tag:blogger.com,1999:blog-62480570852266149352024-03-18T05:41:52.831-05:00the short coatbridging the individual level emergency medicine knowledge translation gaps through FOAMLauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.comBlogger120125tag:blogger.com,1999:blog-6248057085226614935.post-4135800351372069292020-08-06T12:43:00.004-05:002020-08-06T12:43:37.333-05:00COVID-19 Shift Decontamination RoutineWhile the primary form of transmission of the novel coronavirus, SARS-CoV-2, is through respiratory droplets, there remains the possibility of transmission via fomites, particularly the clothing and gear we wear in the emergency department.<div>Whether a stringent decontamination routine adds much on top of diligent handwashing, mask-wearing, and personal protective equipment (PPE) is unknown. Below is my personal routine</div><div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilS5alzsHYt-GMYxDbL44TU8Mp-c1k2kaDM3JqXCh9SvWY1scZMDLNCZutaVC9apxxcjr9s4z_JjqAJjJkh-UWaN9gS3_vNns63EZXBel37_Kk2xUH7WmOple2upGKg2B3-D3exCY7bCE/s2048/Screen+Shot+2020-08-06+at+12.02.53+PM.png" imageanchor="1" style="display: block; padding: 1em 0px; text-align: center;"><img border="0" data-original-height="1280" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilS5alzsHYt-GMYxDbL44TU8Mp-c1k2kaDM3JqXCh9SvWY1scZMDLNCZutaVC9apxxcjr9s4z_JjqAJjJkh-UWaN9gS3_vNns63EZXBel37_Kk2xUH7WmOple2upGKg2B3-D3exCY7bCE/s640/Screen+Shot+2020-08-06+at+12.02.53+PM.png" width="640" /></a></div>The 3 basic principles I abide by are:<div><ul style="text-align: left;"><li>Keep clean things clean </li><ul><li>Have a 'hot' station at desk for ECGs that need to be signed, pen, phone</li></ul><li>Have a system that's sustainable (mine is above)</li><ul><li>I use a bag and bin system - have a clean bag and dirty bag (bought cheap washable bags and use shopping bags and clean and dirty bins in my car.</li></ul></ul><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhzhkUXEv01hXz1gTd5jSOs91nf0Piuqu56HQnWCC_34A-fcROU-y4Y8Z1WYhVM5K5UEXZvIDj-0fj8pRgr2yXtBpAsEHOLJubVAnyC6TR7GTwlW0QUvZmW386G5yV6KqyDrpAZtNzXYkc/s2048/Screen+Shot+2020-08-06+at+12.03.39+PM.png" imageanchor="1" style="display: inline !important; padding: 1em 0px; text-align: center;"><img border="0" data-original-height="1280" data-original-width="2048" height="256" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhzhkUXEv01hXz1gTd5jSOs91nf0Piuqu56HQnWCC_34A-fcROU-y4Y8Z1WYhVM5K5UEXZvIDj-0fj8pRgr2yXtBpAsEHOLJubVAnyC6TR7GTwlW0QUvZmW386G5yV6KqyDrpAZtNzXYkc/w410-h256/Screen+Shot+2020-08-06+at+12.03.39+PM.png" width="410" /></a><br /><ul style="text-align: left;"><li>Don't cross-contaminate</li><ul><li>Ways I prevent cross-contamination - the phone is a key example. I place it in a plastic bag on arrival (pictured below), I sanitize hands after touching, place it on the 'hot' part of my work station, wipe down after removing from bag and place in clean bag to go home. </li></ul></ul></div><div><div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6Cg7ZPRw0uYAqpy3XFVAytyojLR1KZKcRBVIWc-SPro2PF6yY6pBgfiuUEjwE7qp27XmV1HTPiVxh8QvOeYGr8O7jX4riGTdVYzRvUa0of1L2o3BMcWyZn2-LdcQPSiY6usuZnuodGGk/s2048/Screen+Shot+2020-08-06+at+12.03.12+PM.png" imageanchor="1" style="display: block; padding: 1em 0px; text-align: center;"><img border="0" data-original-height="1280" data-original-width="2048" height="256" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6Cg7ZPRw0uYAqpy3XFVAytyojLR1KZKcRBVIWc-SPro2PF6yY6pBgfiuUEjwE7qp27XmV1HTPiVxh8QvOeYGr8O7jX4riGTdVYzRvUa0of1L2o3BMcWyZn2-LdcQPSiY6usuZnuodGGk/w410-h256/Screen+Shot+2020-08-06+at+12.03.12+PM.png" width="410" /></a></div><div class="separator" style="clear: both;"><br /></div><div><br /></div></div>Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com0tag:blogger.com,1999:blog-6248057085226614935.post-85656116211130533892020-02-16T12:48:00.003-06:002020-02-16T12:48:52.975-06:00Fluid Resuscitation in Patients with Sepsis and Heart Failure, ESRD, or Cirrhosis<div dir="ltr" style="text-align: left;" trbidi="on">
<b><u>The Gist</u></b>: While an article in Chest by <a href="https://www.ncbi.nlm.nih.gov/pubmed/31622591" target="_blank">Khan et al</a> reports no association between 30 cc/kg of fluids in patients with congestive heart failure (CHF), end-stage renal disease (ESRD), and cirrhosis and intubation, this study should not be used to justify administration of 30 cc/kg of fluids in these patients. Rather, the decision to administer volume should be made according to the individual patient scenario, particularly given the lack of evidentiary basis for this specific volume of fluid.<br />
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In the United States (US), a standard part of resuscitating patients with severe sepsis and septic shock includes a crystalloid fluid bolus of 30 cc/kg within the first 3 hours. The <a href="https://journals.lww.com/ccmjournal/Fulltext/2017/03000/Surviving_Sepsis_Campaign__International.15.aspx" target="_blank">Surviving Sepsis Guidelines</a> give this a strong recommendation based on low-quality evidence. In fact, the guideline states that this recommendation is based on essentially no evidence other than this was the average volume of fluids given in trials (PROCESS, ARISE) [2]. In the US, clinicians are incentivized to administer this volume in the first 3 hours when treating patients with septic shock as it is part of the <a href="https://www.qualitynet.org/files/5deda2b262faad001ffd7a46?filename=2-1_SEP_v5.8.pdf" target="_blank">SEP-1 core measure.</a> This quality measure is an "all or none" measure, in which many components of treating patients with severe sepsis/septic shock must be met to satisfy the measure. It may seem that 30 cc/kg of fluids is not that much, only ~2 L for a 70 kg patient. However, fluids are not benign and may pose a risk in patients with a tenuous fluid balance at baseline, particularly heart failure (HF), end-stage renal disease (ESRD), and cirrhosis. </div>
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In a study published in Chest (February 2020), Khan et al boldly conclude <i>"We detected no difference in the incidence of intubation in the high-risk cohort of cirrhotic, heart failure, and ESRD</i></div>
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<i>patients with sepsis who received SSC guideline-concordant (30 mL/kg) vs restricted fluid resuscitation. <b>Based on our results, we suggest that guideline-based early fluid resuscitative efforts should not be omitted in patients with cirrhosis, CHF, and ESRD solely for concern of acute respiratory failure</b>" </i>[1]. The basics of the paper can be seen below:</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJIWHhF1J4vFyaO-yUujBt1_SRhREnYG88ZEs31OV1fo4wF0eL5FItQIyoNNkQqdDs9Fec3SSxNwNet-kpo6kA4ltRKn96ypJvK_6g86GiT5aNYOqIZNO_KB8qno-jhieCB80VC3AeIvc/s1600/Screen+Shot+2020-02-16+at+10.34.20+AM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1140" data-original-width="1600" height="456" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJIWHhF1J4vFyaO-yUujBt1_SRhREnYG88ZEs31OV1fo4wF0eL5FItQIyoNNkQqdDs9Fec3SSxNwNet-kpo6kA4ltRKn96ypJvK_6g86GiT5aNYOqIZNO_KB8qno-jhieCB80VC3AeIvc/s640/Screen+Shot+2020-02-16+at+10.34.20+AM.png" width="640" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcK07Sa0bcro3nSMMWbXXVmkpHHvfcXGyHb8Sd9erug9-T-j-fLoMTUTeAhDJEsuy3Qfbuengu0teE0DGD7_wxiEiqJfgWkysTKn4-1wFC3IgWxwF5pM17vqkTXH4P8Zm4natw9FXck2o/s1600/Screen+Shot+2020-02-16+at+1.38.27+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="652" data-original-width="1600" height="162" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcK07Sa0bcro3nSMMWbXXVmkpHHvfcXGyHb8Sd9erug9-T-j-fLoMTUTeAhDJEsuy3Qfbuengu0teE0DGD7_wxiEiqJfgWkysTKn4-1wFC3IgWxwF5pM17vqkTXH4P8Zm4natw9FXck2o/s400/Screen+Shot+2020-02-16+at+1.38.27+PM.png" width="400" /></a></div>
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Unfortunately, this study provides limited insight into whether it is actually safe to administer 30 cc/kg of fluids to patients with HF, ESRD, and cirrhosis. </div>
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<b>This study is a retrospective cohort study, with limited propensity matching. </b>This study design may provide some tentative insight into associations but can certainly not provide a definitive conclusion. Additionally, for this type of study design, there are some limitations with this particular study. </div>
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<li>Few methods regarding data extraction. It's clear exactly which parts of the study were performed using chart review methods and was administrative database extraction. Study methods should be transparent and replicable.</li>
<li>While patients were matched according to age, sex, weight, mean arterial pressure, lactate level at the time of first fluid bolus administration, APACHE III score, and presence of septic shock, cirrhosis, ESRD, and heart failure there are other variables that could be important. Heart failure is variable and it's probable that those with reduced ejection fractions may be most susceptible to fluid overload. In the restricted fluids cohort, 20 patients (28%) had HFrEF vs 12 (16%) in the liberal fluids cohort. Additionally, seemingly important confounders, such as diagnosis of pneumonia, acute lung injury, or ARDS were not accounted for in the propensity matching or in the multivariable model.</li>
