Category Archives: Acute Med

Acute care of the medically sick adult

Acute Med, All Updates, Ultrasound

Echo best test for acute LVF in ED

Three diagnostic tests for acute left ventricular heart failure in dyspnoeic patients were compared, with the gold standard being the diagnosis by three independent reviewers (two cardiologists and one respiratory physician) who were blinded to the results of the tests being examined. The tests in question were  NT-proBNP, the Boston criteria, and limited echo performed by emergency physicians.
The primary goal of the echo study was the detection of the following echocardiographic variables, expressed as present or absent: reduced LV ejection fraction (LV ejection fraction <50% on subjective visual estimation of the change in LV size between diastole and systole) and the ‘‘restrictive’’ pattern on pulsed Doppler analysis of mitral inflow (using the apical view).
According to the authors, pulsed Doppler analysis of mitral inflow can be described by three patterns: 1) an ‘‘impaired relaxation’’ pattern, suggesting no increase in LV filling pressures; 2) a ‘‘normal’’ or ‘‘normalized’’ pattern; and 3) a restrictive pattern, suggesting an increase in LV filling pressures.

Trained emergency physicians were able to perform EDecho in a median of 4 minutes, obtaining Doppler data in an average of 80% of patients presenting for acute dyspnea. Considering the 125 patients with both EDecho variables available, reduced LV ejection fraction was less accurate than the restrictive mitral pattern for the diagnosis of aLVHF. The restrictive pattern was more sensitive (82%) and specific (90%) than reduced LV ejection fraction and more specific than the Boston criteria and NT-proBNP for the diagnosis of aLVHF. The accuracy of the restrictive pattern in the overall population was 75%, compared with accuracy of 49% for both NT-proBNP and Boston criteria.
Diagnostic accuracy of emergency Doppler echocardiography for identification of acute left ventricular heart failure in patients with acute dyspnea: comparison with Boston criteria and N-terminal prohormone brain natriuretic peptide.
Acad Emerg Med. 2010 Jan;17(1):18-26

Acute Med, All Updates, Kids, Resus

10 ml syringe for Valsalva manoeuvre

Previous studies have suggested the following are necessary for a successful Valsalva manoeuvre with maximum vagal effect:

  • Supine posturing
  • Duration of 15 seconds
  • Pressure of 40 mmHg (with an open glottis)

One popular method of generating a Valsalva Manoeuvre is to get the patient to blow into a syringe in an attempt to move the plunger. Different syringe sizes were tested. A 10ml (Terumo) syringe was best
The 10 mL syringe is useful in generating the recommended standard of 40 mmHg intrathoracic pressure for the Valsalva manoeuvre
Emerg Med Australas. 2009 Dec;21(6):449-54

Acute Med, All Updates, Resus

Abnormal head CT in altered mental status

In a study of 674 patients with altered mental status who received a CT scan of the brain, logistic regression analysis identified a series of clinical factors that were associated with an abnormal CT result.
Factors with an adjusted odds ratio between 1 and 2.5 included GCS less than 15, focal weakness, diastolic blood pressure greater than 80mmHg and antiplatelet use.
Four variables were associated with an adjusted odds ratio of 2.5 or above. These included presence of headache, dilated pupils (either unilateral or bilateral), upgoing plantar response and anticoagulant use.
Identifying risk factors for an abnormal computed tomographic scan of the head among patients with altered mental status in the Emergency Department
Eur J Emerg Med. 2009 Sep 21. [Epub ahead of print]

Acute Med, All Updates, Resus

Biphasic shocks for AF and Atrial flutter

Based on a study of 453 consecutive patients undergoing their first transthoracic electrical cardioversion for atrial tachyarrhythmias, recommendations were developed to aim at delivering the lowest possible total cumulative energy with ≤2 consecutive shocks using the specific truncated exponential biphasic waveform incorporated in Medtronic Physio-Control devices: they recommend an initial energy setting of 50 J in patients with atrial flutter or atrial tachycardia, of 100 J in patients with atrial fibrillation (AF) of 2 or less days in duration, and of 150 J with AF of more than 2 days in duration. If the initial shock fails to restore sinus rhythm, a rescue shock of 250 J for AFL/AT or of 360 J for AF should be applied to secure the highest possible probability of successful cardioversion for each patient.
Optimization of initial energy for cardioversion of atrial tachyarrhythmias with biphasic shocks
Am J Emerg Med. 2010 Feb;28(2):159-65

Acute Med, All Updates

Imaging for PE in pregnancy

A review article on pulmonary embolism in pregnancy reminds us that the mortality associated with untreated PE far outweighs the potential oncogenic and teratogenic risk incurred by fetal exposure to diagnostic imaging for PE.
Teratogenicity
The minimum dose of radiation associated with increased risk of teratogenicity in human beings has yet to be firmly established, but on the basis of compiled mouse, rat, and human data, radiation exposure of 0·1 Gy at any time during gestation is regarded as a practical threshold beyond which induction of congenital abnormalities is possible.
Oncogenicity
An exposure of the conceptus to 0·01 Gy above natural background radiation increases the probability of cancer before the age of 20 years from 0·03% to 0·04%.
Reassuringly, a chest radiograph, ventilation perfusion scan, and conventional pulmonary angiogram combined with CT pulmonary angiogram expose the fetus to a total of 0·004 Gy.
Pulmonary embolism in pregnancy
Lancet. 2010 Feb 6;375(9713):500-12

Acute Med, All Updates, Guidelines

Nonvariceal Upper Gl Bleeding – international guidelines

International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding have been published. Here is a summary of the recommendations; a link to the full text document is at the bottom of this page.

