Jock Murray Constance LeBlanc Jennie Leverman Caitlin Wolfe

Transcription

1

2 Jock Murray Constance LeBlanc Jennie Leverman Caitlin Wolfe

3 Disclosures

4 ARTICLE #1

5 Background Physicians are reluctant to use IV contrast for CT scans in patients with impaired renal function We feel that we can not order the optimal test in an emergent situation due to the risk of kidney injury This study helps determine if this concern is justified

6 Methods Objective: To determine if IV contrast administration for CT Scans is independently associated with acute kidney injury

7 Methods Design: The Largest study on this topic. Single- Centre retrospective cohort analysis over 5 years. Serum creatinine levels were recorded within 8 hours before and hours after CT scanning There was propensity matching with patients who had a CT without contrast or no CT at all.

8 Funding and Conflicts Funding: John Hopkins University Conflicts: None Reported

9 Results

10 Results The risk of Acute Kidney Injury as 7.5 % in all three groups

11 Limits Retrospective Study Single centre study Ideally a DBRTC study would be performed but this is unlikely to be approved by any Research Ethics Board. Creatinine range from Some critics (who do their work in the dark) suggest that a study focusing on patient with borderline renal function is needed

12 Discussion This is likely the best done and largest study we will every get addressing the association between kidney Injury and intravenous contrast There was no difference in kidney Injury between groups

13 Discussion If you need a Contrast study to answer an important question then get it. Work with your Radiologist for a more permissive approach to CT Scanning with contrast in patients with impaired renal function.

14 References Risk of Acute Kidney Injury After Intravenous Contrast Media Administration. Hinson, J. S., et. al., Annals of Emergency Medicine. Vol. 69, no. 05. page

15 Contrast: NO PROBLEM

16 ARTICLE #2

17 Background Early Goal Directed Therapy (EDGT) as described by Manny Rivers has been promoted as the standard of care for treatment of sepsis This approach was promoted in the Surviving Sepsis campaign. This approach was eventually recognized to be inappropriate for most Emergency Departments. Which Components of EDGT matter?

18 Methods Objective: To determine if Early Goal Directed Therapy (EDGT) is superior to standard care. Design: A Preplanned Patient Level Meta-Analysis of Three large prospective Double Blind trials patients at 138 hospitals in seven countries. (ProCess, ARISE, and ProMISe)

19 Funding and Conflicts Funding: Funding by Multiple large National and International funding organizations in Australia, the UK and North America Conflicts: Several investigators have financial ties to Drug companies. None had ties to device makers

20 Results

21 Results

22 Results

23 Results

24 Results Mortality at 90 days- EDGT 24.9% vs. 25.4% (P=0.68) EDGT was associated with greater mean use of Intensive care ( vs. 4.9+/-7.0 days ) (P=0.04) Inotrope use (1.9+/-3.7 vs. 1.6+/- 2.9 days) (P=0.01)

25 Results Cost Effectiveness No difference in Quality Adjusted Life Years 4 times as likely that Usual Care is more cost effective than EDGT

26 Discussion EDGT provides no mortality benefit at increased cost

27 Conclusion Physicians should not feel that they need to follow a complicated protocol for patients with sepsis Standard care with early early antibiotics and aggressive fluid is equivalent to a much more complicated protocol Central lines, special catheters and complicated inotrope management are not valuable and can be left to the ICU

28 Just Do It!!!

29 Mensour ARTICLE #3

30 No need to intubate peds patients with IHCA P: Inclusions - IHCA age <18 yrs Exclusions - had invasive airway or being ventilated at the time of starting chest compressions I: Endotracheal intubation C: Those not tracheal intubated O: Survival to hospital discharge (primary) ROSC & favorable neurologic outcome at D/C (secondary)

31 Peds intubation IHCA n = 2294, 57% were male, age~7 months (21 days- 4 yrs) 1555 were intubated during the cardiac arrest Propensity score matched cohort 2270 Survival was lower in those intubated 36% vs 41%

32 What do I do? Put in an LMA to ventilate and measure the quality of CPR using ETCO 2 Although the study design does not eliminate the potential for confounding, findings do not support the current emphasis on early tracheal intubation for peds in-hospital cardiac arrest JAMA. 2016;316(17): doi: /jama

