This document summarizes guidelines and evidence for assessing low-risk chest pain patients. It discusses how clinical history, examination, ECG, and troponin levels can be used to predict risk of acute coronary syndrome. The HEART score and TIMI score are presented as useful tools, with the HEART score shown to more accurately stratify low-risk patients. For those deemed low-risk with a HEART score of 0-3 and negative troponins, the risk of adverse events within 30 days is approximately 1.6%. Studies exploring shared decision making and accelerated diagnostic protocols have achieved even lower risks of around 0.8%. Pre-test probability of coronary artery disease should also be considered to guide need for further
This document provides guidance on evaluating chest pain and discusses the approach to diagnosing aortic dissection. It emphasizes maintaining a high index of suspicion for aortic dissection as the symptoms can mimic other conditions. Aortic dissection often presents with sudden, severe chest or back pain and may migrate. Examination findings like pulse/blood pressure differences between limbs can help but have low sensitivity. The document reviews risk factors and recommends promptly ordering tests like CT scans to diagnose this dangerous condition given the high mortality if left untreated.
Acute Heart Failure Management- Old and New WaysDuke Heart
1. The document discusses new and old ways of managing acute heart failure, focusing on decongestion.
2. It reviews trials of diuretics and vasodilators, and explores strategies like targeting different fluid compartments and restricting cardiac preload.
3. Innovative approaches discussed include modulating the splanchnic nerves, optimizing diuresis, directly draining fluid from the kidneys, and mechanically unloading the heart to aid decongestion.
This document provides information on evaluating and diagnosing chest pain. It begins by defining chest pain and noting that it is a common reason patients present for medical care. It then discusses the causes of chest pain and provides details on distinguishing ischemic from non-ischemic chest pain. Key factors for ischemic cardiac pain are discussed such as onset during exertion and relief with rest. The document provides guidance on evaluating a patient's chest pain by taking a thorough history addressing 10 specific points. Differential diagnoses for chest pain are also reviewed.
This document summarizes guidelines and evidence for assessing low-risk chest pain patients. It discusses how clinical history, examination, ECG, and troponin levels can be used to predict risk of acute coronary syndrome. The HEART score and TIMI score are presented as useful tools, with the HEART score shown to more accurately stratify low-risk patients. For those deemed low-risk with a HEART score of 0-3 and negative troponins, the risk of adverse events within 30 days is approximately 1.6%. Studies exploring shared decision making and accelerated diagnostic protocols have achieved even lower risks of around 0.8%. Pre-test probability of coronary artery disease should also be considered to guide need for further
This document provides guidance on evaluating chest pain and discusses the approach to diagnosing aortic dissection. It emphasizes maintaining a high index of suspicion for aortic dissection as the symptoms can mimic other conditions. Aortic dissection often presents with sudden, severe chest or back pain and may migrate. Examination findings like pulse/blood pressure differences between limbs can help but have low sensitivity. The document reviews risk factors and recommends promptly ordering tests like CT scans to diagnose this dangerous condition given the high mortality if left untreated.
Acute Heart Failure Management- Old and New WaysDuke Heart
1. The document discusses new and old ways of managing acute heart failure, focusing on decongestion.
2. It reviews trials of diuretics and vasodilators, and explores strategies like targeting different fluid compartments and restricting cardiac preload.
3. Innovative approaches discussed include modulating the splanchnic nerves, optimizing diuresis, directly draining fluid from the kidneys, and mechanically unloading the heart to aid decongestion.
This document provides information on evaluating and diagnosing chest pain. It begins by defining chest pain and noting that it is a common reason patients present for medical care. It then discusses the causes of chest pain and provides details on distinguishing ischemic from non-ischemic chest pain. Key factors for ischemic cardiac pain are discussed such as onset during exertion and relief with rest. The document provides guidance on evaluating a patient's chest pain by taking a thorough history addressing 10 specific points. Differential diagnoses for chest pain are also reviewed.
Cryptogenic stroke and PFO have always been a controversial topic with no closure trial in the past showing significant benefit from closing the PFO in preventing the recurrent stroke. Also thought to be due to imperfect definition of cryptogenic stroke which is evolving with drop in the fraction of patients from 20-40% in the past to very fewer numbers due to increased understanding of the mechanisms involved in acute stroke. Recent trials REDUCE and CLOSE targeted the niche population of PFO with moderate to large shunt and atrial septal aneurysm and showed benefit of closing PFO compared to the antiplatelet therapy alone but with the risk of A.fib, device and procedure related complications. This presentation is made in the Cerebrovascular center weekly conference at the Cleveland Clinic with my perspective after these current trials.
The New 2018 SCCM PADIS Guidelines: Quick Hits of Recommendations for Sedatio...Intensive Care Society
Dr. Needham is Professor of Pulmonary and Critical Care Medicine, and of Physical Medicine and Rehabilitation at the Johns Hopkins University in Baltimore, USA. He is Director of the “Outcomes After Critical Illness and Surgery” (OACIS) Research Group and core faculty with the Armstrong Institute for Patient Safety and Quality, both at Johns Hopkins. From a clinical perspective, he is an attending physician in the medical intensive care unit at Johns Hopkins Hospital and Medical Director of the Johns Hopkins Critical Care Physical Medicine and Rehabilitation program.
Dr. Needham received his MD degree from McMaster University in Hamilton, Canada, and completed both his residency in internal medicine and his fellowship in critical care medicine at the University of Toronto. He obtained his PhD in Clinical Investigation from the Bloomberg School of Public Health at Johns Hopkins University. Notably, prior to his medical training, he completed Bachelor and Master degrees in Accounting and practiced in a large international accounting firm, with a focus in the health care field.
Dr. Needham is Principal Investigator on a number of NIH research grants and has authored more than 250 publications. His research interests include evaluating and improving ICU patients’ long-term physical, cognitive and mental health outcomes, including research in the areas of sedation, delirium, early physical rehabilitation, and knowledge translation and quality improvement.