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<b>The binary cut-point of 30 cc/kg is an understandable cut-off based on guidelines, but also somewhat arbitrary</b>. In this study patients were grouped according to fluid administered as boluses (excluding those administered in the prehospital setting) in the first 6 hours as either "restrictive" (<30 cc/kg) or standard (≥30 cc/kg). Thus, a patient receiving 29 cc/kg would be classified as restrictive even though they received 70 cc (2.4 oz) less than a patient in the standard group. This is a trivial volume of fluid. However, the standard group did receive, on average, about 2L more crystalloid in the first 2 hours which does suggest an actual difference between groups. Yet, it might make more sense to analyze ≥30 cc/kg and <15 cc/kg. </div>
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<b>The data actually suggests the groups are fundamentally different</b>. The Kaplan-Meier curve in the article, replicated below, actually shows a trend towards increased probability in intubation after ~18 hours. While propensity matching attempts to mitigate selection bias, it cannot fully do so. The restricted fluid group had a higher probability of intubation throughout much of the study period, either due to their baseline disease or uncaptured clinical factors. Patients who were given ≥30 cc/kg were probably deemed by clinicians to be able to "tolerate" the fluids. This inflated probability may make a difference between the two groups disappear. </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYdQPH7KR196DEYCH_fTKGxRMEl3gZImwpr2Yc5OPK21Kay0tDdgIlVidgWdC-fP1MNSQaL9sIUCdPcpTJGWsz6As-UeCV1add78n0DxN9MBkiGMWBZ6gzytqr5IBClftP_X0eqxxJAVA/s1600/Screen+Shot+2020-02-16+at+10.23.00+AM.png" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1204" data-original-width="1600" height="480" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYdQPH7KR196DEYCH_fTKGxRMEl3gZImwpr2Yc5OPK21Kay0tDdgIlVidgWdC-fP1MNSQaL9sIUCdPcpTJGWsz6As-UeCV1add78n0DxN9MBkiGMWBZ6gzytqr5IBClftP_X0eqxxJAVA/s640/Screen+Shot+2020-02-16+at+10.23.00+AM.png" width="640" /></a></div>
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<ol style="text-align: left;">
<li>Khan RA, Khan NA, Bauer SR, et al. Association Between Volume of Fluid Resuscitation and Intubation in High-Risk Patients With Sepsis, Heart Failure, End-Stage Renal Disease, and Cirrhosis. Chest. 2020;157(2):286-292.</li>
<li>Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017;45(3):486-552.</li>
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Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com0tag:blogger.com,1999:blog-6248057085226614935.post-89811134297664450522020-01-31T11:14:00.005-06:002020-01-31T11:16:17.791-06:00D-Dimer in Patients at "Intermediate Risk" of Pulmonary Embolism<div dir="ltr" style="text-align: left;" trbidi="on">
<b><u>The Gist</u></b>: A D-dimer in the evaluation of suspected pulmonary embolism (PE) in patients with an intermediate probability of PE is recommended in many professional society guidelines [1-4]. The intermediate probability group is the most high-value group for application of a D-dimer, particularly in places such as the United States where the prevalence of PE among those tested is typically <10% [5].<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNRpBWgiu-qxhhk3r2pgHqOn02EE8juLUUoWSYAlIPkV2OeQ1RX8VUIzrfP840B6Wr3u4DnoWihYpGXMrbeaWIXIuVYOnPgiPeQtWhy-vd7udryzSI7VfCLT4BpakRUISLGfSswSA07UU/s1600/Screen+Shot+2020-01-31+at+11.07.38+AM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="918" data-original-width="1600" height="364" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNRpBWgiu-qxhhk3r2pgHqOn02EE8juLUUoWSYAlIPkV2OeQ1RX8VUIzrfP840B6Wr3u4DnoWihYpGXMrbeaWIXIuVYOnPgiPeQtWhy-vd7udryzSI7VfCLT4BpakRUISLGfSswSA07UU/s640/Screen+Shot+2020-01-31+at+11.07.38+AM.png" width="640" /></a></div>
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<b>Risk stratification of pulmonary embolism is complex, partially due to the presence of several cut-offs in Wells, one of the most popular risk stratification scores in the United States</b> [6].<br />
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<u>The origin</u>: The original Wells score used a trichotomized risk scoring system: Low (<2), Intermediate (2-6), and High (>6), however, this was prior to the introduction of computed tomographic pulmonary angiogram (CTPA) and used compression ultrasound and ventilation-perfusion (V/Q) scans [7]. The diagnostic alogrithm proposed by Wells in 2001 was complex yet many patients in the intermediate-risk group who had a negative d-dimer were considered to have PE excluded (all of these patients got a V/Q and then high probability V/Q scans were treated as positive for PE regardless of dimer result) [78]. Further, this iteration employed a D-dimer assay not widely used currently (SimpliRED), a qualitative assay rather than the high sensitivity quantitative assays [8,9].<br />
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<u>The simplification</u>: The initial Wells algorithm was cumbersome and quickly became outdated with CTPA and new d-dimer assays. In 2006, the Christopher Study, evaluated a dichotomized Wells Score that stratified patients into "PE likely" (Wells >4) or "PE Unlikely" (Wells ≤ 4). This study incorporated more relevant diagnostic tests, the CTPA and the VIDAS or Tinaquant quantitative D-dimer assays and found that "PE unlikely" patients with a negative D-dimer had very low risk of PE at 90 days (0.5%; 95%CI 0.2%-1.1%). Approximately 37.1% had PE in the "PE likely" group vs 12.1% in the "PE unlikely" group [10].<br />
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<b>The "intermediate" risk group incorporates patients for whom the D-dimer is the most helpful.</b> Evaluation patterns for suspected PE vary across the world; however, CTPA yield (# positive/#ordered) is particularly low in the United States, generally <10% but often in the 3-5% range [5,11]. In a recent US study the prevalence of PE was 4% and, contrasted with the aforementioned Christopher study, in which the overall prevalence of PE was 20%, demonstrates that in the US the patients we evaluate are at <i>even lower risk</i> of PE. Thus, in the US, the dichotomized Wells score likely moves patients with a probability of PE <15-20% to the "PE likely" group, inflating their perceived risk of PE.<br />
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<b>In the US, we have a problem with overtesting for PE, and the use of the D-dimer in the intermediate-risk group, in addition to<a href="https://shortcoatsinem.blogspot.com/2019/11/probability-adjusted-d-dimer-for.html" target="_blank"> clinically adjusted D-dimer thresholds</a>, may help improve the quality of care we deliver to patients [12].</b><br />
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References:<br />
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<span style="font-size: x-small;">1. Wolf SJ, Hahn SA, Nentwich LM, Raja AS, Silvers SM, Brown MD. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease. Ann Emerg Med 2018;71(5):e59–109. </span></div>
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<span style="font-size: x-small;">2. Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD. Evaluation of patients with suspected acute pulmonary embolism: Best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2015;163(9):701–11. </span></div>
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<span style="font-size: x-small;">3. Lim W, Le Gal G, Bates SM, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism. Blood Adv 2018;2(22):3226–56. </span></div>
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<span style="font-size: x-small;">4. <span style="text-indent: -32pt;">Konstantinides S V, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of. Eur Respir J. 2019;1–61. </span></span><br />
<span style="font-size: x-small;">5. </span><span style="text-indent: -32pt;"><span style="font-size: x-small;">Venkatesh AK, Agha L, Abaluck J, Rothenberg C, Kabrhel C, Raja AS. Trends and Variation in the Utilization and Diagnostic Yield of Chest Imaging for Medicare Patients With Suspected Pulmonary Embolism in the Emergency Department. Am J Roentgenol 2018;210(3):572–7. </span></span></div>
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<span style="font-size: x-small;"><span style="text-indent: -32pt;">6. </span><span style="text-indent: -32pt;">Westafer LM, Kunz A, Mazor KM, Schoenfeld EM, Stefan MS, Lindenauer PK. Provider Perspectives on the Use of Evidence-based Risk Stratification Tools in the Evaluation of Pulmonary Embolism : A Qualitative Study. Acad Emerg Med 2020; In Press.</span></span><br />
<span style="font-size: x-small;"><span style="text-indent: -32pt;">7. </span><span style="text-indent: -32pt;">Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. 1998;129(12):997–1005. </span></span><br />
