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17 minutes | 9 days 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 | 11 days 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: 25% CCT: 28% OR 0.84; 95% CI 0.54 to 1.31 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 | a month 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 | a month 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 | a month 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 | 2 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 be tricky to find and they may have a reassuring abdominal exam. Ask about artherosclerotic risk factors, history of cardiovascular disease including atrial fibrillation and prior embolic events, and a history of intestinal angina to help clue you in to the diagnosis. Lab abnormalities could include leukocytosis, lactemia or elevated d-dimer. But normal labs cannot exclude this disease. The money is in the CTA. Get it as fast as possible because time is bowel. Consult your surgeons and interventional radiologists eary, because again TIME IS BOWEL REBEL Core Cast 45.0 – Mesenteric Ischemia Click here for Direct Download of Podcast For More on This Topic Checkout: Mesenteric Ischemia: A Power Review – emDOCs.net – Emergency Medicine Education References: Cudnik MT et al. The diagnosis of acute mesenteric ischemia: A systematic review and meta-analysis. Acad Emerg Med. 2013. PMID: 24238311. Kärkkäinen JM et al. Acute mesenteric ischemia (part I) – Incidence, etiologies, and how to improve early diagnosis. Best Pract Res Clin Gastroenterol 2017. PMID: 28395784. Kärkkäinen JM et al. Acute Mesenteric Ischemia Is a More Common Cause than Expected of Acute Abdomen in the Elderly. J Gastrointest Surg 2015. PMID: 25917534. Martinez J. Mesenteric Ischemia. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. Updated August 7, 2020. Accessed October 11, 2020. Tilsed JV et al. ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg 2016. PMID: 26820988. Wadman M et al. Survival after operations for ischaemic bowel disease. Eur J Surg 2000. PMID: 11097154. Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie) The post REBEL Core Cast 45.0 – Mesenteric Ischemia appeared first on REBEL EM - Emergency Medicine Blog.
16 minutes | 2 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 more preferred access site given its fixed puncture location, ease for nursing access and low incidence of infections.1 Landmark guided catheterization has a widely variable success rate and has been shown to increase the risk of complications such as hematoma formation and pneumothoraxes.2,3 The use of real-time ultrasound guidance has thus led to more central lines being placed in the internal jugular and femoral lines, however there is substantial debate regarding its use in subclavian vein catheterization.4,5 The authors of this study sought to compare the efficacy and safety of static ultrasound-guided puncture with traditional anatomic landmark guided subclavian vein puncture. REBEL Cast Ep91: Static Ultrasound vs Landmark Placement of Subclavian Central Lines Click here for Direct Download of Podcast Paper: Wang Q, et al. Static Ultrasound Guidance VS. Anatomical Landmarks for Subclavian Vein Puncture in the Intensive Care Unit: A Pilot Randomized Controlled Study. J Emerg Med. Sep 22 2020; PMID: 32978029 Clinical Question: Does ultrasound or landmark guided placement of subclavian central lines result in improved success rates and lower rates of complications? What They Did: Single center blinded randomized controlled pilot trial in China Patients were randomized to: Ultrasound Group Anatomic Landmark Group Subclavian access was at physician discretion All physicians placing lines had at least one-year experience in the ICU. After 3 unsuccessful attempts, the operating physician was replaced with another physician after 3 unsuccessful attempts Defined puncture failure as: unsuccessful cannulation after 5 attempts OR a puncture time > than 5 minutes In the Ultrasound Group, doppler was used to confirm the vein and a marker pen on the skin in front of the clavicle was made to indicate the direction of the subclavian vein puncture. (See IMAGE BELOW). The rest of the procedure, including needle stick and catheter insertion was then performed similar to the Landmark Group. Figure 1. Ultrasound-guided puncture of the subclavian vein (SCV). (A) Short-axis image of the subclavian artery (SCA) and SCV. (B) Long-axis image of the SCV. (C) CA123 probe used for long axis exploration of the SCV and marking of the puncture direction. (D) Anatomic diagram of ultrasound-guided puncture. Image from original paper (PMID: 32978029) Inclusion Criteria: ICU patients Age ≥ 18 years old Required subclavian central access Exclusion Criteria: Severe coagulation disorder INR ≥ 3.5 Disseminated intravascular coagulation with active bleeding Platelet count < 20,000 Bilateral pneumothorax Requiring CPR or emergent central venous access Patients who had a puncture time of > 5 minutes Outcomes: Primary Puncture success rate Secondary Number of puncture attempts Defined as number of individual needle insertions including needle retraction and reinsertion Success rate of first attempt Puncture time Defined as time from skin puncture to placement of guidewire Rates of complications Such as pneumothorax, puncture of an artery, hematoma formation, ectopic catheterization, thoracic duct injury, hemothorax and pericardial tamponade Results: Of the 207 total patients approached, 200 met inclusion criteria, and 194 were included in the final analysis Presence of factors limiting puncture was the only parameter that differed between the two groups and was more common in the ultrasound group This included presence of a pacemaker or local anatomical changes due to surgery/trauma Critical Results: The ultrasound group had a higher rate of puncture success, a lower incidence of complications and a lower rate of artery puncture than the landmark group Secondary outcomes of number of attempts, first-try success rate and puncture time were all comparable between the two groups Strengths: Addresses a clinically relevant question related to ultrasound use during a common procedure of obtaining central venous access Clear definitions of puncture attempt, puncture time and anticipated complications Had an organized system when several unsuccessful punctures were made in succession Both ultrasound and landmark group were fairly well balanced There were no significant differences in age, sex, BMI, APACHE II score, INR, platelets, blood pressure, use of vasoactive medications, use of mechanical ventilation, puncture site or diagnosis upon ICU admission There was no difference between in operator experience between groups Limited confounding variables by using the same procedure for central line insertion across both groups Limitations: Small sample size Unknown ultrasound experience of physicians Unclear if there was central line procedure skills training given beforehand There are several factors that could affect the results of ultrasound-guided puncture including physician experience, inter-physician variability, ultrasound exploration, patient positioning and the population studied Performed in a single center at a single institution which could limit external validity to other institutions All patients were placed in a supine position, however a Trendelenburg position could have helped to obtain the largest vein size Discussion: The ICU physicians involved in this study had at least one year of ICU experience, although most had >3 years. All had ultrasound-guided puncture training; however, the article did not explicitly state how much training these physicians, especially given how operator dependent ultrasonography is Complications were greater in the landmark group and more specifically, mis-puncture of the artery was statistically significant. It is not reported whether there were any arterial cannulations. A possible future study should evaluate the success rate of real-time vs static ultrasound guidance in the placement of subclavian central lines. Although not statistically significant, the use of ultrasound resulted in higher success on the first attempt, less puncture time and less complications than the landmark guided group. Ultrasound is becoming more common in clinical settings and newer generations of physicians are using it more and more. Studies like this one helps raise awareness for their need especially when performing bedside procedures. One thing to consider is that Chinese people may be thinner than westerners and hence easier to image. The average BMI in this study was 22. The debate between using ultrasound and “doing it blind” is clouded behind a potential clinical bias of “wasting time” with ultrasound. While retrieving, setting up and actually performing the procedure with ultrasound does take substantially more time, the results of this study, specifically the rate of mis-puncture complications, show that it’s better for patient care and overall procedural success when ultrasound is used. Author’s Conclusions: Static ultrasound-guided subclavian vein puncture is superior to the traditional landmark-guided approach for critically ill patients in the ICU. It is suggested that static ultrasound-guided puncture techniques should be considered for subclavian vein puncture. Our Conclusion: Although a single center study with some potential limitations, this pilot study showed static ultrasound guided subclavian vein catheterization resulted in a higher overall