Category Archives: Acute Med

Acute care of the medically sick adult

Acute Med, All Updates, Resus

TIA workup renders ABCD2 unhelpful

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ABCD2 is recommended to stratify the risk of stroke in patients presenting to the ED with TIA symptoms. In some centres this is used to differentiate those that need to be admitted for further evaluation and treatment from those that can be followed up in the outpatient setting. A recent study showed that if a detailed work up was done in the ED on all TIA patients (followed by appropriate intervention), the ABCD2 score did not predict adverse outcomes, which were lower in this cohort than in the original ABCD2 cohort.

STUDY OBJECTIVE: We study the incremental value of the ABCD2 score in predicting short-term risk of ischemic stroke after thorough emergency department (ED) evaluation of transient ischemic attack.
METHODS: This was a prospective observational study of consecutive patients presenting to the ED with a transient ischemic attack. Patients underwent a full ED evaluation, including central nervous system and carotid artery imaging, after which ABCD2 scores and risk category were assigned. We evaluated correlations between risk categories and occurrence of subsequent ischemic stroke at 7 and 90 days.
RESULTS: The cohort consisted of 637 patients (47% women; mean age 73 years; SD 13 years). There were 15 strokes within 90 days after the index transient ischemic attack. At 7 days, the rate of stroke according to ABCD2 category in our cohort was 1.1% in the low-risk group, 0.3% in the intermediate-risk group, and 2.7% in the high-risk group. At 90 days, the rate of stroke in our ED cohort was 2.1% in the low-risk group, 2.1% in the intermediate-risk group, and 3.6% in the high-risk group. There was no relationship between ABCD2 score at presentation and subsequent stroke after transient ischemic attack at 7 or 90 days.
CONCLUSION: The ABCD2 score did not add incremental value beyond an ED evaluation that includes central nervous system and carotid artery imaging in the ability to risk-stratify patients with transient ischemic attack in our cohort. Practice approaches that include brain and carotid artery imaging do not benefit by the incremental addition of the ABCD2 score. In this population of transient ischemic attack patients, selected by emergency physicians for a rapid ED-based outpatient protocol that included early carotid imaging and treatment when appropriate, the rate of stroke was independent of ABCD2 stratification.

An Assessment of the Incremental Value of the ABCD2 Score in the Emergency Department Evaluation of Transient Ischemic Attack
Ann Emerg Med. 2011 Jan;57(1):46-51

Acute Med, All Updates, PHARM

Delayed door-to-balloon even with helicopters

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For a whole bunch of reasons, patients with ST-elevation myocardial infarction who undergo interhospital transfer for primary percutaneous coronary intervention may not meet the required 90 minute door-to-balloon time. In a new study of patients transferred by helicopter, only 3% of STEMI patients transferred for reperfusion met the 90-minute goal. Should this result in an increase in the use of fibrinolysis at non–percutaneous coronary intervention hospitals?

Opportunity for gratuitous helicopter shot never knowingly declined

STUDY OBJECTIVE: Early reperfusion portends better outcomes for ST-segment elevation myocardial infarction (STEMI) patients. This investigation estimates the proportions of STEMI patients transported by a hospital-based helicopter emergency medical services (EMS) system who meet the goals of 90-minute door-to-balloon time for percutaneous coronary intervention or 30-minute door-to-needle time for fibrinolysis.
METHODS: This was a multicenter, retrospective chart review of STEMI patients flown by a hospital-based helicopter service in 2007. Included patients were transferred from an emergency department (ED) to a cardiac catheterization laboratory for primary or rescue percutaneous coronary intervention. Out-of-hospital, ED, and inpatient records were reviewed to determine door-to-balloon time and door-to-needle time. Data were abstracted with a priori definitions and criteria.
RESULTS: There were 179 subjects from 16 referring and 6 receiving hospitals. Mean age was 58 years, 68% were men, and 86% were white. One hundred forty subjects were transferred for primary percutaneous coronary intervention, of whom 29 had no intervention during catheterization. For subjects with intervention, door-to-balloon time exceeded 90 minutes in 107 of 111 cases (97%). Median door-to-balloon time was 131 minutes (interquartile range 114 to 158 minutes). Thirty-nine subjects (21%) received fibrinolytics before transfer, and 19 of 39 (49%) received fibrinolytics within 30 minutes. Median door-to-needle time was 31 minutes (interquartile range 23 to 45 minutes).
CONCLUSION: In this study, STEMI patients presenting to non-percutaneous coronary intervention facilities who are transferred to a percutaneous coronary intervention-capable hospital by helicopter EMS do not commonly receive fibrinolysis and rarely achieve percutaneous coronary intervention within 90 minutes. In similar settings, primary fibrinolysis should be considered while strategies to reduce the time required for subsequent interventional care are explored.