<span style="font-size: x-small;"><span style="text-indent: -32pt;">8. </span><span style="text-indent: -32pt;">Wells PS, Anderson DR, Rodger M, et al. Excluding Pulmonary Embolism at the Bedside without Diagnostic Imaging : Management of Patients with Suspected Pulmonary Embolism Presenting to the Emergency Department by Using a. 2001;5(3):98–107. </span></span><br />
<span style="font-size: x-small;"><span style="text-indent: -32pt;">9. </span></span><span style="text-indent: -32pt;"><span style="font-size: x-small;">Riley RS, Gilbert AR, Dalton JB, Pai S, McPherson RA. Widely used types and clinical applications of D-dimer assay. Lab Med 2016;47(2):90–102. </span></span><br />
<span style="text-indent: -32pt;"><span style="font-size: x-small;">10. Van belle A, Büller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006;295(2):172-9.</span></span><br />
<span style="text-indent: -32pt;"><span style="font-size: x-small;">11. Kline JA, Garrett JS, Sarmiento EJ, Strachan CC, Courtney DM. Over-Testing for Suspected Pulmonary Embolism in American Emergency Departments. Circ Cardiovasc Qual Outcomes. 2020;13(1):1–10. </span></span><br />
<span style="text-indent: -32pt;"><span style="font-size: x-small;">12. Kearon C, De Wit K, Parpia S, et al. Diagnosis of Pulmonary Embolism with D-Dimer Adjusted to Clinical Probability. N Engl J Med 2019;381(22):2125–34. </span></span><br />
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Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com0tag:blogger.com,1999:blog-6248057085226614935.post-15021518596844317242019-11-28T12:13:00.002-06:002020-01-12T12:34:04.544-06:00Probability Adjusted D-Dimer for Pulmonary Embolism<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: inherit;"><b><u>The Gist:</u></b> Kearon and colleagues <span style="text-align: center;">found that the PEGeD strategy, </span></span><span style="text-align: center;">which employs an elevated D-dimer threshold of 1000 ng/mL in patients with a Wells score of ≤4, resulted in less imaging than the standard approaching using Wells, age-adjusted D-Dimer with Wells, or the YEARS algorithm while </span><span style="font-family: inherit; text-align: center;"> “missing” ≤2% of venous thromboembolic events (VTE) at 90 days [1]. This multi-center study indicates that this approach is likely safe in low-prevalence settings such as the US and Canada and could dramatically reduce the burden of imaging.</span><br />
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<span style="font-family: inherit;"><span style="text-align: center;"><b><u>The background: </u></b></span></span><span style="font-family: inherit; text-align: center;">Risk stratification is the first step in the evaluation of pulmonary embolism (PE) and this can be assessed using gestalt or a risk stratification tool such as the Pulmonary Embolism Rule Out Criteria (PERC), Wells Score, Revised Geneva Score, or the YEARS algorithm. In conjunction with the age-adjusted d-dimer, these are recommended in guidelines to reduce imaging in patients with suspected PE [2-4]. While provider gestalt yields similar estimates of the probability of PE, risk stratification tools have demonstrated benefit in improving imaging yield (and reducing unnecessary imaging) [5].</span><br />
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<span style="font-family: inherit;"><span style="text-align: center;"><b><u>The problem:</u></b> Unfortunately, the lack of specificity of the D-Dimer renders many patients who are low or intermediate risk requiring imaging. Literature has increasingly supported elevated D-Dimer thresholds in certain patients (such as those > 50 years old) and in pregnant patients [2-4, 6, 7]. However, studies have recently examined, with success, risk adjusting the D-dimer to use higher thresholds in low probability patients [8-10]. </span></span><br />
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This study is an evaluation of a modified Wells + D-Dimer pathway, allowing for patients with a Wells score of ≤4 to have a D-dimer threshold of 1000 ng/mL. </div>
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The study basics are depicted below.<br />
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<b>This study found that VTE at 90 days, a surrogate for "missed PE" was very uncommon</b>. This occurred in 0 patients with a D-Dimer <1000 ng/mL (double the typical threshold!). Two patients, both with low pretest probability and d-dimer >1000 ng/m, had VTE at 90 days. One patient, initially diagnosed with PE on imaging, was also diagnosed with a PE on day 77. This is obviously not a "miss" of the algorithm. Another patient, with active malignancy, was diagnosed with a DVT on day 4. </div>
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<b>Assuming the worst-case scenario, VTE at 90 days still occurred in <2% of patients. </b>Unfortunately, 9 of the 1285 patients with a Wells ≤4 and D-Dimer <1000 ng/mL were lost to follow up. Assuming all of these patients had VTE (which is quite unlikely), 0.7% (95% CI 0.32,1.33) would have had VTE at 90 days with an exact binomial confidence interval below the test threshold of 2%. Treating ALL patients, including those who got imaging for PE who were lost to follow up, as having 90-day VTE, would result in 0.7% (95% CI 0.4,1.2) with VTE, again well within the safe testing margins.</div>
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<b>MANY (253) patients were excluded because they received imaging despite a Wells ≤ 4 and D-Dimer <1000 ng/mL. </b>It is interesting that these patients weren't handled as "protocol violation" and were simply excluded.<b> </b>There are several possible reasons patients received imaging despite their Wells score and low D-Dimer, including something about the patient's clinical course changed or, perhaps, providers just couldn't' help themselves. <b> </b>Data were available for 127 of these patients (from 2 of the centers) who would otherwise have been eligible for the study, and only 2 had PE on imaging (D-Dimer 720 ng/mL and 650ng/mL), resulting in an overall event rate of 0.19% (95%CI 0.05,0.48%) not accounting for those lost to follow up. Assuming all patients lost to follow up had VTE at 90 days, 0.8% (95% CI 0.47,1.25) of patients would have VTE events, still below the 2% threshold. </div>
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<b>The outcome is quite conservative but is a proxy for "missed PE," which is likely lower.</b> Throughout the PE literature, 90-day deep vein thrombosis (DVT) or PE has been used as a surrogate for missed PE. This is an overly conservative measure that attempts to account for not all patients receiving confirmatory testing (which would be unethical in low-risk patients). This is interesting, though, because this treats risk stratification, D-Dimer, and imaging as a fortune-telling test rather than markers of a disease process at point of time it is tested. Patients with risk factors necessitating testing, will continue to have these risk factors.</div>
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<b>This study is also interesting because the "low risk" group in the Wells score is ≤ 4 and the intermediate group is 4.5-6 </b>The Wells scoring systems are complex, with both dichotomous (≤ 4 as "Unlikely, > 4 as "Likely) and trichotomous (<2 as "Low", 2-6 as "Intermediate", or >6 as "High") scoring systems. The major appeal to this cut point is that a patient can still have "Alternative diagnosis less likely than PE," (3 points) and still be classified as "low risk" and have the <1000 ng/mL D-Dimer threshold. While overall 21% of patients in this study met this criterion, most of these patients were in the Wells >4 group and only 11% of patients in the "low risk group" met this criterion. The PEGed algorithm may perform less optimally in a cohort where more low risk patients satisfy this criterion; however, I suspect that this is indicative of the less conservative evaluation in Canada compared with the US (but this is strictly conjecture).</div>
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<b>While this study has limitations, it is a multicentered trial in many centers in Canada, the findings are consistent with other findings suggesting the acceptability and safety of higher D-Dimer thresholds. </b>These findings may not be generalizable to settings in Europe and Asia where PE prevalence is higher than the 7.4% in this study. However, in the United States where the prevalence of PE in those evaluated is less than in Canada, these findings likely apply. Additionally, the PEGeD approach is similar to the YEARS algorithm which has been studied in Europe and the United States with many D-Dimer assays.</div>
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<b>No algorithm or test will result in 0% miss rate. Further, the harms caused by excess testing and treatment if the likelihood is <2% would outweigh the benefit (5-25% false positive rate of CTPA for PE, anticoagulation, harms from contrast, etc). Given the frequency of PE evaluation and the incremental benefit in reducing imaging, the potential to reduce imaging could be profound.</b></div>
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<span style="font-family: inherit;"><span style="font-size: xx-small; text-align: center;">References:</span></span><br />