success of venous catheterization when compared to the landmark group. Furthermore, the higher first pass successes, faster procedure time and less complications strongly support the notion that ultrasound should be used for all central line procedures. The idea of “wasting time” with the ultrasound is a moot point when doing it “blind” takes longer and has a higher likelihood of resulting in an artery mis-puncture as observed in this study. Clinical Bottom Line: Ultrasound should be utilized for venous identification of the subclavian vein prior to central catheterization as it can overcome challenges associated with variation in local vascular anatomy and resulted in more successful punctures when compared to landmark guided palpation. REFERENCES: Wang Q, et al. Static Ultrasound Guidance VS. Anatomical Landmarks for Subclavian Vein Puncture in the Intensive Care Unit: A Pilot Randomized Controlled Study. J Emerg Med. Sep 22 2020; PMID: 32978029 Brass P, et al. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev. 2015 Jan 9; PMID: 25575245 Kornbau C, et al. Central line complications. Int J Crit Illn Inj Sci. 2015 Jul-Sep; PMID: 26557487 Lalu MM, et al; Canadian Perioperative Anesthesia Clinical Trials Group. Ultrasound-Guided Subclavian Vein Catheterization: A Systematic Review and Meta-Analysis. Crit Care Med. 2015 Jul; PMID: 25803646 Rezayat T, et al. Ultrasound-Guided Cannulation: Time to Bring Subclavian Central Lines Back. West J Emerg Med. 2016 Mar;17. PMID: 26973755 Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srreziae) The post REBEL Cast Ep91: Static Ultrasound vs Landmark Placement of Subclavian Central Lines appeared first on REBEL EM - Emergency Medicine Blog.
18 minutes | 2 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 has historically been considered the standard of care when placing arterial lines, however the use of ultrasound is challenging that notion as anatomic landmarks are not helpful in 30% of patients.1 Additionally, increasing obesity and hemodynamic instability can make radial arterial line placement even more difficult when using landmark-guided palpation alone. The literature comparing the different methods of arterial line placement is limited to two prospective studies. The first assessed second- and third-year emergency medicine residents while the second study evaluated only four emergency medicine attendings, all with extensive ultrasound training and experience.2,3 The authors of this study sought to compare radial arterial line placement using ultrasound vs landmark guided palpation performed by novice emergency medicine interns with respect to overall success. REBEL Cast Ep90 – US- vs Landmark-Guided Palpation for Radial Arterial Line Placement Click here for Direct Download of Podcast Paper: Gibbons RC, et al. Ultrasound Guidance Versus Landmark-Guided Palpation for Radial Arterial Line Placement by Novice Emergency Medicine Interns: A Randomized Controlled Trial. J Emerg Med. 2020 Sep 8: PMID: 32917440 Clinical Question: Does the use of ultrasound or landmark-guided palpation achieve a higher success of radial arterial line cannulation? What They Did: Single-center, prospective, randomized control trial at an urban academic level 1 trauma center Prior to the start of the study, the investigators changed the primary outcome from the number of attempts to overall success Randomized to one of the following two groups for arterial line placement: Ultrasound guided (USG) Landmark-guided palpation (LMGP) A novice emergency medicine (EM) intern placed all arterial lines supervised by a second- or third-year EM resident who did not provide any tactile or physical assistance. An independent research assistant blinded to the study’s objectives assessed the operator for the study outcomes listed below If unable to cannulate the artery in the landmark-guided palpation technique after 3 attempts or 15 minutes, operators crossed over to ultrasound guided placement No senior resident or faculty performed any of the cannulations including when a crossover method was necessary Inclusion Criteria: Adult English and Spanish-speaking emergency department patients ≥ 18 years old who required placement of an arterial line placement for hemodynamic monitoring and cardiopulmonary resuscitation based on attending physician discretion Exclusion Criteria: None mentioned Outcomes: Primary Overall success of arterial line placement Secondary First-pass success Number of attempts Time to completion Complications (i.e. hematoma, infection and arterial occlusion) Results: A total of 40 patients were enrolled, 20 in both groups The ultrasound group had 11 different interns and the landmark group had 13 different interns (18 total interns in program means some residents performed both