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Best Articles of 2012-2013 - TMA 2014 Annual Meeting

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Best Articles of 2012-2013 - TMA 2014 Annual Meeting

  1. 1. Best Articles: 2012-2013 Tyson Pillow, M.D., M.Ed. ! Associate Program Director! Section of Emergency Medicine! Assistant Professor! Baylor College of Medicine
  2. 2. I have no financial disclosures
  3. 3. Objectives A few good articles! “A La Casa”! Resuscitation! Post-resuscitation Care
  4. 4. A Few Good Men Articles
  5. 5. VS. When to do head CTs? 314 patients with GCS 15! 22 with any intracranial findings! 11 with “significant” injuries! 3 with neurosurgical emergency
  6. 6. Sensitivity Specificity Any lesion! “Significant”! Neurosurgery 100% 100% 36% 35% 81% 10% 10% 10% Papa, et. al. Acad Emerg Med. Jan 2012.
  7. 7. Low Risk Chest pain Prospective, observational*! TIMI score of 0, negative troponin at 0 and 2 hours, and no “new” EKG changes! Used their own standard troponins Than, et. al. J Am Coll Cardiol. Jun 2012.
  8. 8. Low Risk Chest pain 392 of 1957 patients were low risk! One patient with cardiac event (0.25%)! Sensitivity 99.7% Kelly, et. al. Emerg Med. Jan 2013.
  9. 9. History! EKG! Age! Risk Factors! Troponin Age > 65! > 3 CAD risk factors! Known CAD! ASA use in past 7 days! Recent severe angina! Elevated cardiac markers! ST deviation > 0.5 mm TIMI + HEART
  10. 10. TIMI + HEART No patient with TIMI < or = to 2 and HEART score 0 had an event Retrospectively applied to 9000 patients Marcoon, et. al. Crit Pathw Cardiol. Mar 2013.
  11. 11. Text Distinguishing Causes of Troponin Elevations
  12. 12. Text Cardiac disease associated with: Higher median value! 0.113 mcg/L vs 0.012 mcg/L Higher change in values! 0.019 mcg/L vs 0.001 mcg/L Haaf, et. al. Circulation. July 2012.
  13. 13. Troponins DO NOT “LEAK!”
  14. 14. “A la casa”
  15. 15. Abdomen
  16. 16. Appendicitis Modified Alvarado was only 76% sensitive Decision rule: Meltzer, et. al. Ann Emerg Med. Apr 2013.
  17. 17. Appendicitis 25% of the radiation dose with similar diagnostic accuracy Low dose CT scan vs standard: Kim, et. al. NEJM. Apr 2012.
  18. 18. Neurology
  19. 19. Is it safe to send TIA patients home? 60 patients in France! If met criteria*, then discharged on antiplatelet therapy! F/u in 8 to 15 days! One (1.7%) with stroke! 3 (5.0%) with recurrent TIA Q1 Montassier, et. al. J Emerg Med. May 2013.
  20. 20. Are head CTs useful for vertigo? 448 patients! 2.2% of CT scans abnormal! 104 patients received f/u imaging [78.7% MRI/A; 22.3% CT]! 17 patients with findings on f/u! Most commonly missed ischemic stroke Q2 Lawhn-Heath, et. al. Emerg Radiol. Sept 2012.
  21. 21. Can we stop doing LPs after negative CT scans? Retrospectively applied to 55 patients with SAH ! CT within 6 hours missed 11 (20%)! Q3 Mark, et. al. Ann Emerg Med. Oct 2012.
  22. 22. Cardiovascular
  23. 23. 246 patients Electrical Pharmacologic 89% conversion! 1.5 shocks 74% conversion! 220 min longer 33 more patients cardioverted with electricity Bellone, et. al. Emerg Med. Mar 2012.
  24. 24. Pulmonary
  25. 25. Case 1 34 y/o M presents with wheezing Moderate-severe How do you order your nebulizer treatments?
  26. 26. Continuous vs. intermittent nebulization of beta-agonists in asthma NNT = 7 Gregory.Acad Emerg Med. Nov 2012