<span style="font-size: xx-small;"><span style="font-family: inherit;"><span style="text-align: center;">1. </span></span><span style="text-indent: -32pt;">Kearon C, De Wit K, Parpia S, et al. Diagnosis of Pulmonary Embolism with D-Dimer Adjusted to Clinical Probability. N Engl J Med 2019;381(22):2125–34. </span></span><br />
<span style="font-size: xx-small; text-indent: -32pt;">2. Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD. Evaluation of patients with suspected acute pulmonary embolism: Best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2015;163(9):701–11.</span><br />
<span style="font-size: xx-small; text-indent: -32pt;">3.Wolf SJ, Hahn SA, Nentwich LM, Raja AS, Silvers SM, Brown MD. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease. Ann Emerg Med. 2018;71(5):e59–109. </span><br />
<span style="font-size: xx-small; text-indent: -32pt;">4. Fesmire FM, Brown MD, Espinosa JA, et al. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med. 2011;57(6):628-652.e75. </span><br />
<span style="font-size: xx-small;"><span style="text-indent: -32pt;">5. </span><span style="text-indent: -32pt;">Wang RC, Bent S, Weber E, Neilson J, Smith-Bindman R, Fahimi J. The Impact of Clinical Decision Rules on Computed Tomography Use and Yield for Pulmonary Embolism: A Systematic Review and Meta-analysis. Ann Emerg Med. 2016;67(6):693–701. </span></span><br />
<span style="font-size: xx-small; text-indent: -32pt;">6. van der Pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med [Internet] 2019;380(12):1139–49. </span><br />
<span style="font-size: xx-small; text-indent: -32pt;">7. Kline JA, Williams GW, Hernandez-Nino J. D-Dimer concentrations in normal pregnancy: New diagnostic threshold are need. Clin Chem 2005;51(5):825–9. </span><br />
<span style="font-size: xx-small; text-indent: -32pt;">8. Kabrhel C, Van Hylckama Vlieg A, Muzikanski A, et al. Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism. Acad Emerg Med [Internet] 2018;25(9):987–94. </span><br />
<span style="font-size: xx-small; text-indent: -32pt;">9. van der Hulle T, Cheung WY, Kooij S, et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet 2017;390(10091):289–97. </span><br />
<span style="font-size: xx-small; text-indent: -32pt;">10. Kline JA, Hogg MM, Courtney DM, Miller CD, Jones AE, Smithline HA. D-dimer threshold increase with pretest probability unlikely for pulmonary embolism to decrease unnecessary computerized tomographic pulmonary angiography. J Thromb Haemost. 2012;10(4):572-81.</span><br />
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Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com0tag:blogger.com,1999:blog-6248057085226614935.post-75001295823991472252019-09-18T14:13:00.003-05:002019-09-18T14:13:40.718-05:00Tips for Pumping While Working in the Emergency Department<div dir="ltr" style="text-align: left;" trbidi="on">
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This post is a bit different than the typical evidence-based post. Rather than a post on how to take care of patients, it's a compilation of tips for expressing breastmilk while working in the Emergency Department</div>
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<b>Why is this important?</b></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgerV7iXjD1BKMxxTg9L7q7eKEWm8YizcHWMMuTDa5-wpT9jLholXAz8H1jYBNd77k56e_DICB6zoxwI9_VuKhLQvzoWglIhq_eIrvy4ElzIoRFF3f_vJ98ZXhx0-CxPofnekXb0SaRxPE/s1600/Screen+Shot+2019-09-15+at+10.03.45+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1200" data-original-width="1600" height="298" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgerV7iXjD1BKMxxTg9L7q7eKEWm8YizcHWMMuTDa5-wpT9jLholXAz8H1jYBNd77k56e_DICB6zoxwI9_VuKhLQvzoWglIhq_eIrvy4ElzIoRFF3f_vJ98ZXhx0-CxPofnekXb0SaRxPE/s400/Screen+Shot+2019-09-15+at+10.03.45+PM.png" width="400" /></a></div>
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<b>This is an important issue for everyone, not just women and not only those who are breastfeeding.</b> </div>
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There are tangible ways everyone can contribute to a supportive atmosphere. This includes being supportive of colleagues and reaching out to those who are returning from leave. If your colleagues don't have a place to pump, join them in advocating for a space (by the way, a bathroom is NOT an appropriate place to pump). Know that residents may be especially reticent to ask for time to pump due to being perceived as "weak" or "lazy." </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYyOUJ-GZ-FG4zshurXbk6IzhiLk_7uD2rpYAcoGMqhtHtHgF9fnWzs6LxWlWxKPVx_cjL3Ev148hjceVxhyIfwlBTmqWXzqKdKC12uM0tVaZFDq3GR42RYgZOE6NonU4aUVE5O-l_Z6w/s1600/Screen+Shot+2019-09-16+at+3.29.51+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1152" data-original-width="1542" height="298" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYyOUJ-GZ-FG4zshurXbk6IzhiLk_7uD2rpYAcoGMqhtHtHgF9fnWzs6LxWlWxKPVx_cjL3Ev148hjceVxhyIfwlBTmqWXzqKdKC12uM0tVaZFDq3GR42RYgZOE6NonU4aUVE5O-l_Z6w/s400/Screen+Shot+2019-09-16+at+3.29.51+PM.png" width="400" /></a></div>
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Pumping on shift can be stressful and come with guilt for stepping away from immediate patient care. There are things that you can do to minimize the time away. </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgV4pQHK5uCAd9XMbhyphenhyphenS_UKrwqb-VvVBBr7LIonFFBCA6RMguM21doNTEJIU8L-lshTWyinPQ-0yu4_ilHP0ULVKrU-4Lc8njtaXz-w5bG8TpqRh9xStRD6Gt8_dK_Tp0NfSqD_duX80ks/s1600/Screen+Shot+2019-09-16+at+3.16.05+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1197" data-original-width="1600" height="298" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgV4pQHK5uCAd9XMbhyphenhyphenS_UKrwqb-VvVBBr7LIonFFBCA6RMguM21doNTEJIU8L-lshTWyinPQ-0yu4_ilHP0ULVKrU-4Lc8njtaXz-w5bG8TpqRh9xStRD6Gt8_dK_Tp0NfSqD_duX80ks/s400/Screen+Shot+2019-09-16+at+3.16.05+PM.png" width="400" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5ShFT73OB6-wapEf5XwBa1Qf6Ue-5WwtuSE50_lj8ai5OCs0dFQoG08kCL2Yd9MoBEp9N6UJEOFtD0A03o2rPezg7dMNv83OS12CxOQxgtns1Fko6LXqvf_amud8AKzzaj2zcRJZtslo/s1600/Screen+Shot+2019-09-15+at+10.03.20+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1196" data-original-width="1600" height="298" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5ShFT73OB6-wapEf5XwBa1Qf6Ue-5WwtuSE50_lj8ai5OCs0dFQoG08kCL2Yd9MoBEp9N6UJEOFtD0A03o2rPezg7dMNv83OS12CxOQxgtns1Fko6LXqvf_amud8AKzzaj2zcRJZtslo/s400/Screen+Shot+2019-09-15+at+10.03.20+PM.png" width="400" /></a></div>
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Pumping in the car (or on a commute) can be a game changer to ensure you start the shift at time 0, effectively resetting the clock until your next pump.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgViRQVgRDp4NGRqk7mTFbytCDpRK9X7i8bPVEuq13D87MA22JvxTsKwOIVvUTcgbNPH3n18ZpwixOXG8_AJuVcj6vmgEQvLfU-s7R36x35DrGx4KzzhcEJcQp8gnBYgMquL06Cs_2ZcPs/s1600/Screen+Shot+2019-09-16+at+2.56.06+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1200" data-original-width="1600" height="298" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgViRQVgRDp4NGRqk7mTFbytCDpRK9X7i8bPVEuq13D87MA22JvxTsKwOIVvUTcgbNPH3n18ZpwixOXG8_AJuVcj6vmgEQvLfU-s7R36x35DrGx4KzzhcEJcQp8gnBYgMquL06Cs_2ZcPs/s400/Screen+Shot+2019-09-16+at+2.56.06+PM.png" width="400" /></a></div>
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Pumping on a single coverage shift may seem impossible but it is do-able. One of the most important things is discussing this with your team. Some techs and RNs may feel comfortable coming to you with ECGs or patient updates while pumping, others may prefer to call. Establish a game plan ahead of time.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYQZV3pPt8Qe0tqhLb0vdgSW_BJpNYcvUWrsyRdsLM_DjxvTW1qIYAbD9dTBv_v4qjqTWRrtNiVKgDL9H9MQtGGtBW-SeTHg2cqXjrstdICSUq1KI2zYs4YA9lQfTADAcHsPGpvFWaec4/s1600/Screen+Shot+2019-09-16+at+2.58.59+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1188" data-original-width="1600" height="296" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYQZV3pPt8Qe0tqhLb0vdgSW_BJpNYcvUWrsyRdsLM_DjxvTW1qIYAbD9dTBv_v4qjqTWRrtNiVKgDL9H9MQtGGtBW-SeTHg2cqXjrstdICSUq1KI2zYs4YA9lQfTADAcHsPGpvFWaec4/s400/Screen+Shot+2019-09-16+at+2.58.59+PM.png" width="400" /></a></div>
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Know that being able to pump at work is a legal right in the United States and that the American College of Emergency Physicians (ACEP) released a statement in 2013 supporting workplace support for lactating clinicians. </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9VJ77jOIGjduy6p3Md4Af7HfCuD4V4aEdBaYG9D6WUTFOl0TLq-m3frPfvoRQ2nOSFVrt8ZTAgKs9q62IMkQo5g_IGY1RcGca9iYY5tMB5vnYsbcs7CK4OmmhZ4jbNKmbUKzWIJvBG5A/s1600/Screen+Shot+2019-09-16+at+3.20.55+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="858" data-original-width="1600" height="171" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9VJ77jOIGjduy6p3Md4Af7HfCuD4V4aEdBaYG9D6WUTFOl0TLq-m3frPfvoRQ2nOSFVrt8ZTAgKs9q62IMkQo5g_IGY1RcGca9iYY5tMB5vnYsbcs7CK4OmmhZ4jbNKmbUKzWIJvBG5A/s320/Screen+Shot+2019-09-16+at+3.20.55+PM.png" width="320" /></a></div>