techniques) Critical Results: Of the 20-landmark guided arterial lines attempted, the 17 that were initially unsuccessful had crossed over to be successfully placed under ultrasound guidance Of the failed LMGP, USG crossover was 100% successful with a mean of 1.37 attempts and 180s for placement All 20 patients in the USG group had 100% overall success Strengths: Authors attempted to answer a clinically relevant question that is often frequently debated now that ultrasound is more prevalent in clinical practice Tried to include all the possible complications, both immediate and delayed, that may result from arterial line placement The authors were very clear in their definitions (i.e. Novice, supervising resident, time, complications, etc.) The exact method used to place an arterial was standardized and explicitly written out by the authors Patient characteristics, intern experience, and indications for arterial line placement were similar between groups Limitations: Single center urban academic center with a small sample size Large ultrasound presence in the department and faculty may have unconsciously biased results to favor the USG group Patient enrollment was a convenience sample, thus potentially introducing selection bias Authors did not account for previous POCUS and procedural proficiency of the interns (i.e. when each participant completed the 4-week ultrasound rotation before or after participating in this study) Authors did not account for any specific verbal guidance by supervising residents on needle/probe manipulation or ultrasound setting adjustments As the authors mention, landmark guidance may have been more difficult and prone to failure in hypotensive patients given their subsequent vasoconstriction (i.e. Did not account for vasopressor use or blood pressure differences between patients prior to cannulation). In fact, the only mention as to how hemodynamically unstable (if at all) some of these patients were, was the indications of possibly needing arterial line placement. Discussion: This is the first randomized control trial looking at arterial line placement using ultrasound by EM interns Study results, specifically LMGP match a prior study comparing placement by second- and third-year residents as well as another study comparing placement by four attendings Authors were looking for a 40% difference in the primary outcome which was based on previous evidence This emergency department and its subsequent residency program is very ultrasound friendly. They also have an ultrasound fellowship program thus creating a more receptive and positive culture towards the use of ultrasound for this procedure compared to other emergency departments that may not be as savvy in ultrasound All EM interns participated in an introductory 4-hour ultrasound procedure course taught by EM ultrasound-faculty specifically reviewing central and arterial line placement using dynamic needle-tip guidance. Additionally, each intern is required to complete a 4-week emergency ultrasound rotation. Although, the mean number of previous arterial lines was 6, it’s unclear where the intern-operator was in their course of training (ie. having just come off orientation or their ultrasound rotation) prior to participating in this study Important Definitions: Novice was defined as having placed less than 15 arterial lines and the supervising residents each had previously placed more than 25 arterial lines. These numbers were arbitrarily defined by the authors using the rationale of trying to compare each technique without the bias of significant previous experience with either method Time to completion was defined as time elapsed from needle insertion to complete cannulation of the catheter. Time to suture, time to apply a sterile dressing and time to connect to the monitor were not included Defined alternative methods as changing direction or withdrawing the needle and having to puncture again Vasospasm was not included in the predefined complications because the providers did not have a means to assess for this. Complications were recorded by the research assistant at the time of the procedure and then the authors went back to perform a chart abstraction within 7 days of line placement to record any delayed complications Author’s Conclusions: USG improved first-pass and overall success of radial arterial line cannulation while reducing time to access and attempts when used by novice emergency medicine interns Our Conclusion: In this study of novice emergency physicians, ultrasound-guided radial arterial line placement had a better first-pass and overall success, while minimizing attempts and complications compared to a landmark-guided palpation technique. This study shows that ultrasound guided arterial line placement is safe and more efficient