The document outlines a presentation on hypertension and hypertensive disorders for allied health workers. It begins with an introduction and outline covering hypertension and hypertensive disorders of pregnancy. The outline discusses risk factors and diagnosis of hypertension, as well as management of hypertensive crisis. Guidelines for diagnosing and treating hypertension from sources like the 2020 Philippine CPG are also summarized.
This document discusses various scoring systems used to assess disease severity in cirrhosis patients, including the Child-Pugh score and MELD score. The Child-Pugh score uses 5 clinical measures to stratify patients into 3 prognostic groups but has limitations. The MELD score was developed to address some of these limitations and uses bilirubin, creatinine, INR to predict mortality risk. Several derivative scores of MELD have also been developed to address specific patient populations or clinical scenarios. The document discusses various applications and limitations of these different scoring systems.
An overweight middle-aged man presented with acute shortness of breath, elevated blood pressure, coarse lung sounds, low oxygen saturation, and leg swelling. His initial evaluation found signs of severe congestive heart failure including pulmonary edema. Further assessment is needed to determine the underlying cause, guide treatment, and classify the type and severity of heart failure.
This document provides an overview of ST-elevation myocardial infarction (STEMI) including its epidemiology, etiology, pathophysiology, risk factors, diagnosis, and current guideline-directed management. It begins with definitions of STEMI and acute coronary syndrome. Key points include that STEMI accounts for 30-40% of myocardial infarctions in the US with a mortality rate of 8.8-18.4%. Risk factors include age, gender, family history, hypertension, diabetes, hyperlipidemia, and tobacco use. Diagnosis is made through ECG showing ST elevations and elevated cardiac biomarkers. Current treatment involves prompt reperfusion therapy with either primary percutaneous coronary intervention or fibrinolytic therapy to restore blood flow to the
- Pediatric pain management requires a multidisciplinary team approach to properly assess and treat a child's pain. This includes addressing physiological, sensory, cognitive, behavioral, and affective components of pain.
- It is important to believe the child's reports of pain, listen to parents and children, and consult other experts when needed. Treatment should be individualized and non-pharmacological options considered in addition to pharmacological interventions.
- Common opioid medications used for pediatric pain include morphine, hydromorphone, fentanyl, and methadone. Non-opioid options also have a role to play depending on the situation. Proper protocols and guidelines help ensure children's pain is well-managed
This document discusses acute coronary syndrome and thrombolytic therapy for STEMI. It defines ACS as a spectrum ranging from unstable angina to STEMI depending on the degree of coronary occlusion. For STEMI, the goals of early management are pain relief, early reperfusion, and treating complications to minimize heart muscle loss. Thrombolytic therapy with drugs like streptokinase or tenecteplase is recommended if initiated within 12 hours of symptoms to restore blood flow. Factors that indicate successful reperfusion and guidelines for concomitant medications, complications, and contraindications to thrombolysis are also summarized.
Acute Decompensated Heart Failure : What is New ?drucsamal
Prof. U. C. SAMAL is an expert in cardiology who has held leadership positions in several cardiological societies. The document discusses the management of acute decompensated heart failure and summarizes recent changes to guidelines. It provides an overview of pharmacological interventions for acute heart failure such as diuretics, vasodilators, and inotropes. Non-invasive ventilation and risk stratification scores are also mentioned. The document emphasizes the importance of both short-term stabilization and long-term management through multi-disciplinary programs to prevent readmissions.
1) Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), affects over 900,000 Americans each year and can be fatal. The risk of recurrence of VTE is 17-30% over time without continued anticoagulation treatment.
2) The risk of recurrent VTE depends on factors like whether the initial VTE was provoked by surgery or other transient risk factors, whether the patient has active cancer, and whether it is a first or subsequent episode of VTE. Hereditary thrombophilias alone do not strongly determine recurrence risk.
3) Treatment options for VTE include anticoagulants like warfar
This document discusses guidelines for managing acute coronary syndrome (ACS) in patients without persistent ST-segment elevation. It defines ACS and its classifications. It emphasizes the importance of analyzing chest pain characteristics, ECG, and biomarkers to determine if a patient has unstable angina or non-ST-segment elevation myocardial infarction (NSTEMI). Risk stratification is crucial for deciding admission and treatment strategy. Treatment may involve antiplatelet and anticoagulant medications, as well as invasive procedures depending on risk level. Timely reperfusion is emphasized as the primary therapy for ST-segment elevation myocardial infarction (STEMI) patients. Dosing guidelines are provided for various antiplatelet and anticoagulant drugs used in ACS management
Hypertonic Saline Versus Mannitol for Increased Intracranial Pressure ManagementAde Wijaya
Mannitol has traditionally been used as the first-line osmotic agent for decreasing intracranial pressure in various conditions such as traumatic brain injury, hemorrhage, and cerebral infarction. However, mannitol can cause renal failure and hypovolemia as adverse effects. Hypertonic saline formulations may reduce ICP without volume contraction and less nephrotoxicity risk. A recent meta-analysis found that hypertonic saline is more effective than mannitol for treating elevated ICP.
Pulmonary embolism is a potentially deadly condition caused by blood clots in the lungs. It is difficult to diagnose due to non-specific symptoms. Imaging tests like CT scans and ventilation-perfusion scans are used to identify clots in the lungs. Prompt diagnosis and treatment are important to reduce the high mortality rate associated with untreated pulmonary embolism.
The document discusses cardiogenic shock, outlining its definition, causes, pathophysiology, diagnosis and management, with a focus on shock complicating myocardial infarction. Cardiogenic shock occurs in 5-8% of patients hospitalized with ST-elevation myocardial infarction and has a high mortality rate of 70-80% despite emerging treatments. The document provides details on the hemodynamic parameters defining cardiogenic shock and reviews the various mechanisms that can lead to left or right ventricular failure and shock.
