation within 30 days of randomization Design: Randomized, double-blind, placebo-controlled, investigator-initiated trial. Interim analyses pre-specified at 25, 50 and 75% enrollment Exclusion: Pregnant women Women not practicing adequate contraception Inflammatory bowel disease Chronic diarrhea Pre-existing malabsorption Pre-existing neuromuscular disease GFR < 30 ml/min Severe liver disease Current treatment with colchicine Current chemotherapy History of colchicine sensitivity Results: Primary Results: Enrollment from March 2020 to December 2020 4488 patients underwent randomization Primary endpoint status known for 97.9% of patients 4159 patients found to be SARS-CoV2 PCR positive Patients enrolled a mean of 5.3 days after symptom onset Critical Results: Adverse Events: Diarrhea: Colchicine: 300/2195 (13.7%) Placebo: 161/2217 (7.3%) P<0.0001 Strengths: Randomized, double-blind, placebo-controlled trial Multicenter, multinational study increasing external validity Baseline characteristics that were reported are well-balanced Evaluated patients in the outpatient setting, early in disease with a medication that is orally administered and inexpensive Limitations: Primary endpoint was composite of outcomes that are not equivalent (death and hospitalization are not the same) Enrollment was non-consecutive which may introduce bias Study powered to find a 25% relative risk reduction which may have been overly ambitious Study stopped at 75% enrollment Follow up was only 30 days Discussion: Regardless of press release and spin of data, this was a negative study. It is only after manipulation of the data that the authors were able to show a small benefit in preventing hospitalization. Secondary analysis removed patients who were PCR negative The authors state that this was a prespecified analysis but, there is no indication of this on clinicaltrials.gov PCR results are not 100% sensitive. Exclusion of patients who were PCR negative may have resulted in exclusion from secondary analysis of patients who actually did have COVID Statistical significance was driven by hospitalization rate (subjective) not mortality (objective) Regardless, this is a post-hoc analysis and should not be used to change management Colchicine has considerable toxicity including multisystem organ dysfunction Author Conclusion: “Among non-hospitalized patients with COVID-19, colchicine reduces the composite rate of death or hospitalization. “ Our Conclusions: The authors have taken substantial liberties in their interpretation. Based on the sound methodology set up for this study, there is no significant clinical benefit for colchicine in the treatment of COVID19. Bottom Line: Colchicine should not be given to patients with COVID19 outside of the setting of a clinical study References: Tardif JC et al. Efficacy of Colchicine in Non-Hospitalized Patients with COVID-19. MedRxiv 2021[Link is HERE] ClinicalTrials.gov For More Thoughts on This Topic Checkout: ALiEM: Colchicine Toxicity – A New Threat from COVID-19 Treatments FOAMCast: COVID and Colchicine Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie) The post REBEL Cast Ep95: Colchicine in COVID (COLCORONA)? Don’t Believe the Hype. appeared first on REBEL EM - Emergency Medicine Blog.
10 minutes | 16 days ago
REBEL Core Cast 49.0 – Abdominal Aortic Aneurysm (AAA)
Take Home Points Consider ruptured AAA in patients (especially those > 50 years of age) with unexplained hypotension, back or abdominal pain All ruptured AAAs should be considered unstable regardless of vital signs as rapid deterioration is common A ruptured AAA is 100% fatal without surgical or endovascular intervention. Mobilize your surgical colleagues early REBEL Core Cast 49.0 – Abdominal Aortic Aneurysm Click here for Direct Download of Podcast Definition: An abdominal aortic aneurysm (AAA) is localized dilation (> 3 cm) of the aorta caused by a weakening involving all three layers (intima, media and adventitia) of the aortic wall. It most commonly develops distal to the renal arteries. Epidemiology: Uncommon in patients < 50 yo Found in 2-5% of men > 50 yo It is more common: In men than women In patients with coronary artery disease (CAD) or peripheral arterial disease (PAD) Patients with a family history of AAA Smokers Up to 50% of AAA in patients < 65 occur in women Mortality 30-40% with open aortic repair 20-25% with endovascular repair Normal infrarenal aorta < 2 cm in diameter. Infrarenal aorta > 3 cm is considered to be aneurysmal. Most ruptures occur in aortas > 5 cm in diameter Presentation Unruptured Aneurysm Signs and Symptoms Most AAAs are asymptomatic until expansion or rupture occurs Pain is a common symptom when symptoms are present Abdominal, back and/or flank pain Acute pain associated with a AAA can mimic renal colic Acute pain may be an ominous sign of impending rupture Physical Exam Large aneurysms may be found on routine abdominal examination as pulsatile abdominal masses May be limited secondary to patient body habitus and size of aneurysm Abdominal bruits are uncommon findings Complications of unruptured AAAs Thromboembolic: lower extremity ischemia Direct compression of adjacent structures (duodenum, ureters etc) Ruptured Aneurysm Classic Triad: Pain, hypotension and a pulsatile abdominal mass. Often will only see one or two features of the triad Symptoms Pain is the most common symptom Abdominal, back and/or flank Typically acute in onset, severe and can radiate to the chest, back or groin Acute onset of pain in a patient with a AAA should be assumed to be secondary to rupture Syncope (or near-syncope) is common though hemodynamic compensation may result in near-normalization of blood pressure Physical Exam Large, palpable abdominal mass Aortic pulsation may be felt (may be absent if blood pressure is low) Hypotension Seen in 50% of ruptures on presentation (Gaughan 2009, Rose 2001) Late finding suggestive of impending hemodynamic collapse and death Tachycardia may be variably present Many patients are on beta-blockers at baseline Blood in the abdomen can stimulate vagal responses leading to lower than expected heart rate AAA Variants Aortoenteric fistula Definition: AAA rupture into the GI tract that can be either primary (from an unrepaired AAA) or secondary (after prior aortic repair) Consider diagnosis in any patient with a known AAA or prior repair who presents with GI bleeding Can see both