approach to radial arterial cannulation. Although, the complication rates were low in this trial, complications have been associated with more frequent cannulation attempts and prolonged time to placement. Clinical Bottom Line: Ultrasound-guided arterial line placement improved first pass and overall success when compared to landmark guided placement of radial arterial lines in novice emergency physicians REFERENCES: Gibbons RC, et al. Ultrasound Guidance Versus Landmark-Guided Palpation for Radial Arterial Line Placement by Novice Emergency Medicine Interns: A Randomized Controlled Trial. J Emerg Med. 2020 Sep 8: PMID: 32917440 Wilson C, et al. Comparison of ultrasound-guided vs traditional arterial cannulation by emergency medicine residents. West J Emerg Med 2020; PMID: 32191193 Shiver S, Blaivas M, Lyon M. A prospective comparison of ultrasound-guided and blindly placed radial arterial catheters. Acad Emerg Med 2006; PMID: 17079789 Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srreziae) 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 | 2 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 antibiotics alone. The available literature on non-operative treatment of appendicitis (NOTA) has important limitations: exclusion of patients with appendicoliths, small sample size and predominance of open appendectomy over laparoscopic appendectomy. While data on NOTA is intriguing, it is clear that additional studies are needed. REBEL Cast Ep89 – The CODA Trial – Antibiotics vs Appendectomy for Appendicitis Click here for Direct Download of Podcast Paper: The CODA Collaborative. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. NEJM 2020. PMID: 33017106 Clinical Question: In adult patients, are antibiotics noninferior to surgery for the treatment of acute appendicitis? What They Did: Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) Pragmatic, nonblinded, noninferiority, randomized trial at 25 US centers Patients randomized to: Antibiotics: At least 24 hours of IV antibiotics followed by a 10-day course Surgery: Laparoscopic and conventional (open) appendectomy allowed Outcomes: Primary: 30d health status (Assessed with the European Quality of Life-5 Dimensions – EQ-5D questionnaire) Focuses on mobility, self-care, usual activities, pain/discomfort, and anxiety/depression Scores range from 0 to 1 with higher scores indicating better health status Noninferiority margin = 0.05 points Secondary: Patient-reported resolution of symptoms (Defined as absence of pain, tenderness and fever) Appendectomy in the antibiotics group National Surgical Quality Improvement Program (NSQIP) – defined complications at the time of the index treatment or during follow up Site related infectious complications (incisional infections or abscesses); Specifically, those requiring percutaneous drainage Reactions to antibiotics Diff infections More extensive procedures (i.e. bowel resection, reoperation, laparotomy, colostomy, or ileostomy) Appendiceal perforation found during an operation Appendiceal neoplasm Complications through 90d Serious adverse events Inclusion: English- or Spanish-speaking adults (≥18 years of age) Presenting to the ED Acute appendicitis confirmed on imaging In the absence of exclusion criteria, perforation on imaging was not an exclusion criterion Exclusion: Septic shock Diffuse peritonitis Recurrent appendicitis Evidence of severe phlegmon on imaging (Determined by surgeon that extensive operation such as ileocolectomy likely to be performed) Walled-off abscess Free air or more than minimal free fluid Evidence suggestive of neoplasm Prisoners Immunodeficiency Uncompensated liver failure Taking medication to treat IBD Active treatment for malignancy, not in remission Pregnancy Recent (within 90d) placement of a surgical implant) LVAD Image findings of any of the following Appendiceal soft-tissue mass Imaging features of mucocele or tumor concerning for malignancy Concern for any carcinomatosis on imaging Severe allergy to proposed antibiotics Abdominal/pelvic surgery in past month Results: 1552 adults underwent randomization 414 with an appendicolith 30d EQ-5D Questionnaire: Antibiotics: 0.92 +/- 0.13 Surgery: 0.91 +/- 0.13 Mean difference 0.01 points; 95% CI -0.001 to 0.03 Results were similar in the per-protocol analysis (Mean difference 0.01 points; 95% CI -0.002 to 0.03) In the antibiotics group: 11% underwent surgery by 48hrs 20% underwent surgery by 30d 29% underwent surgery by 90 days 41% underwent surgery by 90 days if appendicolith present 25% underwent surgery by 90days if no appendicolith was present NSQIP-Defined Complications: Antibiotics: 8.1 per 100 participants Surgery: 3.5 per 100 participants Rate Ratio 2.28; 95% CI 1.30 to 3.98 Complications in Pts with Appendicolith: Antibiotics: 20.2 