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Emergency medicine research

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Discussion of some important EM research

Discussion of some important EM research

Published in: Health & Medicine

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  • 1. Dr Dane Horsfall FACEM Cabrini Hospital
  • 2.  Literature extensive Listen to this talk! Journal watch-http://emergency-medicine.jwatch.org/ EM:RAP-http://www.emrap.org/ Landmark Trials -Trials that affect our practice
  • 3.  NINDS 1995/ECASS III 2008 Rivers 2001/Surviving Sepsis 2008 + Case USA vs Canada: NEXUS 2001/Canadian Cervical Spine 2001 SAFE 2004 Sullivan 2007 Perry/Steill SAH 2011
  • 4.  National Institute of Neurological Disorders and Stroke-Washington DC “t-PA for acute ischemic stroke” Randomized, Double Blinded, recombt-PA (Alteplase) tPA 0.9mg/kg(max 90mg) 10% bolus then inf 1/24 Recommended tPA< 3/24
  • 5.  NIHSS-National Institutes of Health Stroke Scale ◦ neuro deficit, 42-point scale, neurologic deficits in 11 categories. Eg mild facial paralysis = 1, complete right hemiplegia/aphasia =25. Barthel Index ◦ perform activities of daily living (eating, bathing, walking, toilet) out of 100 Modified Rankin Scale-overall assessment of function ◦ 0= asymptomatic up to 5 =severe disability Glasgow Outcome Scale-global assessment of function ◦ 1=good recovery, ◦ 2=moderate disability ◦ 3=severe disability ◦ 4=vegetative state ◦ 5=death
  • 6.  Part 1 291pts NIHSS score at 24hrs= no difference Part 2 333pts Combination score at 3/12 Results combined for analysis t-PA minimal/no disability scores- 12% absolute increase, 32% relative, in, NNT=8 t-PA Increase ICH by 6% NNH=17 ◦ Assoc with more severe isch strokes/more oedema on CT Mortality t-PA 17%, Placebo 21% (Not stat. significant)
  • 7.  European Cooperative Acute Stroke Study “Thrombolysis with Alteplase 3 to 4.5 Hrs after Acute Ischemic Stroke” 821pts tPA 3-4.5 hrs 90 day disability –modified Rankin Scale ◦ 0-1 no disability t-PA 52% vsPlac 45% - NNT 14 ◦ 2-6 disability ICH(symp) t-PA 2.4% vsPlac 0.2% - NNH 45 Mortality t-PA 7.7% vsPlac 8.4% no difference BUT studies showing no Difference: ◦ ECASS I 1995 620pts tPA< 6/24 ◦ ECASS II 1998 300pts 0-6hrs
  • 8.  Contraindications: ◦ Bleeding risk  Anticoagulants, Platelets <100  Massive CVA > 1/3 cerebral hemisphere-obtund/complete hemiplegia  Uncontrolled HT >185/110  CVA/Head Injury in last 3/12 or ICH at an time  Bleed in last 3/52, bleeding diathesis, arterial puncture last 7/7  Pregnancy  Trauma/Surgery in last 14/7 ◦ Not Stroke:  Seizures  Hypoglycaemia ◦ No significant improvement possible  Resolving stroke  Previous disability
  • 9.  263 pts Rx in ED for 6/24 prior to ICU: ◦ 130 EGDT ◦ 133 standard Rx ◦ In hospital Mortality EGDT 30%, Standard 46% ◦ NNT 6 EGDT: ◦ CVP 8-12mmHg if < Fill 500ml bolus N/S every 30 mins ◦ MAP >65mmHg if <vasopressorsNoradrenaline ◦ ScvO2 (central mixed venous O2 sat) >70% if <Tx RBC to Hct> 30% if ScvO2 still <inotropes(dobutamine)  Central venous Sats>70% surrogate marker of adequate tissue perfusion-ie adequate resus from septic shock
  • 10.  Funded by manufacturer of CVC High control mortality Dr Rivers managing pts in ED Continuous Scv O2sats not practical to measure Cant argue against concept
  • 11.  EGDT Antibiotic within 1 hr Source Control crystalloid or colloid fluid resuscitation Vasopressor = Noradrenaline Dobutamine if CO low post filling/vasopressors Stress-dose steroid only if BP poorly responsive to vasopressors
  • 12. BIBA at 0430 - fever and severe R leg pain since 0100PHx CLL/Neutropenia - treated with gCSF0435-Temp 400CBP 87/62 mmHgHR 160/min irregular (AF)RR 17/minO2 sat 95% (air)Right leg red / swollen to thigh “Cellulitis”
  • 13. Two peripheral IVs,IV Tazocin 4.5g (early broad spectrum antis✔)IV fluid N/saline 1000mls (filling✔)IV analgesia Morphine incrementsIV Digoxin 500 mcg