Management strategy in HF with ARNI - Recent updates Praveen Nagula
- The document discusses management strategies for heart failure with reduced ejection fraction (HFrEF), including recent updates.
- It summarizes key differences between Indian and Western HF patients, noting that Indians develop HF at a younger age and with lower ejection fractions. Prognosis is also worse for Indian patients compared to those in the West.
- Core therapies for HFrEF are discussed, including a paradigm shift with the approval of sacubitril-valsartan which has been shown to reduce cardiovascular death compared to ACE inhibitors or ARBs alone in clinical trials.
This document discusses risk stratification for patients presenting with unstable angina/NSTEMI. It defines risk stratification and outlines its benefits in guiding initial evaluation and treatment. Several common risk scores for ischemic risk (TIMI, PURSUIT, FRISC, GUSTO, GRACE) and bleeding risk (CRUSADE, ACUITY, HAS-BLED) are described. The GRACE score was found to best predict risk of death or myocardial infarction at one year. ECG patterns suggestive of ischemia and infarction are also reviewed. In conclusion, risk stratification using simple bedside scores like TIMI can categorize patients' risk, while the GRACE score further guides long-term prognosis and care
This document provides information on various cyanotic heart lesions including Tetralogy of Fallot, Transposition of the Great Arteries, Tricuspid Atresia, Ebstein's Anomaly and Total Anomalous Pulmonary Venous Return. It describes the anatomy, clinical features, diagnosis and management of these conditions. Key cyanotic heart lesions are characterized by mixing of oxygenated and deoxygenated blood resulting in central cyanosis.
The PARAGON-HF trial studied the effect of sacubitril/valsartan on NT-proBNP levels in patients with heart failure and preserved ejection fraction. The trial found that sacubitril/valsartan significantly reduced NT-proBNP levels compared to valsartan alone in patients with elevated levels of NT-proBNP at baseline. However, the treatment did not provide a significant reduction in cardiovascular death or hospitalization for heart failure compared to valsartan.
1) This study investigated whether using 64-slice MDCT as part of the initial diagnostic strategy for patients presenting with acute chest pain could reduce emergency department and hospital length of stay, admissions, and 30-day major adverse cardiac events.
2) 267 patients were randomized to either a conventional diagnostic strategy or a MDCT-based strategy. The MDCT-based strategy reduced unnecessary admissions in patients at intermediate risk and decreased hospital length of stay overall and in high-risk patients specifically.
3) Emergency department length of stay was not different between the strategies. No patients in the MDCT group experienced events at the one-month follow-up.
This study aimed to develop a model to characterize patients' chest pain characteristics that can rule out acute coronary syndrome (ACS) with high predictive value. The study included 164 patients presenting with chest pain, of which 82 were diagnosed with ACS and 82 without ACS. Through logistic regression analysis, four questions were identified as the best model to assess risk of ACS: 1) chest pain located at the left/middle chest, 2) chest pain radiating to the back, 3) chest pain provoked by activity and relieved by rest, and 4) chest pain not provoked by food, positional changes, or breathing. This model achieved 92.7% sensitivity, 84.1% specificity, and 86% accuracy in differentiating A
Cryptogenic stroke and PFO have always been a controversial topic with no closure trial in the past showing significant benefit from closing the PFO in preventing the recurrent stroke. Also thought to be due to imperfect definition of cryptogenic stroke which is evolving with drop in the fraction of patients from 20-40% in the past to very fewer numbers due to increased understanding of the mechanisms involved in acute stroke. Recent trials REDUCE and CLOSE targeted the niche population of PFO with moderate to large shunt and atrial septal aneurysm and showed benefit of closing PFO compared to the antiplatelet therapy alone but with the risk of A.fib, device and procedure related complications. This presentation is made in the Cerebrovascular center weekly conference at the Cleveland Clinic with my perspective after these current trials.
The New 2018 SCCM PADIS Guidelines: Quick Hits of Recommendations for Sedatio...Intensive Care Society
Dr. Needham is Professor of Pulmonary and Critical Care Medicine, and of Physical Medicine and Rehabilitation at the Johns Hopkins University in Baltimore, USA. He is Director of the “Outcomes After Critical Illness and Surgery” (OACIS) Research Group and core faculty with the Armstrong Institute for Patient Safety and Quality, both at Johns Hopkins. From a clinical perspective, he is an attending physician in the medical intensive care unit at Johns Hopkins Hospital and Medical Director of the Johns Hopkins Critical Care Physical Medicine and Rehabilitation program.
Dr. Needham received his MD degree from McMaster University in Hamilton, Canada, and completed both his residency in internal medicine and his fellowship in critical care medicine at the University of Toronto. He obtained his PhD in Clinical Investigation from the Bloomberg School of Public Health at Johns Hopkins University. Notably, prior to his medical training, he completed Bachelor and Master degrees in Accounting and practiced in a large international accounting firm, with a focus in the health care field.
Dr. Needham is Principal Investigator on a number of NIH research grants and has authored more than 250 publications. His research interests include evaluating and improving ICU patients’ long-term physical, cognitive and mental health outcomes, including research in the areas of sedation, delirium, early physical rehabilitation, and knowledge translation and quality improvement.
The document outlines a presentation on hypertension and hypertensive disorders for allied health workers. It begins with an introduction and outline covering hypertension and hypertensive disorders of pregnancy. The outline discusses risk factors and diagnosis of hypertension, as well as management of hypertensive crisis. Guidelines for diagnosing and treating hypertension from sources like the 2020 Philippine CPG are also summarized.
This document discusses various scoring systems used to assess disease severity in cirrhosis patients, including the Child-Pugh score and MELD score. The Child-Pugh score uses 5 clinical measures to stratify patients into 3 prognostic groups but has limitations. The MELD score was developed to address some of these limitations and uses bilirubin, creatinine, INR to predict mortality risk. Several derivative scores of MELD have also been developed to address specific patient populations or clinical scenarios. The document discusses various applications and limitations of these different scoring systems.