per 100 participants Surgery: 3.6 per 100 participants Rate Ratio: 5.69; 95% CI 2.11 to 15.38 Complications in Pts without Appendicolith: Antibiotics: 3.7 per 100 participants Surgery: 3.5 per 100 participants Rate Ratio: 1.05; 95% CI 0.45 to 2.43 No difference in resolution of symptoms by day 7, 14, or 30 between groups The mean number of missed workdays for patients was 5.26d in the antibiotics group and 8.73 in the appendectomy group No deaths in either group Strengths: Largest randomized controlled trial investigating NOTA Patients were consecutively enrolled which helps to avoid selection bias Trial was designed to identify outcomes that patients considered to be most important Analyses were prespecified in subgroups according to the presence or absence of an appendicolith Independent data and safety monitoring board reviewed three formal interim analyses were performed annually and did not recommend stopping the trial To address potential selection bias a secondary per-protocol analysis of EQ-5D scores and serious adverse events at 30 days was done Patients that did not undergo randomization were enrolled in an observational cohort or an EMR-only cohort for follow up 90% completion rate of survey at 30d follow up and 86% completion rate of survey at 90d Sociodemographic and clinical characteristics were similar between groups Adherence to antibiotics was 90% among participants in the antibiotics group Broad inclusion criteria reducing chance of selection bias Limitations: Unblinded trial with subjective primary outcome may influence the results of the trial Amount of analgesic agents or pain-control medications provided was not standardized or monitored in either treatment group ≈14% lost to follow-up with no additional information 90d follow data may be too short a time to see recurrence rate and long-term complications in the antibiotic group All patients with appendicitis were approached for participation but only 30% of eligible patients agreed to undergo randomization There was no protocol to specify requirements for hospitalization or for a given antibiotic regimen Discussion: Most common antibiotics in the trial: Initial IV use (at least 24hrs): ertapenem, cefoxitin OR metronidazole plus one of the following…ceftriaxone, cefazolin, levofloxacin For oral use (remainder of 10 total days): metronidazole plus one of the following…ciprofloxacin, cefdinir Authors initially planned to report the results after all participants had at least 1 year of follow up however given the COVID-19 pandemic the results are based on the first 90 days after randomization Although surgeons had the option to perform appendectomy either laparoscopically or open, 96% were performed laparoscopically. In prior studies, open appendectomy was more common, and this procedure is associated with more complications. The predominance of laparoscopic appendectomy is a better reflection of current practice Time to discharge from either the ED or the hospital for index treatment was 1.33d in the antibiotics group and 1.3d in the appendectomy group (i.e. no difference) Percutaneous drainage procedures were more common in the antibiotics group vs appendectomy group overall (2.5 vs 0.5 per 100 participants; rate ratio 5.36; 95% CI 1.55 to 18.50) particularly those with an appendicolith When the analysis was limited to participants in either group who had undergone appendectomy the percentage with a perforation was higher in the antibiotics group vs appendectomy group (32% vs 16%). This higher rate was attributable to those with an appendicolith (61% vs 24%) and not to those without an appendicolith (14% vs 13%) Author Conclusion: “For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith.” Clinical Take Home Point: Although an antibiotic 1st strategy was non-inferior in this trial compared to appendectomy, nearly 3 in 10 patients had undergone appendectomy by 90 days, there were 3x more ED visits, and 2x more complications (This could be balanced with less days of missed work). Patients with an appendicolith are at a much higher risk of complications and need for surgery and in these patients an antibiotic 1st strategy should not be recommended. References: The CODA Collaborative. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. NEJM 2020. PMID: 33017106 Jacobs D. Antibitoics for Appendicitis – Proceed with Caution. NEJM 2020. PMID: 33017105 For More Thoughts on This Topic Checkout: Emlyn’s: Antibiotics or Surgery for Appendicitis REBEL Cast Ep35: Non Operative Treatment of Appendicitis (NOTA) Broome Docs: Appendicitis – Surgery vs. Antibiotics Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami) The post REBEL Cast Ep 89: The CODA Trial – Antibiotics vs Appendectomy for Appendicitis appeared first on REBEL EM - Emergency Medicine Blog.