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Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com0tag:blogger.com,1999:blog-6248057085226614935.post-47737701612594238982019-03-23T20:21:00.004-05:002019-03-24T17:05:08.854-05:00Risk Adjusted Dimer in the Workup of Pulmonary Embolism in Pregnancy<div dir="ltr" style="text-align: left;" trbidi="on">
<b><u>The Gist</u></b>: Use of the <a href="https://www.mdcalc.com/years-algorithm-pulmonary-embolism-pe" target="_blank">YEARS algorithm</a> in pregnant patients with possible pulmonary embolism (PE) appears safe and results in fewer computed tomographic pulmonary angiograms (CTPAs), particularly in low-prevalence testing environments [1]. Given the natural course of d-dimer throughout pregnancy, gestation adjusted versions of this algorithm may better curb overtesting.<br />
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The workup of pregnant patients for suspected pulmonary embolism is challenging for some of the following reasons:<br />
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<li>Risk of ionizing radiation to the fetus.</li>
<li>Risk of ionizing radiation to maternal breast tissue.</li>
<li>Hormones during pregnancy thought to place pregnant patients at higher risk for venous thromboembolism.</li>
<li>The d-dimer is known to increase throughout pregnancy making this test difficult to interpret or useless based on one's approach. A study by Murphy et al found a steady rise in median d-dimer values in healthy pregnant patients throughout pregnancy. This group found that the median d-dimer in pregnant patients crossed the threshold for non-pregnant patients prior to 20 weeks of gestation [2].</li>
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Researchers are tackling this issue with various algorithms. In October 2018, <a href="https://shortcoatsinem.blogspot.com/2018/10/pulmonary-embolism-workup-in-pregnancy.html" target="_blank">Righini and colleagues published an algorithm</a> rooted in the Geneva Score which would have resulted in fewer CTs. Now, van der Pol and colleagues have published the results of using the YEARS algorithm in pregnant patients. The article is summarized below but briefly, this protocol was implemented in ED and OB units at several centers in Europe and patients were followed up. The results demonstrated safety in this population with overall low prevalance of PE (4% overall).<br />
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<b>YEARS in Pregnancy Study Protocol</b></div>
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Notably, a standard YEARS approach to testing for PE in the pregnant patient results in imaging many patients for PE who do not have the disease in question due to the standard trajectory of d-dimer in a healthy pregnant patient. Additionally, the YEARS criteria represent a modified Wells criteria with the most commonly positive criteria being "PE is the most likely diagnosis." Many providers find this criterion frustrating. Future approaches may examine the effects of a gestation adjusted version of the YEARS algorithm. Yet, in the era of overtesting for PE in pregnant patients, use of this algorithm may reduce imaging in these patients.<br />
<span style="font-size: x-small;"><br /></span> <span style="font-size: x-small;">References: </span><br />
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<span style="font-size: x-small;"><span style="text-indent: -42.6667px;">1. van der Pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med. 019;380(12):1139–49. </span>1. </span></div>
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<span style="font-size: x-small;">2. Murphy N, Broadhurst D, Khashan A, Gilligan O, Kenny L, O ’donoghue K. Gestation-specific D-dimer reference ranges: a cross-sectional study. BJOG. 2015;122:395–400. </span></div>
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<span style="font-size: x-small;">3. Righini M, Robert-ebadi H, Elias A, Sanchez O, Moigne E Le. Diagnosis of Pulmonary Embolism During Pregnancy. Annals of Internal Medicine. 2018;</span></div>
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<span style="font-size: x-small; text-indent: -42.6667px;">4. Kline J a, Richardson DM, Than MP, Penaloza A, Roy P-M. Systematic Review and Meta-analysis of Pregnant Patients Investigated for Suspected Pulmonary Embolism in the Emergency Department. Acad Emerg Med. 2014;21(9):949–59. </span></div>
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Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com0tag:blogger.com,1999:blog-6248057085226614935.post-32319592545396414092019-03-07T09:06:00.001-06:002019-03-07T09:06:12.637-06:00Slaying Pre-historic Practice: Epinephrine in OHCA<div dir="ltr" style="text-align: left;" trbidi="on">
<b><u>The Gist:</u></b> For nearly 15 years, the American Heart Association (AHA) Guidelines have stated epinephrine in out of hospital cardiac arrest (OHCA) is reasonable, not that it is standard of care to administer epinephrine routinely [1-3]. A large randomized controlled trial recently confirmed that while epinephrine increases the return of spontaneous circulation (ROSC), it may do so at the expense of a good neurologic outcome [4]. We likely believe we should administer epinephrine routinely because of difficulties <b style="text-align: center;"><a href="https://shortcoatsinem.blogspot.com/2014/02/the-unlearning-process.html" target="_blank">unlearning</a></b> low-value practices.<br />
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Administration of epinephrine 1mg every 3-5 minutes is ubiquitous in OHCA. In fact, the pocket algorithm card included in the AHA guidelines merely lists "Epinephrine q 3-5 minutes." The AHA guidelines, however, give epinephrine a relatively low-level recommendation (Class IIb) and merely state it is "<i>reasonable to consider</i>" using epinephrine in OHCA.<br />
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A recent randomized controlled trial, the PARAMEDIC-2 trial, is the largest trial comparing epinephrine with placebo in OHCA. This trial brought renewed attention to the debate as to whether to administer epinephrine routinely in OHCA as patients survived more frequently with epinephrine but did not achieve better neurologically favorable survival [4]. The study was not powered to detect differences in neurologic survival, which may be difficult to do given the low numbers with a favorable outcome; however, does demonstrate this continued trend toward reviving the heart at the expense of the brain.</div>
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<b>Why do we have a difficult time <a href="https://shortcoatsinem.blogspot.com/2014/02/the-unlearning-process.html" target="_blank">unlearning</a> that epinephrine is "standard of care" in OHCA?</b></div>
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<b>We rarely read the guidelines in depth.</b></div>
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The pocket algorithm card lists "Epinephrine q 3-5 minutes" and does not go into details about the risks and benefits of epinephrine administration. Guidelines are often long, cumbersome and difficult to read so we rely upon the synopses provided in simplified algorithms or on the simplified distillation by others.</div>
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<b>It's harder to unlearn NOT to do something than it is to add something to our repertoire.</b></div>
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Many of us have a bias towards action, particularly in resuscitation. We want to save patients, we want to do whatever we can. In OHCA, survival is poor with a mere 2-10% survival and often depends on shockable rhythm, etiology, and defibrillation [4,5]. Epinephrine may give us the satisfaction of feeling as though we are doing something in a typically futile situation.</div>
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<b>We may be less likely to fear the consequences when they aren't proximate to our intervention.</b></div>
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We often don't see the downstream consequences that happen after achievement of ROSC in the emergency department - including poor neurologic function.</div>
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References:<br />
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<span style="font-size: x-small;">1. ILCOR. Part 4: Adult Cardiac Life Support. Circulation. 2005 Nov 28;112(24_suppl). Available from: http://circ.ahajournals.org/cgi/doi/10.1161/CIRCULATIONAHA.105.170809</span></div>
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<span style="font-size: x-small;">2. Neumar RW, Callaway CW, Sinz E, Davis D, Otto CW, McNally B, et al. Part 8: Adult Advanced Cardiovascular Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18_suppl_3):S729–67. </span></div>
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<span style="text-indent: -32pt;"><span style="font-size: x-small;">3. Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, et al. Part 7: Adult advanced cardiovascular life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18):S444–64. </span></span></div>
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<span style="font-size: x-small;">4. Perkins G, Ji C, Deakin C, Quinn T, et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018;</span> </div>