33

34 ARTICLE #4

35 Introduction Asthma accounts for more than 2.1 million unscheduled emergency department (ED) visits annually, with a prevalence that includes 8.4% of the population

36 OBJECTIVE Oral dexamethasone demonstrates bioavailability similar to that of oral prednisone with a longer half-life Evaluate whether a single dose of oral dexamethasone plus 4 days of placebo is not inferior to 5 days of oral prednisone in treatment Adults with mild to moderate asthma exacerbations to prevent relapse

37 Non-Inferiority Prednisone x 5 Dex + placebo x 4

38 Methods Adult ED patients (18 to 55 years) Randomized to receive either single dose of 12 mg of oral dexamethasone with 4 days of placebo 5-day course of oral prednisone 60 mg a day Follow-up phone interview at 2 weeks

39 Results Dexamethasone 173 completed Relapse rates within 14 days 12.1% Hospitalization for relapse dexamethasone 3.4% Prednisone 203 completed Relapse rates within 14 days 9.8% Relapse rates within 14 days 2.9% Adverse effect rates were the same in the 2 groups

40 Conclusion One dose of oral dexamethasone did not demonstrate non-inferiority to prednisone for 5 days by a very small margin for treatment of adults with mild to moderate asthma exacerbations Enhanced compliance and convenience may support the use of dexamethasone regardless

41 Discussion Technically a negative trial These data support, rather than refute, the use of a single dose of dexamethasone in the treatment of asthma with acute exacerbation Statistically, this non-inferiority trials results mean there simply weren t enough patients enrolled to meet their predefined criteria Choice of single-dose dexamethasone is likely as safe as the typical prednisone burst

42 Take Home! Single oral doses of longer-acting corticosteroids might be just as effective as multi-day short courses of prednisone A single dose of oral dexamethasone 12 mg is either similar to or slightly inferior to a 5-day course of prednisone 60 mg for asthma

43 Steroids

44 ARTICLE #5

45 Why bother? ED visits for skin infections have increased with the emergence of MRSA In cellulitis without purulent drainage, β- hemolytic streptococci are presumed to be the predominant pathogens Do antimicrobial regimens possessing in vitro MRSA activity improve outcomes compared with treatments lacking MRSA activity

46 Question Does cephalexin + TMP-SMX yield a higher clinical cure rate of uncomplicated cellulitis than cephalexin alone

47 Methods Multicenter, double-blind, RTC superiority 5 US EDs among outpatients Over 12 years of age Cellulitis and no wound, purulent drainage, or abscess April 2009 to June 2012 All had soft tissue US Follow-up August 2012

48 Groups Cephalexin + TMP-SMX Cephalexin + placebo 7 days 7 days (n = 248) (n = 248)

49 Outcomes Primary outcome determined a priori as clinical cure Absence of clinical failure criteria Fever increase in erythema (>25%) swelling, or tenderness (days 3-4) no decrease in erythema, swelling tenderness (days 8-10) More than minimal erythema, swelling, or tenderness (days 14-21) A clinically significant difference was >10%

50

51

52 Limitations US use Rechecked frequently Generalizable?

53 Conclusions For uncomplicated cellulitis Cephalexin plus trimethoprimsulfamethoxazole compared to cephalexin alone did not result in higher rates of clinical resolution

54 No Pus = No MRSA

55 ARTICLE #6

56 Problem Patients want/ need this Sometime take it Toxic to cornea Put out an APB?

57 Methods Outcomes were compared between patients who did or did not received tetracaine

58 Retrospective study Simple corneal abrasions Allow EPs to prescribe topical 1% tetracaine drops q 30 minutes prn for 24

59 Groups 1,576 initial ED presentations 532 simple abrasions 1,044 non-simple corneal abrasions Tetracaine was dispensed at the initial visit 303 simple abrasions (57%) 141 non-simple corneal abrasions (14%)

60

61 Results No serious complications or uncommon adverse events attributed to tetracaine in either group (0/459; upper 95% confidence interval [CI] 0.80%) Relative risks of ED recheck and fluorescein staining were increased overall among patients who received tetracaine (RR 1.67, 95% CI 1.25 to 2.23; and RR 1.65, 95% CI 1.07 to 2.53) Relative risks for only SIMPLE ABRASIONS receiving tetracaine was 1.16 (95% CI 0.69 to 1.93) and 0.77 (95% CI 0.37 to 1.62)