An overweight middle-aged man presented with acute shortness of breath, elevated blood pressure, coarse lung sounds, low oxygen saturation, and leg swelling. His initial evaluation found signs of severe congestive heart failure including pulmonary edema. Further assessment is needed to determine the underlying cause, guide treatment, and classify the type and severity of heart failure.
This document provides an overview of ST-elevation myocardial infarction (STEMI) including its epidemiology, etiology, pathophysiology, risk factors, diagnosis, and current guideline-directed management. It begins with definitions of STEMI and acute coronary syndrome. Key points include that STEMI accounts for 30-40% of myocardial infarctions in the US with a mortality rate of 8.8-18.4%. Risk factors include age, gender, family history, hypertension, diabetes, hyperlipidemia, and tobacco use. Diagnosis is made through ECG showing ST elevations and elevated cardiac biomarkers. Current treatment involves prompt reperfusion therapy with either primary percutaneous coronary intervention or fibrinolytic therapy to restore blood flow to the
- Pediatric pain management requires a multidisciplinary team approach to properly assess and treat a child's pain. This includes addressing physiological, sensory, cognitive, behavioral, and affective components of pain.
- It is important to believe the child's reports of pain, listen to parents and children, and consult other experts when needed. Treatment should be individualized and non-pharmacological options considered in addition to pharmacological interventions.
- Common opioid medications used for pediatric pain include morphine, hydromorphone, fentanyl, and methadone. Non-opioid options also have a role to play depending on the situation. Proper protocols and guidelines help ensure children's pain is well-managed
This document discusses acute coronary syndrome and thrombolytic therapy for STEMI. It defines ACS as a spectrum ranging from unstable angina to STEMI depending on the degree of coronary occlusion. For STEMI, the goals of early management are pain relief, early reperfusion, and treating complications to minimize heart muscle loss. Thrombolytic therapy with drugs like streptokinase or tenecteplase is recommended if initiated within 12 hours of symptoms to restore blood flow. Factors that indicate successful reperfusion and guidelines for concomitant medications, complications, and contraindications to thrombolysis are also summarized.
Acute Decompensated Heart Failure : What is New ?drucsamal
Prof. U. C. SAMAL is an expert in cardiology who has held leadership positions in several cardiological societies. The document discusses the management of acute decompensated heart failure and summarizes recent changes to guidelines. It provides an overview of pharmacological interventions for acute heart failure such as diuretics, vasodilators, and inotropes. Non-invasive ventilation and risk stratification scores are also mentioned. The document emphasizes the importance of both short-term stabilization and long-term management through multi-disciplinary programs to prevent readmissions.
1) Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), affects over 900,000 Americans each year and can be fatal. The risk of recurrence of VTE is 17-30% over time without continued anticoagulation treatment.
2) The risk of recurrent VTE depends on factors like whether the initial VTE was provoked by surgery or other transient risk factors, whether the patient has active cancer, and whether it is a first or subsequent episode of VTE. Hereditary thrombophilias alone do not strongly determine recurrence risk.
3) Treatment options for VTE include anticoagulants like warfar
This document discusses guidelines for managing acute coronary syndrome (ACS) in patients without persistent ST-segment elevation. It defines ACS and its classifications. It emphasizes the importance of analyzing chest pain characteristics, ECG, and biomarkers to determine if a patient has unstable angina or non-ST-segment elevation myocardial infarction (NSTEMI). Risk stratification is crucial for deciding admission and treatment strategy. Treatment may involve antiplatelet and anticoagulant medications, as well as invasive procedures depending on risk level. Timely reperfusion is emphasized as the primary therapy for ST-segment elevation myocardial infarction (STEMI) patients. Dosing guidelines are provided for various antiplatelet and anticoagulant drugs used in ACS management
Hypertonic Saline Versus Mannitol for Increased Intracranial Pressure ManagementAde Wijaya
Mannitol has traditionally been used as the first-line osmotic agent for decreasing intracranial pressure in various conditions such as traumatic brain injury, hemorrhage, and cerebral infarction. However, mannitol can cause renal failure and hypovolemia as adverse effects. Hypertonic saline formulations may reduce ICP without volume contraction and less nephrotoxicity risk. A recent meta-analysis found that hypertonic saline is more effective than mannitol for treating elevated ICP.
Pulmonary embolism is a potentially deadly condition caused by blood clots in the lungs. It is difficult to diagnose due to non-specific symptoms. Imaging tests like CT scans and ventilation-perfusion scans are used to identify clots in the lungs. Prompt diagnosis and treatment are important to reduce the high mortality rate associated with untreated pulmonary embolism.
The document discusses cardiogenic shock, outlining its definition, causes, pathophysiology, diagnosis and management, with a focus on shock complicating myocardial infarction. Cardiogenic shock occurs in 5-8% of patients hospitalized with ST-elevation myocardial infarction and has a high mortality rate of 70-80% despite emerging treatments. The document provides details on the hemodynamic parameters defining cardiogenic shock and reviews the various mechanisms that can lead to left or right ventricular failure and shock.
Management strategy in HF with ARNI - Recent updates Praveen Nagula
- The document discusses management strategies for heart failure with reduced ejection fraction (HFrEF), including recent updates.
- It summarizes key differences between Indian and Western HF patients, noting that Indians develop HF at a younger age and with lower ejection fractions. Prognosis is also worse for Indian patients compared to those in the West.
- Core therapies for HFrEF are discussed, including a paradigm shift with the approval of sacubitril-valsartan which has been shown to reduce cardiovascular death compared to ACE inhibitors or ARBs alone in clinical trials.