Reperfusion Is Delayed Beyond Guideline Recommendations in Patients Requiring Interhospital Helicopter Transfer for Treatment of ST-segment Elevation Myocardial Infarction.
Ann Emerg Med. 2011 Mar;57(3):213-220

Acute Med, All Updates, ICU

H1N1 or CAP?

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A scoring system composed of clinical, radiological, and laboratory variables purports to distinguish H1N1 influenza virus infection from community acquired pneumonia1. An accompanying editorial2 suggests that while further validation is required, the most useful application of the score might be in those with a score of 0 or 1 (out of 5), in whom the the high negative predictive value might safely avoid inpatient isolation and neuraminidase inhibitor treatment in the under-65s.

Background Early identification of patients with H1N1 influenza-related pneumonia is desirable for the early instigation of antiviral agents. A study was undertaken to investigate whether adults admitted to hospital with H1N1 influenza-related pneumonia could be distinguished clinically from patients with non-H1N1 community-acquired pneumonia (CAP).
Methods Between May 2009 and January 2010, clinical and epidemiological data of patients with confirmed H1N1 influenza infection admitted to 75 hospitals in the UK were collected by the Influenza Clinical Information Network (FLU-CIN). Adults with H1N1 influenza-related pneumonia were identified and compared with a prospective study cohort of adults with CAP hospitalised between September 2008 and June 2010, excluding those admitted during the period of the pandemic.
Results Of 1046 adults with confirmed H1N1 influenza infection in the FLU-CIN cohort, 254 (25%) had H1N1 influenza-related pneumonia on admission to hospital. In-hospital mortality of these patients was 11.4% compared with 14.0% in patients with inter-pandemic CAP (n=648). A multivariate logistic regression model was generated by assigning one point for each of five clinical criteria: age ≤65 years, mental orientation, temperature ≥38°C, leucocyte count ≤12×10(9)/l and bilateral radiographic consolidation. A score of 4 or 5 predicted H1N1 influenza-related pneumonia with a positive likelihood ratio of 9.0. A score of 0 or 1 had a positive likelihood ratio of 75.7 for excluding it.
Conclusion There are substantial clinical differences between H1N1 influenza-related pneumonia and inter-pandemic CAP. A model based on five simple clinical criteria enables the early identification of adults admitted with H1N1 influenza-related pneumonia.

1. Clinical and laboratory features distinguishing pandemic H1N1 influenza-related pneumonia from interpandemic community-acquired pneumonia in adults
Thorax. 2011 March; 66(3): 247–252 Free Full Text
2. Predicting the unpredictable: is it possible clinically to separate H1N1 from non-H1N1 community-acquired pneumonia?
Thorax. 2011 Mar;66(3):187-8

Acute Med, All Updates, ICU, Resus

Nasal cooling method

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More data on the RhinoChill device from an in-hospital study of post-cardiac arrest patients in Germany. The RhinoChill device (BeneChill Inc., San Diego, USA) allows evaporative cooling by spraying an inert liquid coolant (a perfluorochemical) into the nasal cavity. The liquid evaporates instantaneously, thereby removing heat. It can make your nose discoloured, and in one patient with cardiogenic shock, tissue damage of nose and cheeks due to freezing occurred. Several of the authors are linked with the company that manufactures the device.