hematemesis and melena as the aortoenteric fistula commonly connects the AAA to the duodenum Patients will typically experience rapid, massive exsanguination. Aortoenteric fistula has a very high morbidity and mortality Aortocaval fistula Definition: Periaortic inflammation leads to a connection between the AAA and the adjacent vena cava. Free rupture of the AAA will present in same way as any ruptured AAA Formation of a large arteriovenous (AV) fistula may occur if there is no external AAA leak Signs and Symptoms (Cinara 2005) Palpable mass (80-90%) Abdominal bruit (75%) Palpable thrill (25%) Differential Diagnosis Aortic Dissection Ureteric Colic Pancreatitis Intestinal ischemia Bowel obstruction Diverticulitis AAA US Short Axis (emergencyultrasoundteaching.com) Diagnostics Patients with ruptured aneurysms will often be diagnosed based on clinical presentation alone. Ultrasound Sensitivity for detecting AAA approaches 100% (Lederle 2003) Detection of AAA rupture Presence of free intraperitoneal fluid confirms rupture Rupture may be retroperitoneal or small leading to a false negative US for free fluid Advantages Allows for rapid evaluation of the aorta as a cause for shock in the undifferentiated patient while resuscitation is ongoing Obviates the need for the patient to be transported to the radiology department for imaging Can provide alternative explanations for the patient’s presentation AAA US Transverse ( emergencyultrasoundteaching.com) Limitations Prone to both technical (ultrasonographer skills) and interpretive error Visualization of the aorta can be limited by obesity or the presence of bowel gas Not as sensitive for detecting rupture CT Scan Abdominal CT has a sensitivity and specificity approaching 100% for both diagnosis of AAA as well as rupture (Hermsen 2004) Addition of IV contrast can delineate the patent lumen of the AAA from the mural thrombus but is not necessary for identification of aneurysm or hemorrhage More sensitive than US for detecting retroperitoneal hemorrhage of AAA CT also helpful in identifying alternative diagnoses Management Regardless of vital signs, patients with ruptured AAA should be considered unstable and should be aggressively resuscitated. A ruptured AAA has a mortality rate > 80%. (Adam 1999) Basics: ABCs, Large bore (> 16 gauge) IV X 2, Supplemental O2 (if needed), Cardiac Monitor + Immediate Surgical Consultation for repair Aggressive Volume Resuscitation in Hypotensive patients Target systolic blood pressure of 90-100 mm Hg pre-operatively Exact target unknown Over-resuscitation may contribute to increased bleeding from dilutional coagulopathy Under-resuscitation harmful as prolonged hypotension can lead to end-organ damage (myocardial infarction, renal failure) and cardiac arrest Start with administration of uncrossmatched blood Activate massive transfusion protocol as patients often have large transfusion requirements Consider administration of a 1:1:1 (PRBC:FFP:Platelets) ratio of blood products Administer reversal agents for anticoagulant use if indicated Take Home Points Consider ruptured AAA in patients (especially those > 50 years of age) with unexplained hypotension, back or abdominal pain All ruptured AAAs should be considered unstable regardless of vital signs as rapid deterioration is common A ruptured AAA is 100% fatal without surgical or endovascular intervention. Mobilize your surgical colleagues early Read More CorePendium: Abdominal Aortic Aneurysm EM Cases: Best Case Ever 43 Ruptured Aortic Aneurysm References Adam DJ et al. Community and hospital outcome from ruptured abdominal aortic aneurysm within the catchment area of a regional vascular surgical service. J Vasc Surg 1999; 30:922-928. PMID: 10550191 Cinara IS et al: Aorto-caval fistulas: A review of eighteen years experience. Acta Chir Belg 2005; 105:616-620. PMID: 16438071 Gaughan M et al. Emergency abdominal aortic aneurysm presenting without haemodynamic shock is associated with misdiagnosis and delay in appropriate clinical management. Emerg Med J 2009; 26:334-339. PMID: 19386866 Hermsen K, Chong WK. Ultrasound evaluation of abdominal aortic and iliac aneurysms and mesenteric ischemia. Radiol Clin North Am 2004; 42:365-381. PMID: 15136022 Lederle FA: Ultrasonographic screening for abdominal aortic aneurysms. Ann Intern Med 2003; 139:516-522. PMID: 24957320 Rose J et al. Ruptured abdominal aortic aneurysms: Clinical presentation in Auckland 1993-1997 ANZ J Surg 2001; 71: 341-4. PMID: 11409018 Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie) The post REBEL Core Cast 49.0 – Abdominal Aortic Aneurysm (AAA) appeared first on REBEL EM - Emergency Medicine Blog.
18 minutes | a month ago
REBEL Core Cast 48.0 Frostbite
Take Home Points Frostbite is a severe, localized cold-induced injury due to freezing and thawing of tissue. We usually see these injuries affecting the ears, nose, cheeks, chin, fingers, and toes. Patients will complain of cold, numb or stiff sensations and discoloration of the skin. Critical ED treatment starts with rewarming in a warm, NOT HOT, water bath, analgesia and wound care. More extensive treatments include blister debridement, tPA, prostacyclin analogues and fasciotomy. Patients with severe frostbite will likely require multidisciplinary care with surgery and critical care so consider early consults. And last, be sure to check the patients core temp and treat hypothermia complications, such as diuresis REBEL Core Cast 48.0 – Frostbite Click here for Direct Download of Podcast For More on This Topic Checkout: emDOCS.net: Brrr! ED Presentation, Evaluation, and Management of Cold Related Injuries EP Monthly: Frostbite: How to Classify and Treat It EM in 5: Frostbite References: Cauchy E et al. Retrospective study of 70 cases of severe frostbite lesions: a proposed new classification scheme. Wilderness Environ Med. 2001 Winter. PMID: 11769921. Geng Q et al. Temperature limit values for touching cold surfaces with the fingertip. Ann Occup Hyg. 2006. PMID: 16777911. Grieve AW et al. A clinical review of the management of frostbite. J R Army Med Corps. 2011. PMID: 21465915. Handford C et al. Frostbite. Emerg Med Clin North Am. 2017 May. PMID: 28411928. Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie) Shownotes Created By: Miguel Reyes, MD (Twitter: @miguel_reyesMD) The post REBEL Core Cast 48.0 Frostbite appeared first on REBEL EM - Emergency Medicine Blog.