This document discusses risk stratification for patients presenting with unstable angina/NSTEMI. It defines risk stratification and outlines its benefits in guiding initial evaluation and treatment. Several common risk scores for ischemic risk (TIMI, PURSUIT, FRISC, GUSTO, GRACE) and bleeding risk (CRUSADE, ACUITY, HAS-BLED) are described. The GRACE score was found to best predict risk of death or myocardial infarction at one year. ECG patterns suggestive of ischemia and infarction are also reviewed. In conclusion, risk stratification using simple bedside scores like TIMI can categorize patients' risk, while the GRACE score further guides long-term prognosis and care
This document provides information on various cyanotic heart lesions including Tetralogy of Fallot, Transposition of the Great Arteries, Tricuspid Atresia, Ebstein's Anomaly and Total Anomalous Pulmonary Venous Return. It describes the anatomy, clinical features, diagnosis and management of these conditions. Key cyanotic heart lesions are characterized by mixing of oxygenated and deoxygenated blood resulting in central cyanosis.
The PARAGON-HF trial studied the effect of sacubitril/valsartan on NT-proBNP levels in patients with heart failure and preserved ejection fraction. The trial found that sacubitril/valsartan significantly reduced NT-proBNP levels compared to valsartan alone in patients with elevated levels of NT-proBNP at baseline. However, the treatment did not provide a significant reduction in cardiovascular death or hospitalization for heart failure compared to valsartan.
Similar to Shared Decision Making Using the HEART Score and a Visual Aid in Patients Presenting to the Emergency Department with Chest Pain by Michael Boyd
1) This study investigated whether using 64-slice MDCT as part of the initial diagnostic strategy for patients presenting with acute chest pain could reduce emergency department and hospital length of stay, admissions, and 30-day major adverse cardiac events.
2) 267 patients were randomized to either a conventional diagnostic strategy or a MDCT-based strategy. The MDCT-based strategy reduced unnecessary admissions in patients at intermediate risk and decreased hospital length of stay overall and in high-risk patients specifically.
3) Emergency department length of stay was not different between the strategies. No patients in the MDCT group experienced events at the one-month follow-up.
This study aimed to develop a model to characterize patients' chest pain characteristics that can rule out acute coronary syndrome (ACS) with high predictive value. The study included 164 patients presenting with chest pain, of which 82 were diagnosed with ACS and 82 without ACS. Through logistic regression analysis, four questions were identified as the best model to assess risk of ACS: 1) chest pain located at the left/middle chest, 2) chest pain radiating to the back, 3) chest pain provoked by activity and relieved by rest, and 4) chest pain not provoked by food, positional changes, or breathing. This model achieved 92.7% sensitivity, 84.1% specificity, and 86% accuracy in differentiating A
This presentation is an Evidence-based review that aims to explain the importance of the 10-minute window from arrival with chest pain until obtaining an ECG. It also features a customized protocol that can be applied in the clinical setting to achieve the recommended 10-minute window to ECG.
Please note that you're welcome to use any slides as long as you reference my post when you do so to maintain the integrity of authorship. However, application of this protocol in the clinical setting requires prior permission.
If interested in detailed answers, please email: aamirdash@yahoo.com
Thanks, Ahmad.
The best of_the_pem_literature_in_the_last_year_terry_klassen_presentationtrekkca
This document summarizes several key pediatric emergency medicine studies from 2012-2013. It discusses 10 topics:
1. A randomized controlled trial compared polyethylene glycol 3350 vs enema for fecal disimpaction, finding no significant differences in symptom improvement between groups at day 5.
2. A clinical practice guideline stratified appendicitis risk into low, medium, and high to guide imaging and surgical referral.
3. Two studies examined diagnostic tools and physician accuracy for diagnosing intussusception.
4. An intervention to improve structured pain management in the pediatric ED led to more patients receiving analgesics faster and more frequent reassessment.
5. Studies found that rest improves concussion symptoms and reductions in
Improvement U Adult Mock Code PresentationKim Nelson
This document describes a quality improvement project to improve pediatric residents' competence and confidence in assessing and stabilizing adult patients presenting with chest pain or stroke. It involved implementing mock code simulations with debriefing and distributing learning guides. Results showed pediatric residents demonstrated a 34-46% increase in confidence and a 30-41% increase in medical knowledge regarding adult chest pain and stroke treatment. Adherence to checklist items during simulations also increased. The project concluded educational interventions like simulations can effectively address knowledge gaps pediatric providers have in treating adult patients.
This document discusses strategies to prevent and manage delirium in critically ill patients. It outlines the ABCDEF bundle which includes assessing, preventing, and managing pain, both spontaneous awakening and breathing trials, minimizing sedation, assessing and preventing delirium, early mobility and exercise, and engaging family members. Screening for delirium using the CAM-ICU tool and implementing non-pharmacological interventions can reduce length of hospital stay, duration of mechanical ventilation, and mortality. Widespread use of protocols and bundles that incorporate these strategies may help address the high cost and poor outcomes associated with delirium.
This document discusses isolated head injuries in pediatric trauma patients and the association with shock and hypotension. The key points are:
1) A study found that among pediatric patients with isolated head injuries, rates of hypotension were highest in those aged 0-4 years, with 1/3 of hypotension cases associated with isolated head injuries in that age group.
2) Several potential causes for this association between isolated head injuries and hypotension in young pediatric patients were hypothesized, including neurogenic or autonomic responses.
3) Due to the risks of cerebral edema from large fluid volumes, providers may need to adjust treatment to include early vasopressors or anticholinergic drugs to support blood pressure in these
This document discusses quality improvement in healthcare. It begins by posing questions about defining quality, what quality improvement is, and how quality can be improved. It then discusses the safety paradox in healthcare - that despite highly trained staff and technology, errors are common and patients are frequently harmed. Several studies on adverse event rates in hospitals are summarized. The document discusses concepts for safety and quality improvement like reliability, variation, measurement, and change management. It provides examples of quality improvement tools and approaches like process mapping, care bundles, measurement, and the PDSA (Plan-Do-Study-Act) cycle. Overall, the document provides an overview of key issues and approaches related to quality and safety in healthcare.
