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What's Hot in EM April 2018

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What's Hot in EM April 2018

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What's Hot in EM April 2018

  1. 1. What’s Hot in EM? Dr F Morris Education Registrar
  2. 2. SyncoPE
  3. 3. PE causing syncope • PESIT (PE in Syncope Italian Trial) 2016: – Cross sectional multi-centre study; n=2584 – All patients with 1st episode of syncope admitted from ED (717 -> 560 included) • All had D-dimer and Wells score +/- CTPA or VQ scan • 17.3% (97) diagnosed PE – 45% RR >20, 33% HR >100, 36% SBP <110, 40% signs of DVT, 20% active cancer. – 97/2584 = 3.75% of all syncope presentations. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. Prandoni et al. N Engl J Med. 20/10/2016
  4. 4. PE causing syncope • New retrospective multi-national study – Canada, US, Denmark and Italy – n = 1,671,944 from Jan 2000 to Sept 2016 Prevalence of Pulmonary Embolism in Patients with Syncope. Costantino et al. JAMA Intern Med. 29/01/2018
  5. 5. Prevalence of Pulmonary Embolism in Patients with Syncope. Costantino et al. JAMA Intern Med. 29/01/2018
  6. 6. PE causing syncope • PE identified in <1% of all patients with syncope – Even within 90 days <1% – Suggesting PESIT algorithm has high false positive and subsegmental PE rates. • And only enrolled hospitalised patients. • Possible over-representation of indeterminate syncope in studies. Prevalence of Pulmonary Embolism in Patients with Syncope. Costantino et al. JAMA Intern Med. 29/01/2018
  7. 7. Sepsis update
  8. 8. Sepsis debates • SIRS criteria vs qSOFA • IV fluids vs early pressors • Reduced survival associated with Abx delay • Is there benefit from pre-hospital Abx?
  9. 9. Pre-Hospital Antibiotics • Multi-centre, prospective, open label, RCT. – >18y/o, suspected infection + temp >38/<36 + >1 other SIRS criteria. • IV Ceftriaxone 2g + IV fluid/O2 vs fluid/O2 only 1. All cause 28 day mortality 2. Misdiagnoses, hospital & 90-day mortality, length of stay, ICU admission, length of ICU stay, TTA, adverse events, quality of life 1 month after discharge. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. Alam N et al. The Lancet. Nov 2017.
  10. 10. Pre-Hospital Antibiotics • N=2698 • Mean age 73 • Sepsis, severe sepsis (95%) or septic shock • ~20% already on Abx prior to ambulance. – EMS also given training in recognising sepsis
  11. 11. Pre-Hospital Antibiotics • Intervention group n = 1535 (from 2698) • No difference in mortality at 28 days (8%) – Including subgroups – TTA ~26mins prior to arrival at ED (intervention) – TTA ~70mins after arrival at ED (usual care) • No anaphylaxis; 7 mild allergic reactions
  12. 12. Pre-Hospital Antibiotics • Why is intervention group larger? • Statistical vs clinical significance – Onset of illness • Confounded by sepsis training – Pre-EMS Abx • Urban environment and response times
  13. 13. The Death of MONA?
  14. 14. Morphine • Clopidogrel, prasugrel & ticagrelor • Small studies in healthy volunteers • Absorption, plasma levels +/- anti platelet effects. • Platelet reactivity at 2hrs • Mortality effect? • Fentanyl?
  15. 15. Oxygen • Cochrane review 2016 • No evidence to support routine use • Paucity of RCTs to support use.
  16. 16. Nitrates • Sublingual GTN data appears extrapolated from IV dosing. • IV GTN initiated within 24hrs of symptoms reduced mortality
  17. 17. References 1. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. Prandoni et al. N Engl J Med. 20/10/2016 2. Prevalence of Pulmonary Embolism in Patients with Syncope. Costantino et al. JAMA Intern Med. 29/01/2018 3. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. Alam N et al. The Lancet. Nov 2017. 4. SGEM#207: Ahh (Don’t) Push It – Pre-Hospital IV Antibiotics for Sepsis. Loosley & Doyle. SGEM. 14/02/2018

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