  • 14.  Persistent hypotension, SBP 70-90/DBP 50-60 Remained in AF Pain very difficult to control Temp 38.4 0720-Hypotension persists 80/50 Rx-Gelofusine 500 and further 1000 ml N/Saline (Filling✔)
  • 15.  0845 IDC 0900 IV Metaraminol increments 0930 IV Gelofusine then IV Albumin 1000 CVC (1000, IJV) CVP 28-30-well filled ✔ 1035 Noradrenalineinf -Vasopressor ✔ 1200 IV Vancomycin 1g 1220 Transfer ICU Non EGDT-central venous sats, Survivng sepsis- Source control Outcome ◦ Clinical Dx Necrotizing Fasciitis by ID, pt palliated deceased later that day in ICU
  • 16.  National Emergency X-ray Utilization Study (Jerry Hoffman UCLA) 34,000pts, 21 sites, prospective observation of decision tool: Sens>99% Spec 12% If none of 5 clinical signs=clear Cx spine ◦ Midline tenderness ◦ Distracting injury ◦ Altered GCS ◦ Neurology ◦ Intoxication
  • 17.  9000pts normal conscious state** Sens 100%, spec 45% 1. High risk factors ◦ age>65 ◦ Mechanism (fall>1m,axial,MCA >100km/hr, motorbike, bicycle) ◦ Neuro* 2. Low Risk factors ◦ low speed MCA ◦ sitting/ walking ◦ no midline tenderness*/delayed pain 3. Able to Laterally neck rotation 45 degrees?
  • 18.  Advantages ◦ Mechanism ◦ Age >65 Disadvantages ◦ Complicated ◦ No distracting injury*
  • 19.  A comparison of Albumin and Saline for fluid resus in ICU (Saline vsAlbumin Fluid Evaluation) Multicentre, randomised, double blinded, 7000pts 4% Alb vs N/Saline 28/7- no difference in mortality Conclusion- Use N/Saline
  • 20.  “Early treatment with prednisolone or acyclovir in Bells palsy” Double-blind, placebo-control, randomized trial 500 Pts with Bells (no Herpes vesicles) < 72 hrs onset 10/7 Rx with: ◦ Pred 25mg bd ◦ Acyclovir ◦ Both ◦ Placebo Rating facial paralysis at 3 and 9/12 with “House-Brackmann scale” (1 normal to 6 total paralysis)
  • 21.  Recovery at 3/12 ◦ Pred 83% vs no Pred 64% ◦ Acyclovir 71% vs no Acyclovir 75% ◦ Both 80% Recovery at 9/12 ◦ Pred 94% vs no Pred 82% ◦ Acyclovir 85% vs no Acyclovir 91% ◦ Both 93% Conclusion-Give Prednisolone!!! Supported by results from: T Berg et al “The Effect of Prednisolone on Sequelae in Bells Palsy” Arch Otolaryngololgy - Head Neck Surg. 2012;138(5):445-449 May 2012
  • 22.  “Sensitivity of CT < 6/24 H/A onset for Dx SAH: prospective cohort study” 3100 pts, 11 Hospitals, 2000-2009 Adults, New acute h/a, no abNNeuro-?SAH 240 SAH (8%) Overall CT(3rd Gen) 93% sensitive, 100%specific Subgroup 950pts CT < 6/24 100% sens/specific (Dx all 121 SAH) ie Normal CT <6/24 rules oot SAH
  • 23.  Urgent CT (Cabrini CT ?3rd Gen) ?to LP or not to LP – depends on case and discussion with patient Perry study not validated in Australia-unlikely to be repeated Some ED’s have changed protocols
  • 24.  NINDS - “t-PA for acute ischemic stroke”, N Engl J Med 1995;333:1581-7 ECASS III – “Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke” N Eng J Med 2008;359:1317 Rivers et al – “Early goal-directed therapy in the treatment of severe sepsis and septic shock”, N Engl J Med, 345(19):1368- 77, 2001 Nov 8. Surviving Sepsis–Dellinger RP et al. January 2008 "Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008". Intensive Care Med 34 (1): 17–60. NEXUS – J Hoffman and The National Emergency X-Ray Utilization Study Group – “Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma”, N Engl J Med 2000;343:94-9
  • 25.  Stiell IG et al, “The Canadian C-spine rule for radiography in alert and stable trauma Patients”, JAMA. 2001 Oct 17;286(15):1841-8 SAFE – “A Comparison of Albumin and Saline for Fluid Resuscitation in the ICU”, N Engl J Med 2004;350: 2247-56. Sullivan et al – “Early treatment with prednisolone or acyclovir in Bells palsy”, N Engl J Med. 2007 Oct 18;357(16):1598-607 “The Effect of Prednisolone on Sequelae in Bells Palsy” Arch Otolaryngology Head Neck Surg. 2012;138(5):445-449 May 2012 Perry/Steill et al – “Sensitivity of CT performed within six hours of onset of headache for diagnosis of SAH: prospective cohort study” , BMJ 2011 July18;343:d4277