62 Results Referrals to ophthalmology were significantly decreased for all patients dispensed tetracaine (relative risk 0.33; 95% CI 0.19 to 0.59) The number of complications was too small to permit modeling

63 Limitations Not blinded Retrospective No harm found Large review

64 Conclusions There was no evidence that up to 24- hour topical tetracaine for the treatment of pain caused by SIMPLE CORNEAL ABRASIONS was unsafe CIs were wide Increased risks in NOT SIMPLE

65 Tetracaine OK

66 ARTICLE #7

67 Why is it Important? Ketorolac is a NSAID analgesic that is widely used in the ED It is one of few (? the only) medication(s) that has a higher parenteral dose than the oral form Why is that? Is it necessary? Do the benefits outweigh the harms?

68 Methods Single centre randomized double blind study of 240 subjects Compared 3 doses (10mg, 15mg, 30mg) of IV Ketorolac in the treatment of moderate to severe pain (NRS 5) Convenience sample, presenting to ED with predominantly flank, abdominal pain or headache M-F 9-5 enrolled by research team

69 Methods Recorded pain scores at 15, 30, 60, 90 and 120 minute mark Rescue analgesia morphine if still requesting analgesia 30 minutes after study dose

70 Outcome Measures Primary: Reduction in NRS pain scale at 30 minutes from medication administration Secondary: 1. Rates and numbers of patients experiencing adverse effects 2. Numbers of patients requiring rescue analgesia

71 Results at 30 Min. 10 mg Ketorolac NRS mg Ketorolac NRS mg Ketorolac NRS NO SIGNIFICANT DIFFERENCE between the groups with all having a significant reduction in pain

72 Results by Time No significant difference in pain scores across the time points All pts who reported complete resolution of pain DID NOT receive morphine There was no difference in the number of patients requesting rescue morphine across the doses

73 Results by Time

74 Adverse Effects No patients developed unstable vitals Nausea, dizziness and headache were main adverse effects Again no differences between the groups Not powered to look at safety

75 Limitations Small study, one centre No follow up to assess delayed AE such as GI bleeding Not long enough to assess if higher doses give lasting analgesia beyond 120 minutes

76 Conclusions There appears to be little to no benefit of higher parenteral doses of ketorolac A new standard of 10 mg dosing will provide equivalent analgesia and may decrease adverse events

77 Ketorolac

78 ARTICLE #8

79 Why is it Important Uncontrolled atrial fibrillation/flutter is a relatively common condition in the ED Although similar mortality for rate versus rhythm control in long term management acute management is left to clinical judgment, with little evidence to guide either way

80 Questions For patients presenting with acute Afib/ flutter, if choosing a rhythm control strategy, what are the outcomes after ED discharge? Are there certain patients who are higher risk for negative outcomes with this approach?

81 Methods Prospective cohort study Identified all pts (except 29) presenting with acute Afib/flutter at 6 academic EDs in Canada over 2 years Looked at ED management then followed pts for 30 days post discharge Afib/flutter was primary issue (i.e.: excluded ACS, sepsis, PE, pneumonia etc.)

82 Methods Composite outcome: death, stroke, ACS, CHF, subsequent Afib/flutter related hospitalization or subsequent ED cardioversion Logistic regression to look at independent risk factors associated with the composite outcome

83 Results Patients were most likely (72.8%) to be treated with electrical or chemical cardioversion (procainamide most common chemical choice) Only 9% were admitted Eighty percent were in sinus at d/c Only 4.8% were rx d anticoagulant from ED

84 Results MD follow up was recommended but only 50.7% had seen MD by 30 days Only 9.6% of those who did follow up were on some form of anticoagulation

85 Results Overall 10.5% had an adverse event 6.5% required repeat cardioversion 3.2% required admit for Afib/flutter NO DEATHS related to AFib/flutter One ischemic stroke (in anti-coagulated patient)

86 Results Patients leaving ED in sinus rhythm were less likely to have adverse outcome Independent predictors of adverse outcome: Longer duration of Afib/flutter (OR 1.03/hr) Hx stroke/ TIA (OR 2.09) Pulmonary congestion on CXR (OR 7.37) Patients who were chemically cardioverted had lowest risk (OR 0.23) for adverse events

87 Results

88 Conclusions Cardioversion of acute Afib/flutter is associated with few adverse events at 30-day follow up Pts with CHF, Stroke hx and longer duration before ED presentation are higher risk for adverse events Rates of ED and follow up anticoagulation are low Need head to head trial of rate vs. rhythm to assess for superiority

89 Atrial Fibrillation

90 Mensour ARTICLE #9

91 Why does it matter? Drive to continue improving outcomes in cardiac arrest Training and dogma around need for definitive airway Vs many other tasks that need to occur in early ACLS How should we prioritize our time?

