Category Archives: Acute Med

Acute care of the medically sick adult

Myocardial infarction not so common in LBBB?

An observational cohort study of 7937 ED visits by patients presenting with chest pain or ‘ischemic equivalent’ (shortness of breath for which ACS was considered a possible cause) was done to examine the relationship between left bundle branch block (LBBB) on the ECG and the incidence of acute myocardial infarction (AMI). No difference was observed in the rates of AMI in patients with new or presumed new LBBB, old LBBB, and no LBBB. The authors suggest that this large cohort of undifferentiated ED patients may be more reflective of the true prevalence of AMI in LBBB (7.3% in this study) and question the appropriateness of a liberal fibrinolytic strategy for such patients. Another argument for primary PCI?
Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients
Am J Emerg Med. 2009 Oct;27(8):916-21

12 Lead ECG Features of Proximal LAD Occlusion

An ECG pattern is described in chest pain patients which signifies proximal LAD artery occlusion found at angiography: precordial ST-segment depression at the J-point followed by peaked, positive T-waves. Lead aVR displays also displayed slight ST-segment elevation in the majority of cases.
A letter in response points out that this finding was first reported in 1947.
Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion
Heart 2009;95;1701-1706

NIV after extubation prevented respiratory failure

Spanish investigators compared NIV for 24 hours with conventional oxygen therapy in patients with chronic respiratory disorders who were extubated after a successful spontaneous breathing trial. The NIV group had signficantly lower rates of post-extubation respiratory failure.
Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial.
Lancet. 2009 Sep 26;374(9695):1082-8

Which COPD patients should be admitted to the ICU?

A multicenter ICNARC-supported study of 832 COPD patients admitted to intensive care units showed a 180-day mortality of 37.9%.
A prognostic model was developed that was a better discriminator than the clinicians’ judgement. Factors associated with a poor prognosis included abnormal acute physiology, poor functional status (bed or chair bound, house bound or restricted), atrial fibrillation, male sex, number of days in hospital before intensive care admission, reduced midarm circumference as a measure of nutrition and muscle mass, years of age over 70 and reduced Glasgow Coma Score.
The COPD acute physiology score contains heart rate, mean arterial pressure, pH, sodium, urea, creatinine, albumin and white cell count.
According to a commentary in Thorax, “Results previously published from this study show that a large majority of patients with COPD achieve acceptable quality of life following their stay in the intensive care unit and would want to be readmitted under similar circumstances. This paper suggests that more should be done to help to get them this chance.
Hear, hear.
QJM. 2009 Jun;102(6):389-99

CRP improves mortality prediction by prognostic scales in community-acquired pneumonia

In admitted patients with community acquired pneumonia, adding CRP to either the CURB-65 score or pneumonia severity index improved the area under the receiver operator curve for those prediction tools. In fact, CRP levels greater than 25 mg/dl on admission double the probability of death previously computed in the same class of initial risk
Thorax. 2009 Jul;64(7):587-91