17 minutes | a month ago
REBEL Core Cast 47.0 Nausea and Vomiting
Take Home Points Nausea and Vomiting has an exceedingly large differential – don’t just anchor on GI presentations H&P important – Duration, frequency, content, and associated symptoms Alcohol swab -> If no line and want quick treatment give swab Ondansetron -> oral you can give without hesitation but if giving IV check QTC / electrolytes and give slowly Droperidol / Haloperidol -> Works really well, QTc prolongation has been overhyped and dont give to parkinsons patient. REBEL Core Cast 47.0 – Nausea and Vomiting Click here for Direct Download of Podcast Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie) Shownotes Created By: Miguel Reyes, MD (Twitter: @miguel_reyesMD) The post REBEL Core Cast 47.0 Nausea and Vomiting appeared first on REBEL EM - Emergency Medicine Blog.
19 minutes | 2 months ago
REBEL Cast Ep94: The ITACTIC Trial – Viscoelastic Hemostatic Assay Augmented Protocols
Background: Current trauma resuscitation prioritizes control of bleeding and uses massive transfusion protocols to prevent and treat coagulopathy. This is typically done in the form of massive transfusion protocols delivered in proportions that approach the composition of whole blood. Two strategies to help guide this replacement of blood products are conventional coagulation tests and viscoelastic hemostatic assays. REBEL Cast Ep94: The ITACTIC Trial – Viscoelastic Hemostatic Assay Augmented Protocols Click here for Direct Download of Podcast Special Guest: Ken Milne, MD South Huron Hospital Association Website: The SGEM Twitter: @TheSGEM Paper: Badsaas-Aasen K et al. Viscoelastic Haemostatic Assay Augmented Protocols for Major Trauma Haemorrhage (ITACTIC): A Randomized, Controlled Trial. Intensive Care Med 2020. PMID: 33048195 Clinical Question: Does augmenting massive transfusion protocols using viscoelastic hemostatic assays (VHAs) decrease mortality and massive transfusion at 24 hours compared to conventional coagulation tests (CCTs)? What They Did: Implementing Treatment Algorithms for the Correction of Trauma-Induced Coagulopathy (ITACTIC) Pragmatic, multicenter, randomized controlled trial of trauma patients who received empiric massive transfusion protocols augmented by: Viscoelastic Hemostatic Assays (VHAs) Conventional Coagulation Tests (CCTs) Conducted at 7 major trauma centers in Europe All enrolled patients received: Empiric tranexamic acid Blood components delivered in a 1:1:1 ratio of RBCs, plasma and platelets (Covered on the SGEM #109) Limited infusion of crystalloid fluids Important Definitions: Time of Hemostasis: 1h after last RBC transfusion was given and treating clinicians stated hemostasis had been achieved Massive Transfusion: Administration of ≥10 units of PRBCs in the 1st 24hrs after injury (While this is a common definition, LITFL has used other parameters) One pool of cryoprecipitate = 2 grams of fibrinogen concentrates One pool of platelets = 4 individual platelet units Outcomes: Primary: Proportion of patients alive and free of massive transfusion at 24h after injury Secondary Outcomes of Note (19 secondary outcomes): All-cause mortality at 6h, 24h, 28d, and 90d Total blood components 28d ventilator-free ICU free days Total hospital length of stay Proportion of patients with symptomatic thromboembolic events Proportion of patients with multiple organ dysfunction Proportion of patients with serious adverse events Inclusion: Adult (16 years of age and older) trauma patients presenting with hemorrhagic shock at any time from injury to admission to the ED Hemorrhagic shock defined by HR >100 BPM and/or SBP <90mmHg AND activation of the local massive transfusion protocol Clinical signs of bleeding activating massive transfusion protocol RBC transfusion initiated Randomized within 3hrs of injury and maximum of 1hr after admission to the emergency department Exclusion: If any inclusion criteria were not met Results: 480 patients eligible 411 randomized 396 patients in the intention-to-treat (ITT) analysis 2/3rds had blunt trauma alone Median Injury Severity Score (ISS) = 26 (Range 17 to 36) Median time from injury to admission = 69min Proportion of Patients Alive and Free of Massive Transfusion at 24h After Injury: VHA: 67% CCT: 64% OR 1.15; 95% CI 0.76 to 1.73 In the VHA arm 14% of patients died and 26% received a massive transfusion at 24h In the CCT arm 17% of patients died and 28% received a massive transfusion at 24h Per-protocol analysis excluded 83 patients and found no statistically significant difference between groups No statistical difference in other secondary outcomes QOL on the EQ-5D at 28 and 90d were not statistically different, but trends were worse in the VHA group (0 the worst possible health status to 100 the best) Both were worse in the VHA group 28d: CCT 49 vs VHA 40 90d: CCT 60 vs VHA 53 No statistical difference in any adverse events There was a 10% absolute difference in thrombotic events (i.e. clinically significant) VHA: 14% CCT: 24% 28d Mortality: VHA: 25% CCT: 28% OR 0.84; 95% CI 0.54 to 1.31 Alive and Free of Massive Transfusion at 24h After Injury in Prespecified Subgroup of Patients with TBI (74pts) VHA: 64% CCT: 46% OR 2.12; 95% CI 0.84 to 5.34 Strengths: Multicenter, randomized clinical trial asking an important question in trauma management Used prior data to estimate the number of patients requiring massive transfusion by 24h to calculate sample size Used an intention-to-treat and per-protocol to analyze all primary and secondary outcomes Baseline characteristics were fairly well matched between treatment groups.There were some differences, but whether or not these would have a statistical or clinical impact is unknown Limitations: Trial was unblinded to treating clinical teams potentially causing bias. If physicians thought that VHA was superior, then the results should have been towards finding superiority.The fact they did not strengthens the conclusions Very few patients in this trial had baseline coagulopathy or developed coagulopathy before hemostasis Only ≈7% of patients were on oral anticoagulants in this trial and definitive conclusion on which strategy is better in these patients cannot be determined from this study Lower than predicted difference in effect size between groups of 3% (predicted 13%) Study performed at large trauma centers with experience in the use of VHA devices which may not be the case in centers that do not see trauma frequently or don’t have VHA available In Ken’s shop they do not have VHA testing and only have 2 units of 0 negative blood and some TXA.Therefore, the results of this trial would not have external validity to critical access hospitals with limited resources. The goal therefore would be to get these trauma patients to the level 