Defibrillation strategy for refractory Ventricular fibrillation.pptxAhmed Lotfy
The objective of this trial (Double Sequential External Defibrillation for Refractory Ventricular Fibrillation [DOSE VF]) was to evaluate Double Sequential External Defibrillation (DSED) and Vector Change (VC) defibrillation as compared with standard defibrillation in patients who remain in refractory ventricular fibrillation during out-of-hospital cardiac arrest.
Classification and Regression Tree Analysis in Biomedical Research Salford Systems
This document discusses using classification and regression tree (CART) analysis to develop clinical decision rules for three clinical settings: 1) emergency department triage of HIV-infected patients, 2) survival prediction of patients with colon and rectal cancer, and 3) prediction of neurologic survival in patients following out-of-hospital cardiac arrest. For each setting, the document describes developing CART models using various clinical variables to classify patients into risk groups and reports validation results for predicting outcomes like medical urgency and survival.
This document discusses evidence supporting the use of the ABCDEF bundle and Society of Critical Care Medicine's (SCCM) guidelines for managing pain, agitation, and delirium (PAD) in mechanically ventilated patients. It summarizes the 2013 SCCM PAD guidelines, which establish an overarching approach to daily patient management focusing on assessing and treating pain first, avoiding deep sedation and benzodiazepines, screening for delirium, and using the ABCDEF bundle to improve outcomes. Studies found implementing more than six strategies along with the PAD guidelines or ABCDE bundle reduced mortality and ICU length of stay, while incomplete implementation yielded lower success rates.
J2016 - Tecson et al AJC Impact of EECP on Heart Failure RehospitalizationEmily Hu
1) The study assessed the impact of enhanced external counterpulsation (EECP) combined with heart failure education on reducing 90-day readmission rates in 99 patients with heart failure due to ischemic cardiomyopathy who began EECP within 90 days of hospital discharge.
2) Only 6 patients (6.1%) had unplanned readmissions within 90 days, which was significantly lower than the predicted rate of 34%. Functional status, walk distance, and symptoms also improved after EECP based on various clinical measures.
3) In conclusion, patients who received EECP and education within 90 days of discharge had significantly lower readmission rates than predicted, and also showed improvements in functional status, walk distance, and symptoms.
The document discusses lessons from the United States on caring for patients with chronic illnesses. It outlines three key functions of primary care teams: panel management to ensure patients receive evidence-based care, health coaching to support behavior change and medication adherence, and complex care management for high-needs patients. High-functioning teams with roles like registry use, panel managers, and health coaches are shown to improve health outcomes and lower costs compared to usual individual physician care.
The document discusses lessons from the United States on caring for patients with chronic illnesses. It outlines three key functions of primary care teams: panel management to ensure patients receive evidence-based care, health coaching to support behavior change and medication adherence, and complex care management for high-needs patients. High-functioning teams with roles like registry use, panel managers, and health coaches are shown to improve health outcomes and lower costs compared to usual individual physician care.
Impact of a designed nursing intervention protocol on myocardial infarction p...Alexander Decker
This study examined the impact of a designed nursing intervention protocol on myocardial infarction patients' outcomes at a university hospital in Egypt. Forty adult myocardial infarction patients were included. The study found that after exposure to the nursing intervention protocol, patients had significantly higher total mean knowledge scores and total mean practice scores. It also found that patients had medium to high levels of compliance to lifelong instructions. The results support the hypotheses that the nursing intervention protocol improved patients' knowledge, practices, and compliance. The study concluded that a nursing intervention protocol can have a positive impact on myocardial infarction patient outcomes.
This document provides an overview and education manual for the Canadian Triage and Acuity Scale (CTAS). It describes the origins and development of CTAS, which was created in 1999 to standardize triage across Canada. CTAS uses a 5-level system to prioritize patients based on their condition and established guidelines for reassessment times. The document reviews the goals and objectives of triage, the triage process, unique characteristics of emergency patients, the role of the triage nurse, and challenges like overcrowding. It aims to enhance triage skills and ensure patients receive care according to their level of acuity and need.
This document discusses sickle cell disease (SCD) pain management in the emergency department. It notes that SCD pain is the main reason for healthcare interactions in patients with SCD. There are two main types of SCD pain: vaso-occlusive crisis (VOC) and chronic pain. The patient's self-report of pain is the most reliable indicator of a VOC, as there are no objective diagnostic indicators. Guidelines recommend rapid assessment and aggressive opioid management for severe acute SCD pain. ED triage of SCD pain should be a high priority level if pain is over 7/10.
This study analyzed the clinical profiles of 282 acute coronary syndrome (ACS) patients in Kupang, Indonesia over a 1.5 year period. The study found that NSTEACS cases were more common than STEMI cases. Patients tended to be male and younger than ACS patients in more developed countries. Half had comorbidities like hypertension. Treatment practices followed guidelines but fibrinolytic therapy rates were low at 31% for STEMI patients due to delays. The study highlights the need to improve pre-hospital care and establish telecardiology to help reduce delays and improve outcomes for ACS patients in Kupang.
Integrative Telerehabilitation Strategy after Acute Coronary SyndromeIgnacio Basagoiti
1) The study aims to validate an integrated telerehabilitation model to support post-acute coronary syndrome rehabilitation and secondary prevention using mobile technologies and telemonitoring.
2) Patients will be randomized into two groups - a control group receiving conventional in-hospital rehabilitation and an intervention group using a mobile app and telemonitoring for 10 months of at-home rehabilitation.
3) The primary outcome is adherence to exercise measured by questionnaires and exercise tests, with secondary outcomes of cardiovascular risk factor control, lifestyle changes, and cost analysis.