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<span style="font-size: x-small;">5. Benjamin EJ, Virani SS, Callaway CW, et al. Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association. Circulation. 2018; 137(12)</span></div>
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Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com0tag:blogger.com,1999:blog-6248057085226614935.post-55210711834585075672018-11-02T11:03:00.001-05:002018-11-02T11:03:34.170-05:00Droperidol vs ondansetron vs placebo for nausea <div dir="ltr" style="text-align: left;" trbidi="on">
<b><u>The Gist:</u></b> In the United States, droperidol has been hard to come by in many locations for years. Many lament the loss for a myriad of indications - agitated delirium, nausea, vomiting, and migraines. <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/acem.13650" target="_blank">Meek et al </a>found that in nauseated emergency department (ED) patients, droperidol 1.25 mg IV did not outperform ondansetron 8 mg IV or placebo IV in a randomized, blinded trial in 3 Australian EDs [1]. Common anti-emetics or placebo, reduce nausea scores by similar amounts; however, more patients receiving ondansetron or droperidol reached the desired effect and did not receive rescue medications.<br />
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Nausea is a common condition in the emergency department; yet ED-based studies of anti-emetics have not found consistent benefit [2-5]. Droperidol received a <a href="https://shortcoatsinem.blogspot.com/2012/12/not-black-boxed-droperidol-as-anti.html" target="_blank">controversial black box warning</a> in the US in 2001 after 71 adverse events were reported on a single day. Since that time, many providers have lamented to lack of availability of droperidol in the US and thought...this would be the clear winner for our nauseated patients. Hence Meek and colleagues aimed to settle the debate as to whether any of these drugs were superior to placebo in nauseated ED patients. Details pictured below.<br />
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Unfortunately, this trial leaves several questions unanswered. It's not all bad news in anti-emetic therapy. Recent trials of inhaled isopropyl alcohol have been promising and this intervention appears to be more effective than oral ondansetron alone [6,7]. It's uncertain how long these effects last and how this therapy would perform compared with intravenous therapies.<br />
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References:<br />
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<li>Meek R, Mee MJ, Egerton-Warburton<span style="font-family: inherit;"> D, et al. Randomized placebo-controlled trial of droperidol and ondansetron for adult emergency department patients with nausea. Acad Emerg Med. 2018</span>;In<span style="font-family: inherit;"> Press. </span>doi<span style="font-family: inherit;">: 10.1111/acem.13650 </span></li>
<li>Braude D, Soliz T, Crandall C, Hendey G, Andrews J, Weichenthal L. Antiemetics in the ED: a randomized controlled trial comparing 3 common agents. Am J Emerg Med 2006; 24: 177–82. </li>
<li>Barrett TW, DiPersio DM, Jenkins CA et al. A randomized, placebo-controlled trial of ondansetron, metoclopramide, and promethazine in adults. Am J Emerg Med 2011; 29: 247– 55.</li>
<li>Egerton-Warburton D, Meek R, Mee MJ, Braitberg G. Antiemetic use for nausea and vomiting in adult emergency department patients: randomized<span style="font-family: inherit;"> controlled trial comparing ondansetron, metoclopramide, and placebo. Ann Emerg Med 2014; 64: 526–32.</span></li>
<li>Furyk JS, Meek R, Egerton-Warburton D. Drugs for the treatment of nausea and vomiting in adults in the emergency department setting (Review). Cochrane Database Syst Rev 2015: CD010106. </li>
<li>Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2016;68(1):1-9.e1.</li>
<li>April MD, Oliver JJ, Davis WT, et al. Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial. Ann Emerg Med. 2018;</li>
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Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com0tag:blogger.com,1999:blog-6248057085226614935.post-83688323447409137232018-10-24T14:47:00.000-05:002018-10-29T13:49:44.484-05:00Pulmonary Embolism Workup in Pregnancy: Is D-dimer a Thing?<div dir="ltr" style="text-align: left;" trbidi="on">
<b><u>The Gist</u></b>: D-dimer rises during pregnancy and few patients will have a normal d-dimer by the third trimester. However, integration of d-dimer into a diagnostic algorithm for pulmonary embolism (PE) could reduce the need for CT scan by ~11% [1]. The next step - gestational age adjusted d-dimers.<br />
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The workup of pregnant patients for PE is complicated. Pregnancy is considered a risk factor for PE. However, the algorithms and risk stratification tools widely used excluded pregnant patients in the development phase. Additionally, the use of the d-dimer in pregnancy is controversial in pregnancy. It's known that the d-dimer rises through pregnancy, making the utility questionable. While some have attempted to determine gestational age adjusted d-dimer cut offs and one expert recommends a first trimester cutoff of 750 ng/mL, a second trimester, cutoff of 1000 ng/mL, and a third trimester cut off of 1250 ng/mL, this has not been formally studied in PE[2,3]. Further, the risks of the objective tests in the patients may be greater due to radiation to the fetus and maternal breast tissue.<br />
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A group in Switzerland (also the creators of the Geneva Score) tested an algorithm on nearly 400 patients which appears promising. See algorithm and study summary below. Further research will be needed to ascertain if an elevated dimer cut-off based on gestational week can be used and if another risk stratification tool performs better in this population. For example, the Revised Geneva has age >65, which is essentially incompatible with pregnancy as well as heart rate cut offs of >75 or >95 beats per minute, when the average heart rate in pregnancy rises to >90 beats per minute.<br />
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Reference:</div>
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<span style="font-family: inherit; text-align: center;">1. Righini M et al. </span><span style="font-family: inherit; text-align: center;">Diagnosis of Pulmonary Embolism During Pregnancy.</span><span style="font-family: inherit; text-align: center;"> Ann Internal Med. 2018; In press. doi: 10.7326/M18-1670</span></div>
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<span style="font-family: inherit; text-align: center;">2. </span>Murphy N, Broadhurst D, Khashan A, Gilligan O, Kenny L, O ’donoghue K. Gestation-specific D-dimer reference ranges: a cross-sectional study. BJOG . 2015;122:395–400. </div>
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3. Kline JA, Kabrhel C. Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach. J Emerg Med. 2015;49(1):104-17.</div>
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Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com0tag:blogger.com,1999:blog-6248057085226614935.post-11725421362563421502018-08-01T09:27:00.003-05:002018-09-07T08:09:53.412-05:00Breastfeeding and Alcohol: A sensational but flawed study in Pediatrics<div dir="ltr" style="text-align: left;" trbidi="on">
<b><u>The Gist</u></b>: A recent study by <a href="http://pediatrics.aappublications.org/content/early/2018/07/26/peds.2017-4266?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token" target="_blank">Gibson et al</a> in Pediatrics claims to show a link between cognitive delays and alcohol intake while breastfeeding [1]. Despite wild uptake by lay and medical news outlets, this study is seriously flawed by confounding, multiple comparisons, and inappropriate extrapolation of survey data. As a result, <b>the study findings do not support this conclusion and do not support a causal link between drinking alcohol while breastfeeding and cognitive delays.</b> Breastfeeding while inebriated may pose risks due to safely handling the baby and safe sleeping, but unlikely from the alcohol contained within the breastmilk in otherwise healthy term babies. Further, high-risk alcohol use (binge drinking, dependence) may be associated with other factors that could potentially influence the cognitive and emotional development of children. However, this study only shows our obsession with p values and statistical significance.<br />
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Gibson et al hypothesized that alcohol use during lactation would be associated with lower cognitive scores in children [1]. The lead author has said, "it suggests that there is no safe level of alcohol for a breastfeeding mother to drink" [2]. However, the study does not actually suggest this. An overview of the study can be found in the graphic above.<br />
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<b>1. Misunderstanding the term breastfeeding</b><br />
