Ten conditions you can discharge early and safely from the MAPU? Stephen Dee General Physician

Transcription

1 Ten conditions you can discharge early and safely from the MAPU? Stephen Dee General Physician

2 Which conditions? 1. Chest pain 2. Pneumonia 3. Cellulitis 4. PE 5. DVT 6. Syncope 7. GI bleed 8. TIA 9. Diabetes 10. COPD 11. Heart Failure 12. Headache 13. Pneumothorax

3 Which conditions shall we talk about? 1. Pneumonia 2. DVT 3. PE 4. Headache Aim to find one new piece of useful information about each.

4 Risk Stratification: Identifying low risk patients Most risk stratification is based on short term mortality(30 day) What about adverse events? related to the condition, treatment or comorbidities What about clinical gestalt? Risk tools do not replace clinical judgement they augment it.

5 How much risk are you prepared to take (30 day mortality)? A. 0.1% (1/1000) B. 0.5% (1/500) C. 1% (1/100) D. 2% (1/50) E. 5% (1/20)

6 CASE 1 22 year old Vomiting (5x), diarrhea (10-14x a day), myalgia, fever, cough and inspiratory chest pain 3/7. Obs: Temp 39, BP 119/69, HR 104, RR 16, Sats 95% Phx: Nil Bloods: WCC 28.9, Neut25.2, Na 134, K 3.5, Cr 258, U 11.3, gluc6.4 CRP 300

7 CASE 2:

8 CASE 2:

9 Risk Stratification in Pneumonia PSI CURB-65 CRB-65 ecurb SCAP (30 day mortality) (30 day mortality) (30 day mortality) (30 day mortality) (30 day mortality) SMART-COP (Need for resp. support or vasopressors) SMRT-CO (Need for resp. support or vasopressors)

10 PSI CURB-65 CRB-65 SCAP Validated for identifying Low risk Pneumonia

11 CURB-65 Thorax 2003: 58(5):377-82

12 Pneumonia Severity Index (PSI) Critical Care (Suppl 6):S2 doi: /cc7025 Critical Care (Suppl 6):S2 doi: /cc7025

13 Risk Stratification: PSI: Well validated Statistically performs better in terms of risk stratifying. Long and complicated CURB-65: Well validated Easy Fast Not as discriminating

14 CASE 2: Send him home? CURB-65 = 1 (urea) Mortality 2.7% PSI = 42 Mortality 0.2%. Did you note Cr 258? Patient improves and creatinineimproves and goes

15 Physician judgement is a crucial adjunct to pneumonia severity scores in low-risk patients. Choudreyet al. EurRespir. J (3)643-8 Which low-risk (CURB-65 score 0-1) communityacquired pneumonia patients don t do well. Parameters associated with 30-day mortality: Hypoxia (OR 9.86, 95% CI ; p=0.002) Cardiac comorbidity(or 5.73, 95% CI ;p=0.01) Acidosis (OR 5.14, 95% CI ; p=0.01) Multilobar(OR 4.54, 95% CI ; p=0.03).

16 Other things Oxygen saturations< 92%are associated with major adverse events in outpatients with pneumonia Majumdar et. al. Clin. Inf. Dis. 2011;52(3): Procalcitonin(PCT)on admission identifies a low risk group (for death) for all clinical risk classes Better than CRP or WCC. Eur. Respir J. 2008: 31(2): PCT has been shown to have added value for adverse event prediction Schuetz et. Al. Eur. Respir J. Feb 2011:37;(2) CORTISOL, PRO-ADRENOMEDULLIN, D-DIMERS, ENDOTHELIN-1 During H1N1 we found CURB-65 did not predict those needing ICU/HDU or admission (often pure respiratory failure) Utility of score in elderly, COPD and immunosuppressed.