17 minutes | 2 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 resuscitation Call your obstetric and/or surgical consultants early as operative intervention is often required Replace intravascular volume with blood products Uterine atony is the most common cause of postpartum hemorrhage. Begin treatment with uterine massage and uterotonic medications Consider the development in DIC when patients continue to bleed despite appropriate management REBEL Core Cast 44.0 – Postpartum Hemorrhage Click here for Direct Download of Podcast Definition: Blood loss > 500 ml after a delivery (or > 250 ml after an abortion). The management of post-abortion hemorrhage is similar to that of post-partum hemorrhage (PPH). Causes Uterine atony (~ 50% of cases) Retained products of conception (POCs) Cervical lacerations Uterine perforation Uterine Inversion Abnormal placentation (accreta, increta, percreta) Coagulopathy Background: Occurs in 1-2% of patients undergoing a first trimester surgical abortion Most common cause of abortion-related mortally in 2nd trimester Risk increases with increasing maternal age Clinical Presentation Diagnosis No exact definition but generally thought to be present when bleeding exceeds 500 ml Should be suspected if bleeding “exceeds a clinician’s estimate of ‘normal’.” (Lew 2013) Blood loss is not always brisk. Can be moderate, prolonged bleeding Tachycardia and hypotension will be late findings Look for signs of hypoperfusion Key Examination Pieces Any abnormal vital signs should raise suspicion of PPH Obtain history for bleeding disorders or anticoagulation use Examination of placenta Should be intact without “missing pieces” Looking for retained products of conception as source of ongoing bleeding Examination of fundus of uterus Uterine atony (uterine muscles do not fully contract) is the most common cause of postpartum hemorrhage (~ 80% of cases) (Lew 2013) Abdominal examination will reveal a “boggy” uterus. Can be confirmed on bimanual exam Direct examination of vagina Lacerations to genital tract during delivery can cause brisk blood loss Examine for uterine inversion (displacement of uterus into vagina) Examine sites where blood drawn/IVs started Looking for oozing or ongoing bleeding that may signal the presence of disseminated intravascular coagulation (DIC) Treatment Basic Supportive Care Large bore IV X 2, supplemental O2 if hypoxic, cardiac monitor Volume expansion to replace hemorrhage Replace with blood products as soon as available Give O negative until type specific products available Can use crystalloid early if evidence of hypoperfusion but not ideal resuscitative fluid Call obstetrics or surgical consultants early as patients frequently require surgical intervention Fundal Massage (Robert’s + Hedges) Tranexamic Acid (TXA) Largest study to date demonstrated reduction in death due to hemorrhage (1.9% vs 1.5%) without difference in hysterectomy rate (WOMAN trial 2017) Dose 1 gram over 10 minutes Second dose given if continued bleeding after 30 minutes or recurrent bleeding within 24 hours Full review of WOMAN trial found here Uterine Massage First line treatment for uterine atony Begin with firm massage of the uterine fundus through the abdominal wall Bimanual Uterine Massage (Robert’s + Hedges) Advance to bimanual uterine compression if bleeding continues External hand compresses and massages uterus Hand placed internally in fist to massage anterior aspect of uterus Avoid downward massage with internal hand (can cause uterine inversion or injure blood vessels) Uterotonic Medications Should be given concomitantly with uterine massage Multiple medication options which increase uterine muscle tone Drugs for the Management of Uterine Atony (Roberts + Hedges) Direct Uterine tamponade Uterine packing: Uterus is packed with gauze or hemostatic dressings Balloon tamponade Device is placed into the uterus and balloon filled with saline or water Bakri Balloon Bakri Balloon Commercially available device specifically for this indication Balloon accommodates up to 800 ml but as little as 250-500 ml of inflation can stop bleeding Can potentially obviate need for surgical management Sengstaken-Blakemore Esophogastric tube Has a maximum volume ~ 500 ml Latex Condom (Georgiou 2009, Burke 2017) Case reports + case series of condom secured to foley catheter and inflated