This document discusses how telehealth and real-time analytics can help critical care achieve better health outcomes, better care, and lower costs. It describes how monitoring patients and gaining situation awareness is important for critical care. Real-time data analytics can help clinicians understand a patient's current physiological status and trajectory. Pattern recognition in patient data may help identify issues earlier. The challenges of big data in healthcare including volume, velocity, variety and veracity are discussed. Technologies that provide real-time situation awareness and predictive analytics could help improve patient care and outcomes in the ICU.
Similar to Shared Decision Making Using the HEART Score and a Visual Aid in Patients Presenting to the Emergency Department with Chest Pain by Michael Boyd (20)
This document provides an agenda for the Eighth Annual Barsan Research Forum in 2023 on supporting the academic biomedical workforce. The forum will discuss career interventions to promote equity, retention and advancement in academic careers. It will also discuss innovative models of care delivery to enhance value across acute care and the use of decision systems. Presentations will focus on hospital variation in emergency care, guideline-discordant care, human factors research and human-enabling technologies. The goal is to support the academic biomedical workforce through discussions of career development and care delivery innovations.
The zebrafish endotoxemia model can model specific features of human sepsis pathogenesis. Both in human sepsis patients and zebrafish exposed to LPS, genes involved in cholesterol metabolism are significantly upregulated, including DHCR7. Inhibition of DHCR7 through use of an inhibitor protected zebrafish from endotoxemia-induced death. Next steps involve investigating how DHCR7 inhibition provides this protective effect and determining if DHCR7 inhibitors could be repurposed to treat human sepsis by testing their effects in mouse models of endotoxemia and sepsis.
This study investigated characteristics of 809 children presenting to the emergency department for epistaxis (nosebleed) between 2013-2022. The majority (92.7%) were treated medically with nasal compression or intranasal medications. Older age, bleeding duration over 30 minutes, and antiplatelet medication use were associated with the 6.3% who received procedural intervention like cauterization. Procedural control led to higher rates of transfusion and admission. The results provide guidance on pediatric epistaxis patients needing emergency referral.
This study compared cardiac arrest outcomes between Detroit, Michigan (DEMCA) and Genesee County, Michigan (GCMCA) from 2017-2021. DEMCA had significantly higher rates of poverty, unemployment, and African American patients compared to GCMCA. While bystander witnessed arrests and CPR rates were higher in DEMCA, survival rates were significantly lower - only 1.9% survived with good neurological outcomes in DEMCA compared to 5.5% in GCMCA. Socioeconomic factors likely contributed to the differences in outcomes between the two regions. Further work is needed to improve cardiac arrest survival, especially in communities with higher poverty and unemployment.
This document summarizes the career of Dr. Rebecca Cunningham in academic emergency medicine and injury prevention research over nearly 30 years. It describes her progression from emergency medicine residency training in the late 1990s to becoming Vice President for Research. As an emergency physician, her research initially focused on preventing firearm injuries and violence among youth. This expanded to larger community-based intervention studies and developing emergency medicine training programs in Ghana. Her current role continues to support injury prevention research and new initiatives in areas like hydrogen energy and bridging the funding gap for university startups.
The document provides information about the University of Michigan StrokeNet Regional Coordinating Center #17 (RCC-17). It discusses the origins and growth of StrokeNet and RCC-17 over time. Currently, RCC-17 coordinates clinical trials across 17 counties in Michigan and Kentucky, enrolling over 270 sites on average. RCC-17 runs both prevention and treatment trials, enrolling nearly 500 subjects total. It aims to improve enrollment diversity and provides fellowships for training in stroke research. RCC-17 also develops new clinical trial proposals and represents the region in national StrokeNet committees.
This document summarizes the experiences of a university-based critical care EMS service in transporting 127 COVID-19 patients between March and December 2020. Key findings include that patients were often severely ill, with most requiring intubation and interventions like nitric oxide. Over 40% of patients died, with mortality higher for those needing more respiratory support or vasopressors. Transports were lengthy, especially for patients receiving multiple interventions. The pandemic challenged procedures but the EMS service was able to adapt and provide high level critical care during transport.
The document discusses the Adult ICECAP trial, which aims to study early, high-quality hypothermic temperature management for out-of-hospital cardiac arrest. It notes that no devices are FDA-approved for inducing hypothermia in adults, so the trial is using an investigational device exemption. The goal of the trial is to take better care of patients through new knowledge and design future trials to accomplish this. It then provides rationales for inducing hypothermia to 33°C rather than just controlling fever, and argues for cooling patients early and deeply to give them the best chances of survival based on previous study results.
1) Focused cardiac ultrasound findings suggestive of a patient's ability to tolerate fluid (fluid tolerance) as defined by a normal left ventricular ejection fraction, absence of dilated inferior vena cava, and absence of decreased respiratory variation in inferior vena cava size were associated with greater compliance with administering 30cc/kg of fluid within 3 hours per the SEP-1 sepsis bundle.
2) Patients found to be fluid tolerant on FCU received more fluid within 3 hours and were more likely to meet the 30cc/kg fluid target amount compared to those found to have poor fluid tolerance.
3) The association between FCU findings of fluid tolerance and increased fluid administration was strongest in patients with pre
The document describes a study that provided education on medication for opioid use disorder (MOUD) to emergency residents and found it increased their comfort and confidence in offering treatments like buprenorphine. Clinical process measures showed more patients were offered buprenorphine and referred to outpatient addiction treatment after the educational intervention. The authors conclude targeted education for residents on MOUD and harm reduction holds promise for improving care of patients with opioid use disorder in emergency departments.
This document summarizes the results of a survey of first responders regarding their experiences with a "leave-behind naloxone" program. 56 first responders from EMS and fire departments completed the survey. Key findings include: 23% had previously distributed a naloxone kit, common barriers to distribution were forgetting, patients refusing, and lack of someone to leave the kit with. Most respondents understood the program's purpose and had received related training. Around half expressed interest in additional continuing education on harm reduction and addiction. The study provides insight into facilitators and barriers to naloxone distribution programs from the perspective of first responders.