1 trauma centers ASAP Baseline differences (age 3 years, gender 9%, prior anticoag 2%, severe TBI 2% or received TXA 4%) were not adjusted for in the analysis. These differences could just be a result of randomization, but still can impact the results Discussion: Authors were looking for a 15% difference in the reduction in their primary outcome with VHA compared to CCT Per Protocol Group Excluded: Did not have at least one VHA or CCT test performed Did not meet inclusion criteria Received the wrong test Died within 60min after baseline blood sampling Achieved hemostasis within 60min of baseline sampling Interesting Facts: After enrollment and before hemostasis 67% of patients in the VHA group and 36% of patients in the CCT group had received a study intervention (post hoc analysis) Study intervention was given a median of 21 min earlier in the VHA group (61min vs 80min) (post hoc analysis) Receiving study intervention within 3h of injury: VHA 64% vs CCT 45% Between baseline and hemostasis patients in the VHA arm received more fibrinogen supplementation (median fibrinogen equivalent dose = 4g vs CCT = 0g) These differences of quicker actually strengthen the confidence in accepting the null hypothesis of no superiority of VHA vs CCT The 28-mortality benefit seen with VHA vs CCT in the TBI subgroup of patients is subgroup analysis of a secondary outcome.This may have been random chance, is hypothesis generating, and requires further study to confirm An important point to highlight is that blood products are a precious resource.VHA-augmented resuscitation identified more coagulation deficits than CCT guided resuscitation. However, this resulted in 1.8 times more products than the CCT group with no benefit in the proportion of patients alive and free of massive transfusion at 24h after injury or in any of the secondary mortality outcomes Author Conclusion: “There was no difference in overall outcomes between VHA- and CCT-augmented-major haemorrhage protocols.” Clinical Take Home Point: It is unsurprising that coagulation monitoring did not alter clinical outcomes in this study as there was a high prevalence of patients who never had or developed coagulopathy. This RCT does not provide evidence to support using VHA to guide resuscitation in adult trauma patients. References: Badsaas-Aasen K et al. Viscoelastic Haemostatic Assay Augmented Protocols for Major Trauma Haemorrhage (ITACTIC): A Randomized, Controlled Trial. Intensive Care Med 2020. PMID: 33048195 For More Thoughts on This Topic Checkout: The Bottom Line: ITACTIC St. Emlyn’s Blog: Blood Products in Trauma – What’s the Best (I)TACTIC? Post Peer Reviewed By: Ken Milne, MD (Twitter: @TheSGEM) The post REBEL Cast Ep94: The ITACTIC Trial – Viscoelastic Hemostatic Assay Augmented Protocols appeared first on REBEL EM - Emergency Medicine Blog.
47 minutes | 2 months ago
REBEL Cast Ep93: COVID-19 – A Follow Up on Not Intubating Early and ARDSnet
Back in April 2020, on REBEL Cast episode 79 we sat down to discuss COVID-19. Specifically, we focused on not intubating patients early and why ARDSnet may not be the best ventilator paradigm for patients with COVID-19. By popular demand, we decided to follow up on this podcast. We are now just about 9 months since we recorded this podcast and I wanted to sit down with the same group and see if they had any amendments, they wanted to make regarding what we discussed. REBEL Cast Ep93: COVID-19 – A Follow Up on Not Intubating Early and ARDSnet Click here for Direct Download of Podcast Special Guests: David A. Farcy MD, FAAEM, FACEP, FCCM Immediate Past President of the American Academy of Emergency Medicine Chairman, Department of Emergency Medicine Director, Emergency Medicine Critical Care Mount Sinai Medical Center Miami Beach, FL Twitter: @DFarcy Evie Marcolini, MD, FAAEM, FACEP, FCCM Associate Professor of Emergency Medicine and Neurocritical Care Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Board of Directors, American Academy of Emergency Medicine Twitter: @EvieMarcolini Cameron Kyle-Sidell, MD Critical Care Medicine Emergency Medicine Maimonides Medical Center Brooklyn, NY Twitter: @cameronks US Expanded Access Program: Paper: Joyner MJ et al. Effect of Convalescent Plasma on Mortality Among Hospitalized Patients with COVID-19: Initial Three-Month Experience. medRxiv 2020  >1800 hospitals across the US > 47k patients enrolled in EAP Has anything changed regarding the use of high-flow nasal cannula (HFNC) and non-invasive ventilation (NIV)? We are keeping more patients on HFNC and not paying as much attention to SpO2 Despite the fact that HFNC has been proven to be safe, we still see a trend of increased intubations in some other countries There is more data on the progression of patients that are not intubated, so we are becoming more comfortable with not intubating early Institutions are more comfortable dealing with aerosolization concerns, thus we are more comfortable with the use of NIV In the past, we were restricted due to high patient volumes, full ICUs and resource limitations. Now that we have lower numbers of patients, we are better able to weigh the risks and benefits of early intubations What markers are we using to make our decisions to intubate? Before COVID, tachypnea, tachycardia and SpO2 would be used to make decisions about intubation. Now we’ve added other considerations like mental status, diaphoresis and work of breathing Patients on HFNC don’t seem to be tiring out the way we would typically expect. There are also discussions about the potential role of a new entity referred to as patient self-induced lung injury (P-SILI) The concept is that you can have the same swings in intrapleural pressure with vigorous breathing as you would have with a ventilator. So while the breathing may appear fine, the heavy swings in pressure can cause lung injury. So theoretically, intubating a patient would be protective against this form of lung injury Farcy: Our early data shows that patients with severe COVID who were maintained on HFNC without intubation have had length of stays of about 11 days with a 90% success rate. Some reports state that lung injury may be due to microthrombi. There are also some reports of steroids and aspirin decreasing mortality Thoughts on pathophysiology of COVID-19? Regarding the pathophysiology, some intensivists have drawn parallels between COVID and acute fibrinous and organizing pneumonia (AFOP). This is a disease with a slow progression that responds to steroids, but a patient can also suddenly deteriorate. The strategy in AFOP is usually to monitor work of breathing Marcolini: Fatui et al also discusses stages of the neurological manifestations of COVID. Applying this framework, we ask ourselves, where is our patient in the progression