AIM: Mild therapeutic hypothermia improves survival and neurologic recovery in primary comatose survivors of cardiac arrest. Cooling effectivity, safety and feasibility of nasopharyngeal cooling with the RhinoChill device (BeneChill Inc., San Diego, USA) were determined for induction of therapeutic hypothermia.
METHODS: Eleven emergency departments and intensive care units participated in this multi-centre, single-arm descriptive study. Eighty-four patients after successful resuscitation from cardiac arrest were cooled with nasopharyngeal delivery of an evaporative coolant for 1h. Subsequently, temperature was controlled with systemic cooling at 33 degrees C. Cooling rates, adverse events and neurologic outcome at hospital discharge using cerebral performance categories (CPC; CPC 1=normal to CPC 5=dead) were documented. Temperatures are presented as median and the range from the first to the third quartile.
RESULTS: Nasopharyngeal cooling for 1h reduced tympanic temperature by median 2.3 (1.6; 3.0) degrees C, core temperature by 1.1 (0.7; 1.5) degrees C. Nasal discoloration occurred during the procedure in 10 (12%) patients, resolved in 9, and was persistent in 1 (1%). Epistaxis was observed in 2 (2%) patients. Periorbital gas emphysema occurred in 1 (1%) patient and resolved spontaneously. Thirty-four of 84 patients (40%) patients survived, 26/34 with favorable neurological outcome (CPC of 1-2) at discharge.
CONCLUSIONS: Nasopharyngeal evaporative cooling used for 1h in primary cardiac arrest survivors is feasible and safe at flow rates of 40-50L/min in a hospital setting.
Safety and feasibility of nasopharyngeal evaporative cooling in the emergency department setting in survivors of cardiac arrest
Resuscitation. 2010 Aug;81(8):943-9

Acute Med, All Updates, PHARM, Resus, Ultrasound

Pre-hospital Echo

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Pre-hospital physicians in Germany performed basic echo on patients with symptoms either of profound hypotension and/or severe dyspnoea/tachypnoea where judged by the physician to be in a ‘peri-resuscitation’ state, and on patients undergoing CPR. Features noted were; cardiac motion (present or absent), ventricular function (normal, moderately impaired, severely impaired, absent), right ventricular dilatation or pericardial collection.
A few interesting findings to note:

  • In almost all patients an interpretable view was achieved; in the CPR patients, the subcostal view was best
  • In PEA patients, there was a difference in survival to admission (to discharge isn’t documented) between those with and without sonographically evident cardiac wall motion (21/38 = 55% vs 1/13 = 8%)
  • In ‘suspected asystole’, some patients had sonographically evident cardiac wall motion, and 9/37 (24%) of these survived to hospital admission vs 4/37 (11%) with no wall motion. On this point, the authors note: ‘The ECG performance and interpretation were by experienced practitioners, and this therefore raises questions regarding the accuracy of an ECG diagnosis of asystole in the pre-hospital setting‘.

Purpose of the study: Focused ultrasound is increasingly used in the emergency setting, with an ALS- compliant focused echocardiography algorithm proposed as an adjunct in peri-resuscitation care (FEEL). The purpose of this study was to evaluate the feasibility of FEEL in pre-hospital resuscitation, the incidence of potentially treatable conditions detected, and the influence on patient management.
Patients, materials and methods: A prospective observational study in a pre-hospital emergency setting in patients actively undergoing cardio-pulmonary resuscitation or in a shock state. The FEEL protocol was applied by trained emergency doctors, following which a standardised report sheet was completed, including echo findings and any echo-directed change in management. These reports were then analysed independently.
Results: A total of 230 patients were included, with 204 undergoing a FEEL examination during ongoing cardiac arrest (100) and in a shock state (104). Images of diagnostic quality were obtained in 96%. In 35% of those with an ECG diagnosis of asystole, and 58% of those with PEA, coordinated cardiac motion was detected, and associated with increased survival. Echocardiographic findings altered management in 78% of cases.
Conclusions: Application of ALS-compliant echocardiography in pre-hospital care is feasible, and alters diagnosis and management in a significant number of patients. Further research into its effect on patient outcomes is warranted.
Focused echocardiographic evaluation in life support and peri-resuscitation of
emergency patients: A prospective trial
Resuscitation. 2010 Nov;81(11):1527-33

Acute Med, All Updates, Guidelines, Resus

Testing of Low-Risk Chest Pain Patients

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A summary of the literature on low risk chest pain, including history, physical exam, ECG, biomarkers, and investigations such as exercise tolerance testing, myocardial perfusion imaging, and other investigations, is provided in the American Heart Association’s recently published scientific statement.
The document contains a number of useful statistics on the limitations of clinical assessment in ruling out coronary artery disease, such as these:
“…the Multicenter Chest Pain Study found that 22% of patients presenting with symptoms described as sharp or stabbing pain (13% with pleuritic pain and 7% with pain reproduced on palpation) were eventually diagnosed with ACS.”

Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain
A Scientific Statement From the American Heart Association
Circulation. 2010;122:1756-1776 – Full Text

Acute Med, All Updates, PHARM, Resus

CPR on your own? Stay at the head end

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In this manikin study, single-rescuer bag-mask ventilation (BMV) with chest compressions was tried in three different positions. Staying at the head end to deliver effective BMV, with ‘over-the-head’ chest compressions from that position, was best.