Volume: 250-300 ml Do not use a single foley catheter for this indication Balloon with only 80 ml volume at maximum More likely to hide bleeding than to tamponade it Case reports of placement of multiple foley catheters (Georgiou 2009) Balloon Tamponade Options (Georgiou 2009) Uterine Inversion Treatment involves reduction of the uterus back into position Typically requires procedural sedation or general anesthesia to accomplish Reduction can be facilitated with tocolytic agents (I.e. terbutaline or magnesium sulfate) Disseminated Intravascular Coagulation Administer blood products and adjuncts based on clotting derangements that are present (See LITFL DIC Post) Patients will often require hysterectomy to resolve DIC 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 resuscitation Call your obstetric and/or surgical consultants early as operative intervention is often required Replace intravascular volume with blood products Uterine atony is the most common cause of postpartum hemorrhage. Begin treatment with uterine massage and uterotonic medications Consider the development in DIC when patients continue to bleed despite appropriate management For More on This Topic Checkout: REBEL EM: The WOMAN Trial – Early TXA in Post-Partum Hemorrhage Core EM: Episode 33.0 – Post-Partum Hemorrhage Core EM: TXA in Post-Partum Hemorrhage LITFL: Disseminated Intravascular Coagulation emDocs: EM@3AM – Disseminated Intravascular Coagulation References: Lew GH, Pulia MS: Emergency Childbirth, in Roberts JR, Hedges JR, Custalow CB, et al (eds): Clinical Procedures in Emergency Medicine, ed 6. Philadelphia, Saunders, 2013, Ch 56:p 1155-82. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with postpartum hemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 2017; 389(10084): 2105-16. PMID: 28456509 Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG 2009; 116(6): 748-57. PMID: 19432563 Burke TF et al. Shock progression and survival after use of a condom uterine balloon tamponade package in women with uncontrolled postpartum hemorrhage. Int J Gynaecol Obstet 2017; 139(1): 34-8. PMID: 28675419 Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie) The post REBEL Core Cast 44.0 – Postpartum Hemorrhage appeared first on REBEL EM - Emergency Medicine Blog.
17 minutes | 3 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 | 3 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 | 3 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 | 4 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 | 4 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.
21 minutes | 4 months ago
REBEL Cast Ep86: Baloxavir for Influenza Prophylaxis
Background: Baloxavir (trade name Xofluza) was approved for the treatment of acute, uncomplicated influenza in patients > 12 years of age in October 2018. However,... The post REBEL Cast Ep86: Baloxavir for Influenza Prophylaxis appeared first on REBEL EM - Emergency Medicine Blog.
7 minutes | 4 months ago
REBEL Core Cast 40.0 – Wernicke Encephalopathy
Take Home Points Wernicke encephalopathy is characterized by ataxia, altered mental status and ophthalmoplegia but patients are unlikely to have all these components Suspect Wernicke... The post REBEL Core Cast 40.0 – Wernicke Encephalopathy appeared first on REBEL EM - Emergency Medicine Blog.
18 minutes | 5 months ago
REBEL Core Cast 39.0 – Upper GI Bleed
Take Home Points Focus on resuscitating well by focusing on the basics Recognize Massive GIB (MGIB) with a thorough exam of the patient and vital... The post REBEL Core Cast 39.0 – Upper GI Bleed appeared first on REBEL EM - Emergency Medicine Blog.
18 minutes | 6 months ago
REBEL Core Cast 38.0 – Productivity
REBEL Core Cast 38.0 – Productivity Click here for Direct Download of Podcast Resources EMCrit: Getting Shit Done EMCrit: GTD Redux David Allen: Getting Things... The post REBEL Core Cast 38.0 – Productivity appeared first on REBEL EM - Emergency Medicine Blog.
9 minutes | 6 months ago
REBEL Core Cast 37.0 – Spinal Epidural Abscess
Take Home Points Spinal Epidural Abscess may present insidiously and patients often lack the classic triad of fever, back pain and neurologic symptoms Empiric Antibiotics... The post REBEL Core Cast 37.0 – Spinal Epidural Abscess appeared first on REBEL EM - Emergency Medicine Blog.
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