A systematic review on use of GPIIb/IIIa inhibitors in NSTEACS has been updated as part of the Annals of Emergency Medicine‘s Evidence Based Emergency Medicine series. The bottom line:
In patients with non-ST-segment elevation acute coronary syndromes who do not undergo early percutaneous coronary intervention, administration of platelet glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors, given in addition to aspirin and unfractionated heparin, does not reduce 30-day or 6-month mortality. For the composite endpoint of myocardial infarction or death, there was modest benefit at 30 days and 6 months; however, there was an increased risk of major hemorrhage among those receiving GPIIb/IIIa inhibitors.
Update: Use of Platelet Glycoprotein IIb/IIIa Inhibitors in Patients With Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction
Annals of Emergency Medicine Volume 56, Issue 5 , Pages e1-e2, November 2010
Compare this with the recommendations of the European Resuscitation Council who provide the following summary regarding this class of drug:
Gp IIB/IIIA receptor inhibition is the common final link of platelet aggregation. Eptifibatide and tirofiban lead to reversible inhibition, while abciximab leads to irreversible inhibition of the Gp IIB/IIIA receptor. Older studies from the pre-stent era mostly support the use of this class of drugs. Newer studies mostly document neutral or worsened outcomes. Finally in most supporting, as well as neutral or opposing studies, bleeding occurred in more patients treated with Gp IIB/IIIA receptor blockers. There are insufficient data to support routine pre-treatment with Gp IIB/IIIA inhibitors in patients with STEMI or non-STEMI-ACS. For high-risk patients with non-STEMI-ACS, in-hospital upstream treatment with eptifibatide or tirofiban may be acceptable whereas abciximab may be given only in the context of PCI. Newer alternatives for antiplatelet treatment should be considered because of the increased bleeding risk with Gp IIB/IIIA inhibitors when used with heparins.
European Resuscitation Council Guidelines for Resuscitation 2010 Section 5. Initial management of acute coronary syndromes
Resuscitation 81 (2010) 1353–1363 – full text downloadable
Category Archives: Guidelines
Guidelines relevant to the critically ill patient
AED Use in Children Now Includes Infants
From the new 2010 resuscitation guidelines:
For attempted defibrillation of children 1 to 8 years of age with an AED, the rescuer should use a pediatric dose-attenuator system if one is available. If the rescuer provides CPR to a child in cardiac arrest and does not have an AED with a pediatric dose-attenuator system, the rescuer should use a standard AED. For infants (<1 year of age), a manual defibrillator is preferred. If a manual defibrillator is not available, an AED with pediatric dose attenuation is desirable. If neither is available, an AED without a dose attenuator may be used.
Summary: Adult AEDs may be used in all infants and children if there is no child-specific alternative
Highlights of the 2010 American Heart Association Guidelines for CPR and ECC
Resuscitation Guideline Changes
The European Resuscitation Council’s Summary of Major Changes in the 2010 guidelines can be downloaded here
CAB rather than ABC
The 2010 ILCOR resuscitation guidelines were published today. Key changes and continued points of emphasis from the 2005 BLS Guidelines include the following:
- Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
- Immediate recognition of sudden cardiac arrest based on assessing unresponsiveness and absence of normal breathing (ie, the victim is not breathing or only gasping)
- “Look, Listen, and Feel” removed from the BLS algorithm
- Encouraging Hands-Only (chest compression only) CPR (ie, continuous chest compression over the middle of the chest) for the untrained lay-rescuer
- Health care providers continue effective chest compressions/CPR until return of spontaneous circulation (ROSC) or termination of resuscitative efforts
- Increased focus on methods to ensure that high-quality CPR (compressions of adequate rate and depth, allowing full chest recoil between compressions, minimizing interruptions in chest compressions and avoiding excessive ventilation) is performed
- Continued de-emphasis on pulse check for health care providers
- A simplified adult BLS algorithm is introduced with the revised traditional algorithm
- Recommendation of a simultaneous, choreographed approach for chest compressions, airway management, rescue breathing, rhythm detection, and shocks (if appropriate) by an integrated team of highly-trained rescuers in appropriate settings
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 5: Adult Basic Life Support
Circulation. 2010;122:S685-S705
http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S685
New CPR Guidelines
The International Liaison Committee on Resuscitation has published its five-yearly update of resuscitation guidelines.
The American Heart Association Guidelines can be accessed here
The European Resuscitation Guidelines can be accessed here
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Circulation. 2010;122:S639
New ICH Guidelines
A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association on the management of spontaneous intracerebral haemorrhage has been published in Stroke. The full text is available here.