17 Takeaway message CURB-65 + O 2 sats>/=92 Seems easiest and safest Be aware of co-morbidities Consider PCT CURB-65 If low risk (0 or 1 ) CHAM (cardiac, hypoxia, acidosis & multilobar)

18 Multicentre 17,000 patient cohort study Address risk stratification in pneumonia

19 Should a patient with a DVT ever stay in Hospital?

20 DVT always treated as outpatients? Areas where evidence is weaker or uncertain: Malignancy Very proximal clot (iliac system) Pregnancy Known thrombophilia Recurrent clots Patient with a high risk of bleeding 20-70% of patients screened for those studies were excluded Levine et al. NEJM 1996;334: Koopman et. Al NEJM 1996;334: Wells et al. Arch. Int. Med : Impt social factors (telephone, distance from hospital etc)

21 Predicting adverse outcomes in outpatients with acute DVT (from the RIETE Registry) Bilateral DVT Renal Insufficiency Weight <70kg Recent immobility Chronic Heart Failure Cancer </=2 1.2% rate of an adverse event >2 6.8% rate of an adverse event J Vasc Surg. 2006; 44(4):789-93

22 Case 3 50 year old woman Sudden onset SOB and pleuritic chest pain No intercurrent illness No Phx. Sats93% RA. BP 120/80, HR 96. RR 20. CXR normal D-dimer 4500 Trop T negative ECG: Sinus tachycardia otherwise normal. Pain controlled with paracetamol. CTPA: Two sub-segmental pulmonary emboli.

23 The imptquestion: When would you discharge her? From ED 24hrs 48hrs 72 hrs When INR therapeutic When INR is therapeutic x2

24 Risk stratifications tools Pulmonary Embolism Severity Index (PESI) most well validated PESI is safer than the Geneva Prognostic Score (GPS) GPS more low risk but higher mortality for low risk (5.6% vs0.9%). Jemenezstal. CHEST 2007; 132(1):24-30 Simplified PESI (s-pesi) recently developed and validated. Shock Index 30 day mortality 8.3% vs1.3% spesi EurRespirJ 2011; 37: Side issue: PERC rule (Deciding to investigate for PE or not). 6.4% Had PE who low pre-test prob and PERC-ve JTH:2011; 9:(2);

25 Pulmonary Emboli Severity Index (PESI) Our patient = 50 (very low risk). </=65 class I very low risk; class II low risk class III intermediate risk class IV high risk 125+ class V very high risk. * Defined as disorientation, lethargy, stupor, or coma. With and without the administration of supplemental oxygen. Aujesky et al. Am. J Resp. Crit. care med. 2005;172(8)1041-6

26 Simplified PESI Age >80 Co-morbidity (Heart/Lung) Cancer HR >110 Sys BP < 100mmHg Sats <90% Our patient = 0 low risk (C 2 AS 2 H) Table 1. Original and Simplified Pulmonary Embolism Severity Index (PESI) Arch. Int Med. 2010;170(15):

27 Arch. Int Med. 2010;170(15):

28 Sending home PE PESI Validated prospectively multiple studies Negative Predictive Value (NPV) 99.4% ( %) for 30 day mortality Aujeski Eur Heart J 2006 Greater number classified as low risk (40%) Adverse event NPV 86% - requiring hospital intervention (92% for class 1) Hariharan st. al. Thrombosis and Haemostasis 2011; 105: Simplified PESI (s-pesi) Validated in 3 studies Negative Predictive Value (NPV) 98.9% ( ) for 30 day mortality Jimenez Arch. Int med Lesser number are low risk (30%) More conservative

29 Can we do better? Bleeding risk at home is still area of concern What about other adverse eventsother than mortality? Respiratory failure, Hypotension requiring vasopressorsor thrombolysis, recurrent PE, major bleeding and cardiac dysrhythmia.