<b>The authors inappropriately describe "drinking while breastfeeding." Consuming alcohol while lactating is not the same as drinking while breastfeeding, although it is unlikely that either have clinical significance in most scenarios.</b> The <a href="https://growingupinaustralia.gov.au/data-and-documentation/study-questionnaires" target="_blank">questionnaire</a> administered at Wave 1 asked about general current alcohol intake and whether or not the infant was breastfed (in general). They did not ask about the specific timing of drinking, not that this necessarily matters. Further, the authors did not measure alcohol concentration in the milk they were feeding their infants, which would really be the only way to demonstrate causation (which would be an impossible study to conduct, yet the authors used the word "cause" in the manuscript).<br />
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Alcohol intake during breastfeeding has been controversial as it is known that alcohol does transfer into breast milk [2]. Official recommendations are to refrain from drinking while breastfeeding or limit to 1 drink per day based on this notion [3]. However, the amount of alcohol an infant would ingest is minimal as the percentage of alcohol in the breastmilk approximates that of the mother's blood alcohol level (or approximately 5% of the intake) [2]. Further, milk production and composition is a dynamic process such that when an individual is no longer inebriated, the breastmilk does not contain alcohol [2]. As such consuming alcohol and directly feeding the baby at the time of peak ethanol effects is different than consuming alcohol at a time period when the mother is not feeding the baby (ex: immediately after nursing or at night).<br />
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<b>2.</b> <b>Multiple comparisons</b><br />
Only one transient, statistically significant association<b> </b>was found, as seen below. Children who were ever breastfed, the bulk of whom were not being breastfed at the time the alcohol questionnaire was administered (~age 9.7 months), with mothers who had scores associated with high or risky alcohol consumption performed less well on the Matrix Reasoning subtest of the Wechsler Intelligence Scale at Wave 4 (~age 7) but not Wave 5 (~age 10). The more comparisons, the greater likelihood of finding a positive association due to chance. While these authors did use the Benjamini and Hochberg procedure to control the false discovery rate (proportion of false positives), the bulk of the data including the vocabulary test and the early literacy/numeracy tests do not support this association.<br />
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<b><br /></b> <b>3. Data dredging: p-value without clinical significance</b><br />
Researchers have an obsession with <a href="https://shortcoatsinem.blogspot.com/2016/05/p-values-everything-you-know-is-wrong.html" target="_blank">p values</a>. This study had greater than 99% power to detect a small effect size. Even with this power, the study did not detect an association in 6 of the 7 time-outcome combinations they evaluated. Yet,the authors focused on the single statistically significant association that was not found on follow up tests (i.e. a child whose mom had ever breastfed them and engaged in high/risky alcohol use at Wave 1 performed less well on the matrix reasoning test at Wave 4 but performed on par with peers at Wave 5). Additionally, if it were the alcohol that resulted in the lower scores, we would expect to see the same (or greater) results in infants who were currently being breastfed.<br />
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Even if this association was real rather than a statistical anomaly, the kids who were being breastfed at the time of the alcohol questionnaire had no measurable deleterious cognitive outcome at follow up.<br />
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<b>4. Lack of an adequate control group and missing data. </b><br />
Just over 8% of infants were classified as "never breastfed." This is a tiny group with few expected outcomes. Additionally, this cohort had significant missing data, notably 17.2% missing data for alcohol consumption.<br />
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Most physicians lack significant training regarding the care of lactating patients and advice regarding "pumping and dumping" (pumping and discarding milk instead of feeding it to the baby) is rampant, even when medications are safe in lactating patients [3]. For example, as recently as 2017 major anesthesia texts recommended empiric "pumping and dumping" for 24 hours following anesthesia [4,5]. Studies such as the one by Gibson et al, which has been picked up by news outlets, only serve to increase fears without actually contributing meaningfully to the knowledge base [1]. It is time to move from the overly cautious approach to the lactating woman to a reasonable, evidence-based approach in order to support breastfeeding without creating hysteria amongst parents.<br />
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<span style="font-size: x-small;">References: </span><br />
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<ol style="text-align: left;">
<li><span style="font-size: x-small;">Gibson L and Porter M. <a href="http://pediatrics.aappublications.org/content/pediatrics/early/2018/07/26/peds.2017-4266.full.pdf" target="_blank">Drinking or Smoking While Breastfeeding and Later Cognition in Children</a>. Pediatrics; In Press.</span></li>
<li><span style="font-size: x-small;">Rapaport L. Drinking while breastfeeding tied to cognitive problems in young kids. July 31, 2018. https://www.mdlinx.com/internal-medicine/top-medical-news/article/2018/07/31/7539902</span></li>
<li><span style="font-size: x-small;">Haastrup MB, Pottegård A, Damkier P. Alcohol and breastfeeding. Basic Clin Pharmacol Toxicol. 2014;114(2):168-73</span></li>
<li><span style="font-size: x-small;">CDC. "Alcohol." https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/vaccinations-medications-drugs/alcohol.html</span></li>
<li><span style="font-size: x-small;">Cobb B, Liu R, Valentine E, Onuoha O. Breastfeeding after Anesthesia: A Review for Anesthesia Providers Regarding the Transfer of Medications into Breast Milk. Transl Perioper Pain Med. 2015;1(2):1-7</span></li>
<li><span style="font-size: x-small;">Dodd SE, Sharpe EE. Pump and Dump; Anesthesiologists Lead the Feed. Anesthesiology. 2018;128(5):1046-1047.</span></li>
<li><span style="font-size: x-small;">Wijeysundera D, Sweitzer BJMiller RDPreoperative Evaluation, Miller’s Anesthesia. 2015, pp 8th Edition. Edited by Elsevier, 1085–1155</span></li>
</ol>
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Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com1tag:blogger.com,1999:blog-6248057085226614935.post-22687945332086914092017-09-13T12:45:00.000-05:002017-09-13T14:30:02.738-05:00Quarterly Literature Update - September 2017<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="background-color: transparent; color: black; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Do abscesses need antibiotics after incision & drainage (I&D)</span></div>
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<span style="background-color: transparent; color: black; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Two recent studies have rendered many with the conclusion that antibiotics improve cure and recurrence rates when added to I&D. </span><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1507476#t=article" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;"> Talan et al </span></a><span style="background-color: transparent; color: black; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">randomized people with abscesses after I&D to TMP-SMX or placebo and found improved clinical cure rates in the TMP-SMX group (80.5% vs 73.6%). This year, </span><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1607033" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Daum et al</span></a><span style="background-color: transparent; color: black; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> randomized patients to TMP-SMX, clindamycin, or placebo after I&D and specifically looked at small abscesses (<5 cm) and again found higher rates of 10-day clinical cure in patients receiving antibiotics (TMP-SMX 83.1%, Clindamycin 81.7%, Placebo 68.9%). Many people have pushed the idea that all abscesses need antibiotics after drainage based on these studies. However, these studies included patients with significant surrounding cellulitis (on average, >25 cm</span><span style="background-color: transparent; color: black; font-family: "times new roman"; font-size: 7.199999999999998pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: super; white-space: pre-wrap;">2</span><span style="background-color: transparent; color: black; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">) and most recommendations have historically recommended antibiotics to those with more than a 5 cm diameter of surrounding cellulitis</span></div>