In summary:
Medical Treatment for ICH
- Until ongoing clinical trials of BP intervention for ICH are completed, physicians must manage BP on the basis of the present incomplete efficacy evidence. Current suggested recommendations for target BP in various situations are listed in an accompanying table and may be considered
- In patients presenting with a systolic BP of 150 to 220 mmHg, acute lowering of systolic BP to 140 mm Hg is probably safe
Inpatient Management and Prevention of Secondary Brain Injury
- Initial monitoring and management of ICH patients should take place in an intensive care unit with physician and nursing neuroscience intensive care expertise
- Glucose should be monitored and normoglycemia is recommended
Seizures and Antiepileptic Drugs
- Clinical seizures should be treated with antiepileptic drugs
- Continuous EEG monitoring is probably indicated in ICH patients with depressed mental status out of proportion to the degree of brain injury
- Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with antiepileptic drugs
- Prophylactic anticonvulsant medication should not be used
Procedures/Surgery
- Patients with a GCS score of ≤8, those with clinical evidence of transtentorial herniation, or those with significant IVH or hydrocephalus might be considered for ICP monitoring and treatment. A cerebral perfusion pressure of 50 to 70 mmHg may be reasonable to maintain depending on the status of cerebral autoregulation
- Ventricular drainage as treatment for hydrocephalus is reasonable in patients with decreased level of consciousness
Intraventricular Hemorrhage Recommendation
- Although intraventricular administration of recombinant tissue-type plasminogen activator in IVH appears to have a fairly low complication rate, efficacy and safety of this treatment is uncertain and is considered investigational
Clot Removal
- For most patients with ICH, the usefulness of surgery is uncertain. Specific exceptions to this recommendation follow
- Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible. Initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended
- For patients presenting with lobar clots ≥30 mL and within 1 cm of the surface, evacuation of supratentorial ICH by standard craniotomy might be considered
- The effectiveness of minimally invasive clot evacuation utilizing either stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain and is considered investigational
- Although theoretically attractive, no clear evidence at present indicates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate. Very early craniotomy may be harmful due to increased risk of recurrent bleeding
Outcome Prediction and Withdrawal of Technological Support
- Aggressive full care early after ICH onset and postponement of new DNR orders until at least the second full day of hospitalization is probably recommended. Patients with preexisting DNR orders are not included in this recommendation. Current methods of prognostication in individual patients early after ICH are likely biased by failure to account for the influence of withdrawal of support and early DNR orders. Patients who are given DNR status at any point should receive all other appropriate medical and surgical interventions unless otherwise explicitly indicated.
Prevention of Recurrent ICH
- In situations where stratifying a patient’s risk of recurrent ICH may affect other management decisions, it is reasonable to consider the following risk factors for recurrence: lobar location of the initial ICH, older age, ongoing anticoagulation, presence of the apolipoprotein ε2 or ε4 alleles, and greater number of microbleeds on MRI
- After the acute ICH period, absent medical contraindications, BP should be well controlled, particularly for patients with ICH location typical of hypertensive vasculopathy
- After the acute ICH period, a goal target of a normal BP of <140/90 (<130/80 if diabetes or chronic kidney disease) is reasonable
- Avoidance of long-term anticoagulation as treatment for nonvalvular atrial fibrillation is probably recommended after spontaneous lobar ICH because of the relatively high risk of recurrence. Anticoagulation after nonlobar ICH and antiplatelet therapy after all ICH might be considered, particularly when there are definite indications for these agents. Avoidance of heavy alcohol use can be beneficial. There is insufficient data to recommend restrictions on use of statin agents or physical or sexual activity
Rehabilitation and Recovery
- Given the potentially serious nature and complex pattern of evolving disability, it is reasonable that all patients with ICH have access to multidisciplinary rehabilitation. Where possible, rehabilitation can be beneficial when begun as early as possible and continued in the community as part of a well-coordinated (seamless) program of accelerated hospital discharge and home-based resettlement to promote ongoing recovery
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association
Stroke published online Jul 22, 2010
Delirium guidelines
The UK’s National Institute for Health and Clinical Excellence (NICE) has produced guidelines on delirium.
Delirium (sometimes called ‘acute confusional state’) is a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course.
Some snippets from the guideline include:
- If indicators of delirium are identified, carry out a clinical assessment based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria or short Confusion Assessment Method (short CAM) to confirm the diagnosis.
- In critical care or in the recovery room after surgery, CAM-ICU should be used. A healthcare professional who is trained and competent in the diagnosis of delirium should carry out the assessment.
- If there is difficulty distinguishing between the diagnoses of delirium, dementia or delirium superimposed on dementia, treat for delirium first.
- If a person with delirium is distressed or considered a risk to themselves or others and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, consider giving short- term (usually for 1 week or less) haloperidol or olanzapine.
The CAM-ICU assessment tool is demonstrated in the video below, which is found along with other helpful delirium resources at http://www.icudelirium.co.uk
NICE Guidance: Delirium: diagnosis, prevention and management
British Thoracic Society pneumothorax guideline
The Britsh Thoracic Society has published its 2010 guidelines on the management of spontaneous pneumothorax. These are one of number of guidelines for the management of pleural disease.
Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010
Thorax 2010;65(Suppl 2):ii18-ii31
All pleural disease guidelines
Stab wounds to the neck
An algorithm for the management of patients with stab wounds to the neck has been proposed by authors of a review of the topic.
‘Hard’ signs of vascular injury include severe active bleeding, unresponsive shock, evolving stroke, and large/expanding haematoma. ‘Soft’ signs include a non-expanding moderate haematoma, a bruit/thrill, or a radial pulse deficit (although some consider the latter two to be hard signs). Mentioned in the text, but omitted from the algorithm, is the option of placing a Foley catheter into the wound and inflating the balloon to blindly control bleeding in a crashing haemodynamically unstable patient in order to buy time to get to the operating room.
Review article: Emergency department assessment and management of stab wounds to the neck.
Emerg Med Australas. 2010 Jun;22(3):201-10
Brain tumours in kids
When might you suspect a brain tumour in a child who presents with, say, nausea and vomiting, or behavioural disturbance? A guideline has been produced which might prompt one to think of this important but often delayed diagnosis.
The diagnosis of brain tumours in children: a guideline to assist healthcare professionals in the assessment of children who may have a brain tumour Arch Dis Child. 2010 Jul;95(7):534-9