92 Methods Retrospective analysis Get-with-the-Guidelines- Resuscitation registry Multicenter Sponsored by AHA All in-hospital cardiac arrests Jan 1, Dec 31, 2004

93 Methods Inclusion: adult, in-hospital, CPR given, no DNR Exclusion: invasive airway at the time, data missing Definitions Tracheal intubation if successful Unsuccessful attempts not counted Time to ROSC or ending CPR without ROSC

94 Methods Outcomes Survival to hospital discharge ROSC Favourable functional outcome Cerebral performance category 1-2 Statistics Matched patients being intubated with non-intubated (yet?) for each time score

95 Results 108,079 total patients 69.9% intubated at some point 94.8% of intubations in first 15 mins Median time of 5 mins

96 Results 22.4% overall survived to discharge Intubated patients had lower survival 17% vs 33.2% (RR 0.58, 95% CI , p< 0.001) 3% absolute reduction in survival 16% relative

97 Results 62.5% of patients attained ROSC Intubated patients less likely to get ROSC 59.2% vs 69% (RR 0.75, 95% CI , p<0.001) 2% absolute reduction Similar results for functional outcome but some data missing

98 Subgroups etc. Effect of tracheal intubation lowering survival: most pronounced if initially had shockable rhythm 32% relative decrease vs 9% Not present if presented with respiratory insufficiency!

99 Limitations Matched cases to others within data set who were potentially intubated later Indication for intubation, cause of arrest, and skill level not specifically recorded in registry Unsuccessful attempts not logged But would have biased to null

100 Conclusions In adults with in-hospital cardiac arrest. Initiation of tracheal intubation at any point in first 15mins was associated with worse scores on all outcomes vs not intubating Probably we shouldn t be doing this early/as a matter of priority Congruent with current guidelines

101 Conclusions In adults who arrest in hospital 70% got intubated within 15mins ¼ survived to hospital discharge 1/6 had good neurological status

102

103 ARTICLE #10 Academic Emergency Medicine 2017;24:

104 Why does it matter? Traumatic intracranial bleeding is the feared complication of head injury How can we apply decision rules to our patients? Are anti-platelets as scary as anticoagulants? full dose antiplatelet vs small?

105

106 Methods Consecutive patients at trauma center Prospective, observational, cohort Inclusion Adult patients (>18) Ground-level fall (or lesser mechanism) On ASA, clopidogrel, warfarin, LMWH, DOACs, other antiplatelets Exclusion Injury >24 hours Patients transferred with known injury

107 Methods Treating clinician noted ground level fall + antiplatelet or anticoagulant All received CT scan on first visit Outcomes Primary: traumatic bleed Subdural, epidural, subarachnoid, intraparenchymal Secondary: clinical characteristics, intervention, disposition

108 Results 939 patients enrolled 78% were on ASA 71% alone 24% on Warfarin 3.3% on DOAC Some on multiple agents Mean age: 78 (+/-11.9 years)

109 Results 33 intracranial hemorrhages 3.5% of all cases reviewed 99% were awake and alert, only 30% had LOC Antiplatelets: rate of 4.3% (3-6.2% CI) And 82% of those who bled on ASA were on 81mg alone Anticoagulants: 1.7% ( %) Mean INR on warfarin 3.3

110 Results Medical interventions in several Vit K, FFP, platelets 0.4% rate of surgery or death 2 craniotomies 4 deaths 3 on ASA alone

111 Limitations Fair approximation of patient population, although all low risk First presentation, well at triage Needed CT head for age alone Numbers in the non-asa groups were small, less reliable No control group Can t confirm if were taking Rx Could bleeds have preceded fall?

112 Conclusions No statistical difference between tich rate on anti-platelet or anti-coagulants Including low dose ASA! Because platelets are important earlier in clotting cascade? Because strength of inhibition not measureable? Beware both yourself and patients being falsely reassured about risk

113

114