  1. Prognostic scales are recommended for early stratification of patients into low- and high-risk categories for rebleeding and mortality.
  2. Blood transfusions should be administered to a patient with a hemoglobin level of 70 g/L or less.
  3. In patients receiving anticoagulants, correction of coagulopathy is recommended but should not delay endoscopy.
  4. Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield.
  5. Selected patients with acute ulcer bleeding who are at low risk for rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy.
  6. Preendoscopic PPI therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention but should not delay endoscopy (the observed lesion downstaging attributable to PPI therapy before endoscopy may be even more beneficial in situations in which early endoscopy may be delayed or when available endoscopic expertise may be suboptimal).
  7. Early endoscopy (within 24 hours of presentation) is recommended for most patients with acute upper gastrointestinal bleeding.
  8. A finding of a clot in an ulcer bed warrants targeted irrigation in an attempt at dislodgement, with appropriate treatment of the underlying lesion.
  9. The role of endoscopic therapy for ulcers with adherent clots is controversial. Endoscopic therapy may be considered, although intensive PPI therapy alone may be sufficient.
  10. Epinephrine injection alone provides suboptimal efficacy and should be used in combination with another method.
  11. Clips, thermocoagulation, or sclerosant injection should be used in patients with high-risk lesions, alone or in combination with epinephrine injection
  12. Routine second-look endoscopy is not recommended.
  13. An intravenous bolus followed by continuous-infusion PPI therapy should be used to decrease rebleeding and mortality in patients with high-risk stigmata who have undergone successful endoscopic therapy.
  14. Patients should be discharged with a prescription for a single daily-dose oral PPI for a duration as dictated by the underlying etiology.
  15. Most patients who have undergone endoscopic hemostasis for high-risk stigmata should be hospitalized for at least 72 hours thereafter.
  16. Where available, percutaneous embolization can be considered as an alternative to surgery for patients for whom endoscopic therapy has failed.
  17. Patients with bleeding peptic ulcers should be tested for H. pylori and receive eradication therapy if it is present, with confirmation of eradication.
  18. Negative H. pylori diagnostic tests obtained in the acute setting should be repeated
  19. In patients with previous ulcer bleeding who require an NSAID, it should be recognized that treatment with a traditional NSAID plus PPI or a cyclooxygenase-2 (COX-2) inhibitor alone is still associated with a clinically important risk for recurrent ulcer bleeding.
  20. In patients with previous ulcer bleeding who require an NSAID, the combination of a PPI and a COX-2 inhibitor is recommended to reduce the risk for recurrent bleeding from that of COX-2 inhibitors alone.
  21. In patients who receive low-dose ASA and develop acute ulcer bleeding, ASA therapy should be restarted as soon as the risk for cardiovascular complication is thought to outweigh the risk for bleeding.
  22. In patients with previous ulcer bleeding who require cardiovascular prophylaxis, it should be recognized that clopidogrel alone has a higher risk for rebleeding than ASA combined with a PPI.

International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
Ann Intern Med. 2010 Jan 19;152(2):101-13 (Full Text)

Acute Med, All Updates, ICU, Resus

Lactate clearance goal in sepsis

Previous work in severe sepsis/septic shock patients has shown that a decrease in lactate concentration by at least 10% during emergency department resuscitation predicts survival. Since this is a potential alternative resuscitation goal to a central venous oxygen saturation (ScvO2) of 70% (as per surviving sepsis campaign guidelines), lactate clearance was compared with ScvO2 in a randomised non-inferiority trial of 300 patients.
All patients were managed in the ED and received fluids, antibiotics, and vasopressors as needed. Then lactate clearance or ScvO2 were measured, and if the respective goals of 10% or 70% were not met, packed cells or dobutamine were given depending on haematocrit. Lactate clearance was the percentage decrease in lactate between two venous specimens taken two hours apart.
Interestingly only 29 patients received either packed cells or dobutamine. Each group was similar in terms of time to antibiotic therapy and amount of fluid given. Patients in the group resuscitated to a lactate clearance of 10% or higher had 6% lower in-hospital mortality than those resuscitated to an ScvO2 of at least 70% (95% CI for this difference, –3% to 15%) exceeding the –10% predefined noninferiority threshold.
The authors conclude ‘these data support the substitution of lactate measurements in peripheral venous blood as a safe and efficacious alternative to a computerized spectrophotometric catheter in the resuscitation of sepsis.’
Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial
JAMA. 2010 Feb 24;303(8):739-46

Acute Med, All Updates

Alternative to warfarin after VTE

In a randomised noninferiority trial the oral direct thrombin inhibitor dabigatran was compared with warfarin in patients with venous thromboembolic disease (VTE) after acute treatment with parenteral anticoagulation. Recurrent VTE and major bleeding rates were similar in the two groups. Dabigatran has the advantage of not requiring blood monitoring.
Dabigatran versus Warfarin in the Treatment of Acute Venous Thromboembolism
N Engl J Med. 2009 Dec 10;361(24):2342-52

Acute Med, All Updates, Resus

Take bloods before giving Lipid Rescue

Intralipid therapy is recommended for local anaesthetic toxicity and in some overdoses. After large doses of Intralipid, the results of blood tests may be difficult to analyse, delayed, or spuriously abnormal. If possible, all blood tests should be taken before the administration of Intralipid. While laboratories will readily identify significant lipaemia, communication about the presence of Intralipid is important. In one case, the inability to obtain a haemoglobin result led to delay in the identification of haemorrhage which was the cause of deterioration initially thought to be local anaesthetic toxicity.
Possible side effects of Intralipid rescue therapy
Anaesthesia 2010;65(2):210-11