This study evaluated the impact of combining aortic balloon occlusion with a percutaneous left ventricular assist device (pL-VAD) during cardiopulmonary resuscitation (CPR) in a swine model of cardiac arrest. The addition of transient aortic occlusion to pL-VAD support during CPR led to synergistic improvements in coronary perfusion pressure and cerebral perfusion pressure compared to pL-VAD alone. This enhancement was associated with improved cardiac function recovery and cerebral oxygenation. Post-resuscitation, coronary and cerebral perfusion pressures as well as cardiac function improved more rapidly in groups that received continued pL-VAD support. Further research is needed to evaluate potential long-term benefits
This presentation discusses harm reduction approaches for patients with substance use disorders in emergency departments. It provides background on the opioid epidemic and overdose deaths locally. It describes current harm reduction services at the University of Michigan emergency departments, including social work consultations, syringe access, naloxone distribution, and medication for opioid use disorder initiation. It outlines two research projects - one training emergency medicine residents on medication for opioid use disorder and one evaluating a first responder naloxone leave behind program. It introduces the project team members, which includes house officers, medical students, faculty advisors, and other collaborators from various departments.
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The document summarizes emerging technology platforms in healthcare, specifically the Mayo Clinic Platform. It discusses how healthcare is transitioning from reactive to preemptive care using molecular data and early detection. The Mayo Clinic Platform aims to discover, develop, validate, and deliver insights and algorithms through collecting, harmonizing and storing diverse data sources. It provides examples like using machine learning for ejection fraction detection in cardiology. Advanced Care at Home is highlighted as a virtual hospital ecosystem to provide 24/7 medical support to patients at home using technologies like mobile imaging and labs. The document emphasizes data transparency and population representation in algorithms.
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Determine the frequency of 16 high-risk conditions and associated complications in a Michigan state-wide network of academic and community EDs (MiPEM) during the COVID-19 pandemic
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Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
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We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx
Shared Decision Making Using the HEART Score and a Visual Aid in Patients Presenting to the Emergency Department with Chest Pain by Michael Boyd
1. Shared Decision Making Using the HEART Score and
a Visual Aid in Patients Presenting to the Emergency
Department with Chest Pain
Gregory Gafni-Pappas, DO, Susanne Demeester, MD, Michael Boyd,
MD, Arun Ganti, MD
2. Background
• Chest pain = 5 to 8% of ED volume
• Classically, these patients have been admitted or observed.
8. Step 2: The HEART Score
• Prospectively and externally validated
–Utilizes 5 components:
• History
• EKG
• Age
• Risk factors
• Troponin
9.
10. The Heart Score
• Backus, et al, 2008
Risk Level End Point Percentage Reached
Endpoint
Low 1/39 2.5%
Moderate 12/59 20.3%
High 16/22 72.7%
Neth Heart J. 2008 Jun;16(6):191-6.
11. Validation
• Backus, et. al 2013
– 2,440 Patients
– Low HEART Score
• MACE 6 weeks
– 1.7%
• Mahler, et. al 2011
– 1070 patients
– Low HEART Score
• MACE at 30 days
– 0.6%
Int J Cardiol. 2013 Oct 3;168(3):2153-8. Crit Pathw Cardiol. 2011
Sep;10(3):128-33
12. The Heart Score
• 30 days MACE is <1% in patients with a low HEART score
and two sets of troponins.
15. Step 3: Visual Aid
• A visual tool is used to explain ED course, diagnosis,
and true risk.
16. Step 3: Visual Aid
• Educational
• Shared decision making
• Documents understanding
17. Shared Decision Making
• The visual aid is chosen based on the
patient’s calculated HEART score and
risk.
18.
19. Background
• Chest pain = 5 to 8% of ED volume
• Classically, these patients have been admitted or observed.
20. Background
• Chest pain = 5 to 8% of ED volume
• Classically, these patients have been admitted or observed.
21. Implementation
1. HEART score calculated for patients with chest
pain and concern for ACS
2. 2 hour NSTEMI rule-out begins
3. Patient given corresponding visual aid (low,
moderate, high) after first troponin result
4. Patient and providers sign the visual aid.
Patient keeps a copy of the visual aid
5. Forms are scanned into chart
25. Key Points
• Chest pain is common
• Low-risk chest pain patients can safely
be discharged home provided they
understand their risk and have a plan for
follow-up.
26. Conclusions
• The HEART Score is a tool that can be
used to determine risk for 30 day
MACE.
• Visual aids improve provider and
patient understanding.
• All discharged patients still need time-
sensitive follow-up instructions.
27. References
1. Hess E. The chest pain choice decision aid: a randomized trial.Circ
Cardiovasc Qual Outcomes. 2012 May;5(3):251-9.
2. Six A et al. The HEART score for the assessment of patients with chest
pain in the emergency department: a multinational validation study. Crit
Pathw Cardiol. 2013 Sep;12(3):121-6.
3. Backus BE1, A prospective validation of the HEART score for chest pain
patients at the emergency department. Int J Cardiol. 2013 Oct
3;168(3):2153-8. doi: 10.1016/j.ijcard.2013.01.255. Epub 2013 Mar 7.
4. Mahler SA et al. The HEART Pathway Randomized Trial: Identifying
Emergency Department Patients With Acute Chest Pain for Early
Discharge. Circ Cardiovasc Qual Outcomes. 2015 Mar;8(2):195-203. doi:
10.1161/CIRCOUTCOMES.114.001384. Epub 2015 Mar 3.
5. Flynn D et al. Engaging patients in health care decisions in the
emergency department through shared decision-making: a systematic
review. Acad Emerg Med. 2012 Aug;19(8):959-67.
6. Neumar RW et al. Part 1: Executive Summary: 2015 American Heart
Association Guidelines Update for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl
2):S315-67