Emergency Medicine Updates. Dr. Timothy Cobb March 1, 2018
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1 Emergency Medicine Updates Dr. Timothy Cobb March 1, 2018
2 Topics Chest pain Renal colic Atrial fibrillation Pediatric head trauma Asymptomatic hypertension
3 Chest Pain Non traumatic chest pain 2nd most common reason for ED visit 8 million visits annually
4 From: A National Study of the Prevalence of Life-Threatening Diagnoses in Patients With Chest Pain JAMA Intern Med. 2016;176(7): doi: /jamainternmed Table Title: Top 10 Diagnoses Per Age Group Date of download: 2/10/2018 Copyright 2016 American Medical Association. All rights reserved.
5 5
6 Heart Score Published in 2008 in the Netherlands Validated in the United States Five components Essentially replaced TIMI score in ED
7 HEART SCORE History! Highly suspicious!!! 2 Moderately suspicious!!! 1 Slightly suspicious!!!! 0 ECG Significant ST depression!!! 2 Nonspecific depolarization disturbance! 1 Normal!!!!! 0 Age >65 year!!!!! year!!!!! 1 < or equal to 45 year!!!! 0 Risk factors >3 risk factors or history of CAD!! 2 1 or 2 risk factors!!!! 1 No risk factors known!!! 0 Troponin >2x normal limit!!!! 2 1-2x normal limit!!!! 1 < normal limit!!!!! 0
8
9
10 A MACE (Major Adverse Cardiac Event) was defined as: -All-cause mortality -Myocardial infarction -Coronary revascularization.
11 Delta Troponin
12
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14 High Sensitivity Troponin Recent FDA approval in United States Used in Europe
15 HS-Troponin To be classified as high-sensitivity assays, concentrations below the 99th percentile should be detectable above the assay s limit of detection for >50% of healthy individuals in the population of interest.
16 Current cnt mcg/liter HsT- 1.2 ng/liter or.0012 mcg/liter Advantages:! Earlier detection of MI! Disadvantages:! False positive! Change definition of MI
17 Renal Colic
18 Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial Annals of Emergency Medicine, Aug. 2017
19 Tamsulosin Clinical Question: Are alpha blockers effective in facilitating the passage of ureteric stones and are there specific groups that appear to stand more benefit?
20
21 Alpha blockers for treatment of ureteric stones: systematic and meta-analysis. BMJ 2016 Alpha blockers facilitate stone passage: RR = 1.49 (CI: ) Smaller stones (generally < 5 mm) No benefit in stone passage RR = 1.19 (CI ) Larger stones (generally > 6 mm) Modest benefit RR = 1.57 ( )
22 Pediatric Head Trauma
23 PECARN Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Nathan Kuppermann, James F Holmes, Peter S Dayan, John D Hoyle, Jr, Shireen M Atabaki, Richard Holubkov, Frances M Nadel, David Monroe, Rachel M Stanley, Dominic A Borgialli, Mohamed K Badawy, Jeff E Schunk, Kimberly S Quayle, Prashant Mahajan, Richard Lichenstein, Kathleen A Lillis, Michael G Tunik, Elizabeth S Jacobs, James M Callahan, Marc H Gorelick, Todd F Glass, Lois K Lee, Michael C Bachman, Arthur Cooper, Elizabeth C Powell, Michael J Gerardi, Kraig A Melville, J Paul Muizelaar, David H Wisner, Sally Jo Zuspan, J Michael Dean, Sandra L Wootton-Gorges, for the Pediatric Emergency Care Applied Research Network (PECARN)*
24 Age less than 2 years
25 Age over 2 years
26
27 To CT or not to CT If all criteria was met, then it is imperative that CT not be performed If clinical concern persists, despite negative predictive rule, it is more prudent to observe patient
28 Disposition If CT was performed and negative, patients can usually be discharged home If MTBI and rule negative, patients can usually be discharged home One study showed that the rate of neurological deterioration in children with minor head injuries was 0.57/100,000 PECARN states hospitalization is generally not needed
29 New Onset Atrial Fibrillation Common ED complaint Management options Unstable- Immediate cardioversion Stable Rate control Rhythm control
30 New onset A.F. <48 hours Cardioversion (rhythm control) Initiate A/C Discharge >48 hours Rate control Discharge vs Admission
31 Rhythm control Cardioversion Electrical cardioversion Chemical cardioversion
32 Aggressive Ottawa protocol
33 CHADSVASC
34 Asymptomatic Hypertension
35 Summary of Recommendations
36 HTN Summary If asymptomatic, generally do not require ED work up or treatment Initiation of HTN medication will be physician and patient specific
37 Review Chest Pain Renal Colic PECARN Atrial Fibrillation Asymptomatic Hypertension
38 Questions
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