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
Category Archives: All Updates
How to spot paediatric myocarditis
The most common aetiology of heart failure in previously well children is myocarditis. A review of 62 cases whose final diagnosis was viral myocarditis showed that common features included:
- multiple visits / evaluations before the diagnosis was made
- initial misdiagnosis as respiratory disease (eg. pneumonia, asthma)
- presenting symptoms of shortness of breath, vomiting, poor feeding, lethargy, fever
- signs included hepatomegaly (50%), tachypnoea, respiratory distress
- although a normal heart rate for age was found in 41(66%) patients, ALL patients had an abnormal ECG
- Most had abnormal chest x-rays
The take home messages regarding this rare disease are that initial misdiagnosis is common, do not expect a resting tachycardia, look for hepatomegaly, CXR signs, and particularly ECG abnormalities.
Pediatric myocarditis: presenting clinical characteristics
Am J Emerg Med. 2009 Oct;27(8):942-7
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
Deciding who doesn't need abdominal CT in trauma
A derivation then validation study on adults with blunt torso trauma found the absence of the following factors to be associated with a very low risk of significant (intervention-requiring) abdominal pathology and such patients were unlikely to benefit from abdominal CT scanning:
- GCS score less than 14
- costal margin tenderness
- abdominal tenderness
- femur fracture
- hematuria level greater than or equal to 25 red blood cells/high powered field
- hematocrit level less than 30%
- abnormal chest radiograph result (pneumothorax or rib fracture)
Clinical Prediction Rules for Identifying Adults at Very Low Risk for Intra-abdominal Injuries After Blunt Trauma
Ann Emerg Med. 2009 Oct;54(4):575-8
New Guidelines for Care of Children in the Emergency Department
A joint policy statement from the American College of Emergency Physicians and the American Academy of Pediatrics lists guidelines and resources that should be in place for emergency departments to serve paediatric patients. Well worth a look through while asking yourself whether your ED ticks all the boxes.
Joint Policy Statement—Guidelines for Care of Children in the Emergency Department
Free full text access
A similar, even more comprehensive, document by these organisations’ UK counterparts was published in 2007
Services for Children in Emergency Departments
Free full text access
Effects of bed height on the performance of chest compressions
In a manikin study of CPR, there was a decrease in mean depth of chest compressions when the height of the bed was over 20cm above the knee height of the nurse doing the compressions.
The study has several limitations, but serves as a helpful reminder that adjusting the height of the bed to suit the rescuer is an option not to be forgotten. At least for those areas where manual CPR is still performed.
Effects of bed height on the performance of chest compressions
Emerg Med J. 2009 Nov;26(11):807-10
Paramedics apply cervical spine rule successfully
The Canadian C-Spine rule – a decision instrument designed to clinically rule out important cervical spine injuries in alert patients – was successfully and safely applied by Canadian paramedics in a study of 1949 patients. Any misinterpretation erred on the side of safety.
This important work could ultimately result in less stress, discomfort, and wasting of ambulance resources and time for this large subgroup of pre-hospital patients.
The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics
Ann Emerg Med. 2009 Nov;54(5):663-671
Tying the tracheal tube
After intubation it is critical to securely fasten the tracheal tube so it does not dislodge during transfer. Dedicated devices are available for this although mostly cloth tape is used.
Different knots have been compared although not found be significantly different in terms of security1. One favoured knot, which is easy to learn and to teach, is the lark’s head (also called cow’s hitch)2.
The tape is folded in half so there is a loop at one end and two free ends at the other. The loop is wrapped around the tube and the two free ends are fed through the loop, and then taped around the patient’s head. It has been suggested that this results in the tape gripping the tube over the widest possible area, thereby reducing the potential for slippage and displacement.
Easy!
1.The insecure airway: a comparison of knots and commercial devices for securing endotracheal tubes
BMC Emerg Med. 2006 May 24;6:7 Open Access
2. A knotty problem resolved
Anaesthesia. 2007 Jun;62(6):637
Two new studies on ECMO
Extracorporeal Membrane Oxygenation (ECMO) for severe respiratory failure features in two important papers recently.
The first, the CESAR trial, is an RCT showing a improvement in six-month disability-free survival in patients referred to an ECMO centre. The complexity of the study and the potential confounding factors led an editorialist to say: ‘This study will likely provide ammunition for both those in favour and those against the use of ECMO in the adult population‘.
Perhaps the Australasians have their own ammunition. In a paper describing the use of ECMO for patients with H1N1, they treated 68 patients with ECMO in three months, the same number of patients that actually received ECMO in the five year CESAR study!
Maybe the Aussies need to do a bigger, better RCT than CESAR?
Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial
Lancet. 2009 Oct 17;374(9698):1351-63
Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome
JAMA. 2009;302(17) (Full text)
Further information on the impact of H1N1 on Australasian critical care services, and the 722 patients admitted to ICU with the disease, is published in the New England Journal:
Critical Care Services and 2009 H1N1 Influenza in Australia and New Zealand
N Engl J Med. 2009 Oct 8. [Epub ahead of print]
Bivalirudin in STEMI
Bivalirudin is a direct thrombin inhibitor, and Continue reading Bivalirudin in STEMI