30 Predictive value of hs-troponinassay and the s-pesi in haemodynamicallystable patients with acute pulmonary embolus N=526 patients with PE Lankeit et. Al. Circulation Nov. 2011; 124: S-PESI of 0 and hstnt<14 (24.1%) None of them had an adverse event in 30 days. Prior study N=156 with PE who were normotensive hs-troponin <14 (36%) NPV 100% for adverse outcome Lankeit et. Al. Eur Heart J (2010) 31:

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32 Case 4: Acute Severe Headache 40 year old woman with a background history of migraine presents with a different sort of headache. Came on suddenly, on top of head (peaked immediately <1 min)*. Worse than her previous headaches*. Came on when watching TV. No visual symptoms. No nausea, no vomiting, no fever or systemic symptoms. Phx: Hypertension on accupril 10mg od. No Relevant Fhx No focal neurological features Alert and orientated. Attends within 3 hours of onset* Significant improvement after paracetamoland Ibuprofen (that she had at home)*

33 Headache Pearls In patient s without altered consciousness and no focal neurology: Thunderclap has greatest association with SAH (Landtblom et. al. Cephalalgia 11% +3-4% other significant pathology) Worst headache has little association with SAH but does have association with finding some pathology (3% SAH - Morgenstern LB et al: Ann Emerg Med September 1998;32: ). HIV +ve strongly associated with pathology Response to pain relief does do not reliably predict a benign headache

34 Causes of thunderclap headache? J. Neuro. Neurosurg. Psychiatry 2012;83:e1 doi:1136/jnnp different causeshave been described in the literature. Primary Headache Associated with Sexual Activity, Reversible Cerebral Vasoconstriction Syndrome (RCVS), Non-aneurysmal Subarachnoid Haemorrhage, Pituitary Apoplexy, Arterial Dissection, and Cerebral Venous Sinus Thrombosis. Non-vascular neurological causes included pneumocephalus, spontaneous intracranial hypotension and colloid cyst of third ventricle. Non-neurological causes included Phaeochromocytoma, Acute Q fever, Transitional Personality Disorder, Dengue Haemorrhagic Fever, and Acute Myocardial Infarction

35 High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study 1999 patients enrolled there were 130 cases of subarachnoid haemorrhage Age >40 Complaint of neck pain or stiffness Witnessed loss of consciousness Onset with exertion Arrival by ambulance Vomiting at least once Diastolic blood pressure >100 mm Hg Systolic blood pressure >160 mm Hg BMJ 2010;341:c5204. doi: /bmj.c5204

36 Do you need to do an LP if an early CT is normal? If you have a normal CT <6 hours of arrival do you need to do a LP to exclude SAH? CT performed within 6 hours of symptom onset in neurologically intact patients had 100% negative predictive value in this prospective multicenter study. Perry JJ et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: Prospective cohort study. BMJ 2011 Jul 18; 343:d4277. (

37 Sensitivity of CT for SAH CT within 6hrs 100% Sensitivity CT within 24hrs 93% Sensitivity CT within 3 days 80% Sensitivity CT within 1 week 50% Sensitivity Suarez et al. NEJM 2006;354(4) Perry et al. BMJ. 2011;343:d4277.

38 Bayesian approach to CT in SAH If sensitivity of CT scan is 90% Usual prevalence of SAH in ED acute severe headache series is 5% You will need to do 200 LPs to find one abnormal one. Sensitivity of 16-slice or better CT scanner in the study was 131/134, or 97.8% (95% confidence interval %) Gee et. al. J. Emerg. Med doi: /jemermed Assuming same prevalence you would need to do 1000 LPs to find one SAH. (lower confidence 285 LPs) Doesn t apply to high risk (high pre-test probability)

39 Take home messages CT head is valuable (and evidence based) Many causes of acute severe headache SAH, Sinus thrombosis, dissection are acutely important Not sure if outpatient MRI and follow up is the way for other lone acute severe headache or not? LP acutely may be becoming less valuable if an early CT is performed but think about pre-test probability?

40 Final Take away messages: Risk Score methods are available for many acute conditions. Need to be aware of the risk you are taking (as does the patient). Risk scores do not replace clinical judgement but can augment it. Be aware of patient groups not enrolled in trials Always applies Murphy s Law and decide if you are still comfortable with your decision.