of the disease In the first stage, the virus stays in the nasal passages and there is no cytokine storm or entry into the brain In the second stage, you have a cytokine storm that causes inflammation and hypercoagulability in addition to neurologic symptoms In the third stage, the cytokine storm explodes, and you have a huge systemic inflammatory response Kyle-Sidell: Work of breathing is inherently tied to compliance. Patients that we thought would tire out, don’t, due to having a preserved lung compliance. We have patients with poor P/F ratios, but they have higher tidal volumes than we would expect. Through intubation and the use of high PEEP, we are trying to increase recruitment in the lungs. However, in patients with COVID, we are causing over-distension of alveoli which were already damaged due to the vascular effects of COVID. (We now know that this disease is primarily a platelet-driven, endothelial-activated vascular process Some people consider COVID a heterogenous disease, however if we put aside the complications, it is relatively uniform in terms of pathophysiology. The heterogeneity is in the time-frames and severities that patients present with. So depending on the time-frame of when the complications present, the management can change. Although best management is not always clear, we do need to take into consideration what is going on in the patients’ lungs and how to best address that Farcy: We try to manage patients with HFNC and proning as long as they are mentating appropriately and do not have an increased work of breathing. For those who are intubated, we give steroids and aspirin. With this, we have seen less cytokine storm than in patients that were intubated early. I think the gradual escalation of therapy may have helped curb the severe cytokine storm that is associated with multi-system organ failure in patients with severe disease. Putting it all together Time does matter. COVID is a heterogenous disease because we don’t know what those timeframes are along its natural progression. There is a viremic phase, followed by a pulmonary phase, followed by a hyper-inflammatory phase We are mostly seeing patients on days 5 -10 by the time they come in to the ED, which corresponds with the pulmonary phase We are in agreement that we should avoid intubating early. But with the added consideration that there may be patient-induced lung injury in patients we manage on HFNC and NIV for too long, a theory that is yet to be proven Despite considering COVID an alveolar disease earlier this year, the thinking has now changed to COVID being a vascular disease associated with endothelial injury and platelet hyper-activation. So putting people on high tidal volumes and high PEEP can over-distend damaged alveoli and cause more injury. And this may be one of the reasons for the hyper-inflammatory, multi-organ failure we see in patients that were intubated early If you had to choose between HFNC and NIV, which would you choose and why? HNFC is preferable initially for several reasons: BiPAP at high settings is more aerosolizing than HFNC at any setting While useful in ARDS due to regional collapse, NIV has not been as useful in COVID because there seems to be a different pathophysiology In the absence of helmets, NIV masks are harder to tolerate for patients for a week or more. With nasal cannula, patients can still eat and they are generally more comfortable. Marcolini: If a patient is hypoxic, I go with HFNC. If they are hypercarbic, I am thinking about BiPAP If a patient on HFNC is found to have significant collapse on CT without consolidation, it would make sense to then progress to NIV. Assuming that you have the staff to monitor them appropriately. It appears that COVID starts with a higher compliance and air-filled alveoli and then transitions to a more traditional ARDS with a lower compliance where recruitment and proning would be helpful. What are your thoughts? Although proning appears to improve SpO2, it does not seem to increase recruitment in a significant way. And an additional benefit of repositioning is the shifting of oxygenation and blood flow that potentially prevents ischemia to lung segments When proning is typically used in the ICU on non-COVID diseases, we do see some sustained recruitment in the form of improving P/F ratios. In COVID patients, however, that has not been the case Kyle-Sidell: I was initially not using NIV partly because we didn’t have negative pressure rooms or staff to watch the patients. But some patients managed with HFNC do progress to a low-compliance, non-recruitable state. These are patients that if stable enough, young enough and at the right center, could be considered for ECMO or lung transplantation Proning should still be used at all stages of COVID. Early stages: Shifting of blood flow to areas with less damage (COVID most often affects the posterior lower segments) Late stages: some beneficial recruitment in the lungs Allows for the use of less aggressive interventions with less oxygen and lower pressures Farcy: I have some patients being managed at home with HFNC who report dramatic improvements to SpO2 with proning. However, their SpO2 drops again when they leave the prone position. What are the triggers to intubate? Have they changed since we last talked? Kyle-Sidell: The initial threshold we had for intubation was when they required 100% FiO2 to achieve a SpO2 of 88-90% combined with distress (defined as anxiety and tachypnea), or sustained SpO2 levels below 80%. We then learned that when a patient knocks off their nasal cannula and goes down to 29% SpO2, to just leave them there and replace the nasal cannula and let them come up again before getting respiratory therapy involved. The only thing that has changed for me is wondering whether or not I am waiting too long to intubate. I am constantly thinking about whether or not there is a way to protect the patient’s lungs We’ve stopped looking at numbers or following SpO2, so no changes to our approach since then Take-Home Messages: Early intubation should still be avoided Consider mental status and work of breathing when thinking about intubation In a stable patient, HFNC should be attempted first, followed by NIV for patients that require more support Proning is still beneficial at all stages of COVID References: Joyner MJ et al. Effect of Convalescent Plasma on Mortality Among Hospitalized Patients with COVID-19: Initial Three-Month Experience. medRxiv 2020. [Epub Ahead of Print] Transcript By: Yasien Eltigani, MS4 at St. George’s University (Twitter: @yasieneltigani) Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami) The post REBEL Cast Ep93: COVID-19 – A Follow Up on Not Intubating Early and ARDSnet appeared first on REBEL EM - Emergency Medicine Blog.