Background The 2005 guidelines for cardiopulmonary resuscitation (CPR) do not include a statement on performance of basic life support by a single healthcare professional using a bagevalveemask device. Three positions are possible: chest compressions and ventilations from over the head of the casualty (over-the-head CPR), from the side of the casualty (lateral CPR), and chest compressions from the side and ventilations from over the head of the casualty (alternating CPR). The aim of this study was to compare CPR quality of these three positions.
Methods 102 healthcare professionals were randomised to a crossover design and performed a 2-min CPR test on a manikin for each position.
Results The hands-off time over a 2-min interval was not significantly different between over-the-head (median 31 s) and lateral (31 s) CPR, but these compared favourably with alternating CPR (36 s). Over-the-head CPR resulted in significantly more chest compressions (155) compared with lateral (152) and alternating CPR (149); the number of correct chest compressions did not differ significantly (119 vs 122 vs 109). Alternating CPR resulted in significantly less inflations (eight) compared with over-the-head (ten) and lateral CPR (ten). Lateral CPR led to significantly less correct inflations (three) compared with over-the-head (five) and alternating CPR (four).
Conclusions In the case of a single healthcare professional using a bagevalveemask device, the quality of over-the-head CPR is at least equivalent to lateral, and superior to alternating CPR. Because of the potential difficulties in bagevalveemask ventilation in the lateral position, the authors recommend over-the-head CPR.
Comparison of the over-the-head, lateral and alternating positions during cardiopulmonary resuscitation performed by a single rescuer with a bag valve mask device
Emerg Med J. 2010 Oct 14. [Epub ahead of print]

Acute Med, All Updates, ICU, Resus

Extracorporeal CPR

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Extracorporeal cardiopulmonary resuscitation (E-CPR) using extracorporeal membrane oxygenation (ECMO) support during inhospital cardiac arrest has been attempted to improve the outcome of cardiopulmonary resuscitation (CPR). A retrospective, single-center, observational study from Korea analysed a total of 406 adult patients with witnessed inhospital cardiac arrest receiving cardiopulmonary resuscitation for >10 mins.
How their system works: An ECMO cart was transported to the CPR site within 5–10 mins during the day and within 10–20 mins during the night shift. The decision to use E-CPR was dependent on the CPR team leader. Application of ECMO was usually considered under conditions of prolonged arrest (when there was no ROSC after 10–20 mins of CPR), recurrent arrest (when ROSC could not be maintained), or when the patient could not be expected to recover as a result of underlying severe left ventricular dysfunction or coronary artery disease despite a short CPR duration (end-stage heart failure requiring transplantation, left main coronary artery occlusion, etc)
The primary end point was a survival discharge with minimal neurologic impairment.

No. ECMO. I said ECMO.

85 patients underwent E-CPR and 321 underwent C- CPR. ECMO implantation was successful in 94.1% (80 of 85) in the E-CPR group, except for three cannulation failures and two ECMO flow failures. There was a signficantly greater proportion of patients with primary cardiac disease in the E-CPR group. Propensity score matching was used to balance the baseline characteristics and cardiopulmonary resuscitation variables that could potentially affect prognosis. In the matched population (n = 120), the survival discharge rate with minimal neurologic impairment in the extracorporeal cardiopulmonary resuscitation group was significantly higher than that in the conventional cardiopulmonary resuscitation group (odds ratio of mortality or significant neurologic deficit, 0.17; 95% confidence interval, 0.04-0.68; p = .012). In addition, there was a significant difference in the 6-month survival rates with minimal neurologic impairment (hazard ratio, 0.48; 95% confidence interval, 0.29-0.77; p = .003; p <.001 by stratified log-rank test). In the subgroup based on cardiac origin, extracorporeal cardiopulmonary resuscitation also showed benefits for survival discharge (odds ratio, 0.19; 95% confidence interval, 0.04-0.82; p = .026) and 6-month survival with minimal neurologic impairment (hazard ratio, 0.56; 95% confidence interval, 0.33-0.97; p = .038; p = .013 by stratified log-rank test).
The authors conclude that extracorporeal cardiopulmonary resuscitation showed a survival benefit over conventional cardiopulmonary resuscitation in patients who received cardiopulmonary resuscitation for >10 mins after witnessed inhospital arrest, especially in cases of cardiac origin. These results contrast with these recently published French findings in patients receiving ECMO after out-of-hospital cardiac arrest.
Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: A comparison with conventional cardiopulmonary resuscitation
Crit Care Med. 2011 Jan;39(1):1-7

Acute Med, All Updates, Resus

RV involved in AMI more often than you think

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We know that inferior STEMI may be complicated by right ventricular involvement, which is why I whack a V4R lead on all my inferior AMI patients. A recent study using cardiac magnetic resonance imaging showed that RV oedema and regional or global RV dysfunction were common in anterior infarcts too, although the proportion significantly decreased at four month follow up.