  27. 27. Case 2 56 y/o M presents with mild COPD exacerbation “Antibiotics always clear it up for me” Are antibiotics indicated in this patient?
  28. 28. 310 patients in initial study 152 in the placebo arm analyzed! (80.1% did well without abx) Increased purulence CRP > 40 mg/L Miravitlles. Chest. Nov 2013
  29. 29. Case 3
  30. 30. Case 3
  31. 31. 122/78, 104, 22, 100.6 F Healthcare worker What is your management for this patient?
  32. 32. New strategy for healthcare-associated pneumonia Marayuma. Clin Infect Dis. Sept 2013 HCAP CAP p-value n 321 124 - MDR pathogens 15.3% 0.8% < 0.001 Mortality 13.7% 5.6% 0.017
  33. 33. Mortality for 0-1 MDR risk factor without severe PNA still 4.4%!
  34. 34. www.ann-clinmicrob.com Don’t forget MRSA Of 595 patients with CAP, 2.4% overall and 4.8% of ICU admits with MRSA as source 2 of 14 (14.3%) died Moran, et. al. Clin Infect Dis.Apr 2012.
  35. 35. Can PE patients be sent home? Meta-analysis of 7 studies including 741 patients! Included “symptomatic” patients*! 13 with recurrent PE (all undergoing active cancer treatment) and 3 with bleeding complications! None of the patients died within 90 days Vinson, et. al. Ann Emerg Med. Nov 2012.
  36. 36. Resuscitation
  37. 37. Lactate predicts mortality... In medical disease In trauma Lactate > or = 4 mg/dL had a 18.8% mortality Linear relationship of lactate to mortality ranging from 6% (< 1 mmol/L) to 39% (19-20 mmol/L) Puskarich, et. al. Acad Emerg Med.Aug 2012. Odom, et. al. JTrauma Acute Care Surg. Apr 2013.
  38. 38. ...but not useful in trauma after negative CT scan 0 of 104 patients with negative w/u has post- traumatic sequelae Vohra, et. al. WJEM. May 2013.
  39. 39. “Fast” = 75-120 bmp! ! Machine is better! ! Blacks don’t do CPR??? Idris, et. al. Circulation. Jun 2012. Sasson, et. al. NEJM. Oct 2012. Westfall, et. al. Crit Care Med. May 2013.
  40. 40. Should we be giving epi?!
  41. 41. Epinephrine 417,188 patients analyzed from 2005 to 2008! ! Epi associated with 2.36 adjusted odds ratio for ROSC! ! ...but after one month, survival (AOR 0.46) and cerebral performance (AOR 0.31) suffered Hagihara, et. al. JAMA. Mar 2012.
  42. 42. Should we be giving epi?! ! Role of ECMO?
  43. 43. Extracorporeal Membrane oxygenation 29% vs 8% with good neurologic outcomes! NNT in study was 4.8 ...but ECMO group younger, healthier, more likely to receive PCI and therapeutic hypothermia, etc... Maekawa, et. al. Crit Care Med. Feb 2013.
  44. 44. Extracorporeal Membrane oxygenation ...however 61 patients received ECMO ! (45 min + down time prior to arrival) then PCI with a 100% rate of ROSC and 33% rate of survival to discharge with good neurologic function Kagawa, et. al. Circulation.Aug 2012.
  45. 45. Resuscitation
  46. 46. Post-resuscitation Care
  47. 47. HypothermiaParalysis?! (Salciccioli. Resus. Jun 2013.) ROSC Prevent secondary injury PCI + CT protocol! (Chelly. Resus. Dec 2012) Prevent hyperoxygenation! (Janz. Crit Care Med. Dec 2012) Prophylactic lidocaine?! (Kudenchuk. Resus. Jun 2013.)
  48. 48. Summary
  49. 49. Best Articles: 2012-2013 Tyson Pillow, M.D., M.Ed. ! Associate Program Director! Section of Emergency Medicine! Assistant Professor! Baylor College of Medicine

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