25 minutes | 2 months ago
REBEL Cast Ep92: Alteplase for Stroke of Unknown Time of Onset?
Background: Intravenous alteplase is the current standard care for treatment of acute ischemic stroke (AIS) despite active debate on the research supporting its use. The window for its use has been restricted to <3h of symptom onset based on the results of the NINDS trial and extended to a time window of <4.5h based on the results of the ECASS-3 trial. Both studies excluded patients with unknown time of onset and these patients are excluded from consideration for thrombolytics in real life as well. These trials are the only randomized studies showing benefit of intravenous alteplase vs placebo in acute ischemic stroke to date. Of note, both of these trials have undergone reanalysis calling the validity of their results into question. Despite which side of the debate you fall on, stroke care has moved on with advanced perfusion imaging and thrombectomy in large vessel occlusion strokes. Increased use of perfusion imaging has challenged the idea that time is a critical determinant of which patients should be considered for thrombolytics. REBEL Cast Ep92: Alteplase for Stroke of Unknown Time of Onset? Click here for Direct Download of Podcast Paper: Thomalla G et al. Intravenous Alteplase for Stroke with Unknown Time of Onset Guided by Advanced Imaging: Systematic Review and Meta-Analysis of Individual Patient Data. Lancet 2020. PMID: 33176180 Clinical Question: Is thrombolysis safe and effective in patients with unknown time of onset of stroke when salvageable brain tissue has been identified with advanced imaging? What They Did: Systematic review and meta-analysis of individual patient data for trials published before Sept 21, 2020 Randomized trials of intravenous alteplase versus standard care or placebo in adults with stroke of unknown time of onset and perfusion-diffusion MRI, perfusion CT, or MRI with diffusion weighted imaging-fluid attenuated inversion recovery (DWI-FLAIR) Outcomes: Primary: Favorable functional outcome (Score of 0 to 1 on the mRS) at 90d Secondary: mRS shift towards a better functional outcome Independent outcome (mRS 0 to 2) at 90d Safety: Death Severe disability or death (mRS 4 to 6) Symptomatic ICH Inclusion: Randomized trials comparing alteplase vs standard care or placebo Adults ≥18 years of age Acute ischemic stroke and unknown time of symptom onset Patients had advanced brain imaging with either penumbral imaging (i.e. perfusion-diffusion MRI or perfusion CT) or MRI-based tissue-clocking (i.e. DWI-FLAIR mismatch) Studies with more than 20 patients enrolled Results: 4 trials met eligibility criteria (843 patients could have meta-analysis performed) WAKE-UP 503 patients using 0.9mg/kg alteplase Terminated early due to cessation of funding EXTEND 225 patients using 0.9mg/kg alteplase Terminated early due to results of WAKE-UP THAWS 131 patients using 0.6mg/kg alteplase Terminated early due to results of WAKE-UP ECASS-4 119 patients using 0.9mg/kg alteplase Terminated early due to lack of recruitment All 4 trials stopped early Baseline Characteristics of Note: Waking Up with Symptoms: 89.0% Median NIHSS Score: 7 Large Vessel Occlusion: 25% Median Time from Symptom Recognition to Treatment Initiation: 3.3h Median Time Between Last Seen Well and Treatment Initiation: 10.6h Favorable Functional Outcome (mRS 0 to 1) at 90d (Primary Outcome): Alteplase: 47% Control: 39% aOR 1.49; 95% CI 1.10 to 2.03; p = 0.011 NNT = 12 Alteplase was associated with a significant shift towards better functional outcome (aOR 1.38; 95% CI 1.05 to 1.80) Alteplase was associated with higher odds of independent outcome (aOR 1.50; 95% CI 1.06 to 2.12; p = 0.22) Alteplase was associated with less patients who were dependent or had died (mRS 3 to 6) at 90 days (aOR 0.67; 95% CI 0.47 to 0.94; p = 0.022) Severe Disability or Death (mRS 4 to 6) at 90d Alteplase: 21% Control: 25% aOR 0.76; 95% CI 0.52 to 1.11; p = 0.15 Death at 90d: Alteplase: 6% Control: 3% aOR 2.06; 95% CI 1.03 to 4.09; p = 0.40 Of the 27 deaths in the alteplase group, seven were attributable to symptomatic ICH Of the 14 deaths in the control group, all were of non-neurological cause and unrelated to treatment or index stroke Symptomatic ICH: Alteplase: 3% Control: <1% aOR 5.58; 1.22 to 25.50; p = 0.024 Strengths: Searched multiple databases for eligible articles: PubMed, Web of Science, SciELO, LILACS, clinicaltrials.gov, EU Clinical Trials Register etc Meta-analysis of randomized clinical trials with individual patient data Asks a clinically important question in patients previous excluded from stroke trials Patient level data allows for quantification of the benefits and risks of intravenous alteplase Subgroup analyses did not identify a significant treatment heterogeneity and confirmed a consistent treatment effect across a wide range of patients Protocol for the study was prespecified and followed PRISMA guidelines for meta-analyses No funding source for this study Baseline characteristics appear to be fairly balanced between groups including number of patients waking up with symptoms, median time between last known well and