T2w image of patient with LAD occlusion. Hyperintense appearance of jeopardised anteroseptal and anterior LV myocardium (arrowheads), extending to adjacent RV lateral free wall (arrows)

RV abnormalities are contiguous to the jeopardized LV myocardium and do not occur exclusively in inferior LV infarcts, but are found in up to 33% of anterior LV infarcts as well. The presence of RV ischemic injury is associated with early RV dysfunction as well as with RV functional recovery at follow-up.
Right Ventricular Ischemic Injury in Patients With Acute ST-Segment Elevation Myocardial Infarction: Characterization With Cardiovascular Magnetic Resonance.
Circulation. 2010 Oct 5;122(14):1405-12

Acute Med, All Updates, PHARM, Resus

Improved survival with modified CPR

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A large randomised controlled trial1 on out-of-hospital cardiac arrest patients compared standard CPR with CPR augmented by two modifications:

  • active compression-decompression using a hand-held suction device to compress the chest. The device is attached to the chest of the patient during CPR and the rescuer actively lifts the chest upwards after each compression, which are done at a rate of 80/min

  • augmented negative intrathoracic pressure using an impedance threshold device, which is a valve that limits passive air entry into the lungs during chest compressions, thereby reducing intrathoracic pressure and increasing blood flow to vital organs

The primary study endpoint was survival to hospital discharge with favourable neurological function.
Funding issues resulted in premature cessation of the study. 47 (6%) of 813 controls survived to hospital discharge with favourable neurological function compared with 75 (9%) of 840 patients in the intervention group (odds ratio 1·58, 95% CI 1·07–2·36; p=0·019]. 74 (9%) of 840 patients survived to 1 year in the intervention group compared with 48 (6%) of 813 controls (p=0·03), with equivalent cognitive skills, disability ratings, and emotional-psychological statuses in both groups. The overall major adverse event rate did not differ between groups, but more patients had pulmonary oedema in the intervention group (94 [11%] of 840) than did controls (62 [7%] of 813; p=0·015).
An accompanying editorial2 points out that previous studies in animal models of cardiac arrest gave reassuring results for both devices individually and when used together, but results from clinical trials in patients have been mixed for each device when used individually:

  • For compression-decompression CPR, a systematic review pooled the existing data for such CPR versus standard CPR in 4162 patients and found no difference in short-term mortality (relative risk 0·98, 95% CI 0·94–1·03) or survival to hospital discharge (0·99, 0·98–1·01). The 2010 CPR guidelines for the USA and Europe do not recommend the use of compression–decompression CPR alone.
  • The most current systematic review for the impedance-threshold device showed a significantly improved early survival (relative risk 1·45, 1·16–1·80), and a short-term improved neurological outcome (2·35, 1·30–4·24); however, improved long- term survival did not reach conventional statistical significance (1·48, 0·91–2·41).

The Resuscitation Outcomes Consortium (ROC) PRIMED study3 showed no survival benefit in 8718 patients randomised to standard CPR with an active or sham impedance-threshold device (the Consortium includes the same investigators as the Lancet paper). This was published as an abstract in Circulation recently.
The editorialist has reservations regarding a change in clinical practice resulting from this new study, partly because the trial was stopped prematurely and enrolment of a larger cohort could have changed the findings, and partly because the open use of both devices might have unintentionally introduced bias into the study. Further validation is recommended.
1. Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial
 Lancet 2011;377:301-11
2. Augmented CPR: rescue after the ResQ trial
Lancet. 2011 Jan 22;377:276-7
3. The Resuscitation Outcomes Consortium ROC) PRIMED Impedance Threshold Device (ITD) Cardiac Arrest Trial: A Prospective, Randomized, Double-Blind, Controlled Clinical Trial
Circulation 2010; 122: 2215–26 (abstr)