symptom recognition, comorbid conditions, median NIHSS score and vessel occlusion on baseline CT- or MR-angiography Vessel imaging included a DWI-FLAIR mismatch and penumbral imaging looking for small infarct cores surrounded by a larger area of critically hypoperfused tissue with MRI or CT. This increases generalizability as either type of imaging is more effective than non-contrast head CT at identifying patients with potential for improvement Limitations: All 4 trials stopped early and only had modest sample sizes which limits the strength/precision of the findings and can overestimate benefit of the individual trials Only one study used 0.6mg/kg of intravenous alteplase and therefore no definitive conclusions can be made about lower dosing vs higher dosing from this meta-analysis Due to the overall small sample size of 843 patients, the study was not powered to provide treatment effect estimates for smaller subgroups. This can also be seen in the wide 95% Cis for some of the subgroup analyses Most patients in this meta-analysis had mild to moderate strokes to begin with (median NIHSS score of 7) and therefore the results may not be generalizable to patients with more severe strokes 60% of the patients included in this meta-analysis were from the WAKE-UP trial The requirement of advanced imaging beyond non-contrast CT and vessel imaging might still be a potential limitation for implementation in some regions Discussion: Both WAKE UP and EXTEND were started before compelling evidence for stroke thrombectomy was available for large vessel occlusion strokes and patients in which thrombectomy was planned were also excluded Overall risk of bias amongst included studies was low The availability of perfusion imaging can affect all stroke care, where time is no longer brain. There will be plenty of patients who present <3 hours with no penumbra and no mismatch. This group may not require thrombolysis and perfusion imaging can help confirm that and spare them the potential harms Authors found a fifth study (MR WITNESS) which was not a RCT but met all the other eligibility criteria They included the analysis with these results in the supplementary appendix This increased the number of patients up to 923 for analysis Favorable Neurologic Outcome (mRS 0 to 1) at 90d Alteplase: 46% Control: 39% Death at 90d Alteplase: 7% Control: 3% Severe Disability or Death (mRS 4 to 6): Alteplase: 22% Control: 25% Symptomatic ICH: Alteplase: 2% Control: <1% One thing to consider in this study is that despite having a lower number of deaths in the control group (mRS 6) compared to alteplase there were far more patients who were bedridden (mRS 5). This is a tough one to wrestle with from a patient care standpoint. Do we save a life at the expense of being bedridden or do we spare the patient being bedridden at the expense of death? DWI-FLAIR mismatch requires MRI which may not be feasible at every institution. In centers where it is available, DWI-FLAIR mismatch allows for treatment of patients with lacunar strokes. These patients would not have met criteria for a relevant amount of salvageable tissue in perfusion-based penumbral mismatch imaging. Penumbral mismatch imaging might identify patients with salvageable tissue despite already marked hyperintensity on FLAIR and potentially increases the number of patients given thrombolysis The authors also make note that in patients with large vessel occlusion, treatment with alteplase prior to thrombectomy showed treatment benefit (OR 2.35; 95% CI 1.04 to 5.32). We have covered this issue on REBEL EM, with our review of the DIRECT-MT trial. The conclusion of that trial was that in patients who can immediately be taken for endovascular intervention, systemic thrombolysis is not necessary Author Conclusion: “In patients who have had a stroke with unknown time of onset with a DWI-FLAIR or perfusion mismatch, intravenous alteplase resulted in better functional outcome at 90 days than placebo or standard care. A net benefit was observed for all functional outcomes despite an increased risk of symptomatic intracranial haemorrhage. Although there were more deaths with alteplase than placebo, there were fewer cases of severe disability or death.” Clinical Take Home Point: This meta-analysis provides level 1a evidence for the use of advanced brain imaging beyond non-contrast CT to help guide treatment with intravenous alteplase in patients with acute ischemic stroke with an unknown time of onset. However, despite a consistently better functional outcome at 90d with alteplase compared to placebo or standard of care there was still an increased risk of symptomatic intracranial hemorrhage and a higher mortality which has also been consistent across all randomized clinical trials. References: Thomalla G et al. Intravenous Alteplase for Stroke with Unknown Time of Onset Guided by Advanced Imaging: Systematic Review and Meta-Analysis of Individual Patient Data. Lancet 2020. PMID: 33176180 Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami) The post REBEL Cast Ep92: Alteplase for Stroke of Unknown Time of Onset? appeared first on REBEL EM - Emergency Medicine Blog.
9 minutes | 2 months ago
REBEL Core Cast 46.0 – Resuscitative Hysterotomy
Take Home Points This is a resuscitative hysterotomy – focus is on saving the mother first. Delivering the fetus can improve venous return thus increasing chance to save mom Don’t focus on gestational age to make the decision – if you think the belly is big enough to be causing compression of vascular structures, the procedure is indicated Once you’ve made the decision – it’s go time. The faster you do it, the more likely you can salvage mom and the fetus Large vertical incision to maximize exposure, locate uterus, vertical incision with scalpel and extend with scissors REBEL Core Cast 46.0 – Resuscitative Hysterotomy Click here for Direct Download of Podcast Resuscitative Hysterotomy Critical Concept: The goal of the procedure is to resuscitate the mother. Performing a resuscitative hysterotomy improves the chances of saving the mother. The procedure can also improve outcomes for the fetus. Key to procedure: The procedure itself is not difficult but the decision to make the incision is difficult. Delays in procedure lead to worse outcomes in both mother and fetus Prior to arrival Run through the Zero Point Survey Setup and prepare Rally your consultants – OB/GYN, Trauma, Anaesthesia Team assignments: Need multiple teams Resus team Airway team Hysterectomy team Fetus team If trauma -> blood & thoracotomy team Indications Cardiac arrest Periarrest Uterus large enough to cause compression on vasculature Fetus >20 weeks often quoted but, can be challenging to calculate the gestational age in a high-stress situation Uterus palpable above the umbilicus can be used as well Pre-Procedure Time is of the essence Skip sterility, measuring fetal HR or waiting for OB If medical arrest -> continue CPR and arrest algorithm If traumatic arrest -> another team should be performing a thoracotomy if indicated The Procedure Equipment: scalpel, scissors (ideally blunt tipped), and two Kelly clamps Located xiphoid process and pubic symphysis Use scalpel to cut from xiphoid process to pubic symphysis. Need to cut down through multiple layers until you reach the uterus Have assistant retract both edges of your incision Make a small, 3-4 cm incision with a scalpel into uterine fundus (low incision recommended) Will see a rush of amniotic fluid Use your scissors to extend the incision caudally Can place fingers into the uterus to guide scissors and avoid the fetus Deliver baby headfirst – grasp behind neck supporting the head Clamp umbilical cord and cut – pass the baby to neonatal resus team Deliver placenta Pack the uterus Take-Home Points This is a resuscitative hysterotomy – focus is on saving the mother first. Delivering the fetus can improve venous return thus increasing chance to save mom Don’t focus on gestational age to make the decision – if you think the belly is big enough to be causing compression of vascular structures, the procedure is indicated Once you’ve made the decision – it’s go time. The faster you do it, the more likely you can salvage mom and the fetus Large vertical incision to maximize exposure, locate uterus, vertical incision with scalpel and extend with scissors Additional Resources: Core EM: Perimortem C-Section EMCrit: Perimortem C-section REBEL EM: Resuscitative Hysterotomy Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie) Shownotes Created By: Miguel Reyes, MD (Twitter: @miguel_reyesMD) The post REBEL Core Cast 46.0 – Resuscitative Hysterotomy appeared first on REBEL EM - Emergency Medicine Blog.
15 minutes | 3 months ago
REBEL Core Cast 45.0 – Mesenteric Ischemia
Take Home Points Be sure to consider mesenteric ischemia in any elderly patient with abdominal pain or lower gastrointestinal (GI) complaints. Remember, the presentation can... The post REBEL Core Cast 45.0 – Mesenteric Ischemia appeared first on REBEL EM - Emergency Medicine Blog.
16 minutes | 3 months ago
REBEL Cast Ep91: Static Ultrasound vs Landmark Placement of Subclavian Central Lines
Background Information: Central venous catheterization is a common procedure performed in the ICU for the purposes of drug administration and resuscitation. The subclavian vein is the... The post REBEL Cast Ep91: Static Ultrasound vs Landmark Placement of Subclavian Central Lines appeared first on REBEL EM - Emergency Medicine Blog.
18 minutes | 3 months ago
REBEL Cast Ep90: Ultrasound vs Landmark-Guided Palpation for Radial Arterial Line Placement
Background Information: Ultrasound guided peripheral and central venous access has become more common while simultaneously decreasing complications and increasing first pass success. Landmark guided palpation... The post REBEL Cast Ep90: Ultrasound vs Landmark-Guided Palpation for Radial Arterial Line Placement appeared first on REBEL EM - Emergency Medicine Blog.
21 minutes | 3 months ago
REBEL Cast Ep 89: The CODA Trial – Antibiotics vs Appendectomy for Appendicitis
Background: The well-established, standard treatment for acute appendicitis is surgical appendectomy. However, recent research has challenged the dominance of the surgical approach in looking at... The post REBEL Cast Ep 89: The CODA Trial – Antibiotics vs Appendectomy for Appendicitis appeared first on REBEL EM - Emergency Medicine Blog.
17 minutes | 4 months ago
REBEL Core Cast 44.0 – Postpartum Hemorrhage
Take Home Points Watch for continued bleeding in excess of 500 ml or bleeding that is “more than normal.” Call it postpartum hemorrhage and start... The post REBEL Core Cast 44.0 – Postpartum Hemorrhage appeared first on REBEL EM - Emergency Medicine Blog.
17 minutes | 4 months ago
REBEL Cast Ep88: The MIDAS Trial – Midodrine vs Placebo for Pressor Discontinuation
Background: ICU discharge is often delayed due to intravenous vasopressor requirements to maintain clinically indicated blood pressure goals. In some patients without impairment of tissue... The post REBEL Cast Ep88: The MIDAS Trial – Midodrine vs Placebo for Pressor Discontinuation appeared first on REBEL EM - Emergency Medicine Blog.
25 minutes | 4 months ago
REBEL Core Cast 43.0 – Measles + Antivax
Take Home Points Measles is highly infective: One infected person can infect approximately 10-20 unvaccinated people 2 doses of MMR is 97% protective Unvaccinated people... The post REBEL Core Cast 43.0 – Measles + Antivax appeared first on REBEL EM - Emergency Medicine Blog.
7 minutes | 4 months ago
REBEL Core Cast 42.0 – Orbital Compartment Syndrome
Take Home Points Trauma resulting in a retrobulbar hemorrhage can lead to orbital compartment syndrome which is a vision threatening injury Diagnosis is made clinically... The post REBEL Core Cast 42.0 – Orbital Compartment Syndrome appeared first on REBEL EM - Emergency Medicine Blog.
9 minutes | 5 months ago
REBEL Cast Ep87: Video Laryngoscopy – Standard vs Hyperangulated Geometry
Background information: There are two popular blade shapes for video laryngoscopy, a standard-geometry blade comparable to a Macintosh blade and a hyperangulated blade. The standard-geometry... The post REBEL Cast Ep87: Video Laryngoscopy – Standard vs Hyperangulated Geometry appeared first on REBEL EM - Emergency Medicine Blog.
21 minutes | 5 months ago
REBEL Core Cast 41.0 – Acute Chest Syndrome
Take Home Points 100k people in US have sickle cell, the majority will at some point develop acute chest syndrome (ACS) The mortality rate per... The post REBEL Core Cast 41.0 – Acute Chest Syndrome appeared first on REBEL EM - Emergency Medicine Blog.
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