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<li><span style="color: #333333; font-family: "times new roman"; font-size: 12pt; font-weight: 700; vertical-align: baseline; white-space: pre-wrap;">Bottom Line</span><span style="color: #333333; font-family: "times new roman"; font-size: 12pt; vertical-align: baseline; white-space: pre-wrap;">: After I&D of an abscess, give antibiotics if there is >5 cm diameter of surrounding cellulitis (~30 cm2 total). We probably do not need to do this if less cellulitis.</span></li>
<li style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><b>Stats/Study Design point:</b></span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> With any study check out the baseline/demographics table and ask - are these patients like my patients. </span></li>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiXxu8BwJrAHvWc8Nx8XW2hA76PNXmZ-NL0yiJHNd1HpZiJITC5gakpObfzRqiAGi_cCmrr_UjmO3cHIXmXcjeQla9eGNIGlAHBjmyfWm2lH9u8OGJAIS1xgb3Q69IUw-0L2_UCRjZY578/s1600/Screen+Shot+2017-09-13+at+11.30.40+AM.png" imageanchor="1" style="font-size: 12pt; margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1150" data-original-width="1536" height="239" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiXxu8BwJrAHvWc8Nx8XW2hA76PNXmZ-NL0yiJHNd1HpZiJITC5gakpObfzRqiAGi_cCmrr_UjmO3cHIXmXcjeQla9eGNIGlAHBjmyfWm2lH9u8OGJAIS1xgb3Q69IUw-0L2_UCRjZY578/s320/Screen+Shot+2017-09-13+at+11.30.40+AM.png" width="320" /></a></div>
<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">FAST is fast, but is it good?</span></div>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The FAST exam, initially developed to assess for free fluid in unstable trauma patients, is widely used and may be an area where indication creep (i.e. we start expanding the indication for it) has really taken hold.</span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> </span><a href="http://jamanetwork.com/journals/jama/article-abstract/2631528" style="text-decoration: none;"><span style="background-color: white; color: #1155cc; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Holmes et al</span></a><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> performed an RCT on 945 stable pediatric blunt trauma patients who were randomized to standard trauma evaluation + FAST or just a standard trauma evaluation. There was no difference in rates of CT scans (~50% in each arm), missed intra-abdominal injuries (n=1 in FAST arm), or hospital charges. Even things like length of stay and hospitalization rates were about the same between groups.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6vxhUhZdfs5H0e92CuDrqZEsEatEmT8JFhprZVJ3U7uWbNZTthPtZnF0HnU3v7RW-bKkbobJlUSFsz2nl4HRXsaxlM5esJJCQc1UeYSO28g85fBLVQk8YQRSZBuNIQ0JBqrPT6MUhmy8/s1600/Screen+Shot+2017-09-13+at+11.39.25+AM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1000" data-original-width="1600" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6vxhUhZdfs5H0e92CuDrqZEsEatEmT8JFhprZVJ3U7uWbNZTthPtZnF0HnU3v7RW-bKkbobJlUSFsz2nl4HRXsaxlM5esJJCQc1UeYSO28g85fBLVQk8YQRSZBuNIQ0JBqrPT6MUhmy8/s320/Screen+Shot+2017-09-13+at+11.39.25+AM.png" width="320" /></a></div>
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<li style="background-color: white; color: #333333; font-family: 'Times New Roman'; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Bottom Line</span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">: Keep FASTing trauma patients who are unstable or borderline unstable and management may change based on the FAST results (i.e. thoracotomy or OR). Find a negative FAST on a trauma patient? That’s called a false sense of security.</span></div>
</li>
<li style="background-color: white; color: #333333; font-family: 'Times New Roman'; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span style="color: #333333; font-family: "times new roman"; font-size: 12pt; vertical-align: baseline;"><b>Stats/Study Design point:</b></span><span style="color: #333333; font-family: "times new roman"; font-size: 12pt; vertical-align: baseline;"> Beware of indication creep (using a test in patients it was not originally designed or validated in - this can change parameters such as sensitivity and specificity)</span></span></li>
</ul>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt; text-align: center;">
<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">A magic sepsis cocktail?</span></div>
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<a href="https://www.ncbi.nlm.nih.gov/pubmed/27940189" style="text-decoration: none;"><span style="background-color: white; color: #1155cc; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Marik et al</span></a><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> have made a wave in public media for a magic sepsis cocktail of vitamin C, hydrocortisone, and thiamine. In this paper, they published their findings of a paltry 47 patients who underwent treatment and report an incredible mortality reduction in the cocktail arm (8.5 % 4/47 vs 40.4% 19/47). The primary author, very well respected in the sepsis/critical care community, has argued that this treatment should be adopted immediately because prior studies show biological plausibility. However, this is a supremely tiny hypothesis generating study subject to incredible bias (</span><a href="http://thesgem.com/2017/04/sgem174-dont-believe-the-hype-vitamin-c-cocktail-for-sepsis/" style="text-decoration: none;"><span style="background-color: white; color: #1155cc; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">see this podcast</span></a><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">) due to no blinding and other factors. Further, prior studies of individual components (ex: steroids) have been negative. </span></div>
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<li dir="ltr" style="background-color: white; color: #333333; font-family: 'Times New Roman'; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Bottom Line</span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">: Vitamin C, hydrocortisone, thiamine is an inexpensive and relatively benign therapy; however, a single retrospective study of 47 patients cannot inform us of efficacy or harm. Medicine is rife with examples of adopting therapies too early because they look promising based on terrible studies only to later find out that they don’t work. Further studies will be needed to determine whether or not this practice should be adopted. </span></div>
</li>
<li dir="ltr" style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><b>Stats/Study Design pearl</b></span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">: Before/after studies are subject to significant bias and confounding. In this study we worry about the lack of blinding as all providers and patients knew what they were getting and that there was this new "life saving" cocktail - perhaps this could have influenced other care.</span></li>
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<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Haloperidol HUGS and Love</span></div>
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<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Gastroparesis and cyclic vomiting patients are frustrating and often their medication allergy lists are extensive. Enter haloperidol, a butyrophenone antipsychotic (dopamine antagonist), a sister medication of droperidol. </span><a href="https://www.ncbi.nlm.nih.gov/pubmed/28646590" style="text-decoration: none;"><span style="background-color: white; color: #1155cc; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Roldan et al</span></a><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> randomized 15 patients with gastroparesis to 5 mg IV haloperidol + conventional treatment and 18 patients to conventional treatment alone. Pain and nausea dropped from 8.5/10 to 1.83 (pain) and 4.53/10 to 1.83 (nausea) at 1 hour in the haloperidol group compared with a drop from 8.28 to 7.17 (pain) and 4.11 to 3.39 (nausea) in the placebo group. Another small, not especially well done observational study, termed HUGS, by </span><a href="https://www.ncbi.nlm.nih.gov/pubmed/28320545" style="text-decoration: none;"><span style="background-color: white; color: #1155cc; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Ramirez et al</span></a><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> echo these findings.</span></div>
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<li dir="ltr" style="background-color: transparent; color: #333333; font-family: 'Times New Roman'; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Bottom Line</span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">: These studies aren't necessarily practice changing but correlate with significant prior literature for pain and nausea treatment in migraines and in the anesthesia literature.It’s worth a shot to try haloperidol 2.5-5 mg IV in patients with gastroparesis (or even cyclic vomiting/cannabinoid hyperemesis although this is based on case series). It's nice to have literature out there saying "hey, this is a thing we are doing."</span></div>
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<li dir="ltr" style="background-color: transparent; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><b>Stats/Study Design Pearl</b></span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">: Size does matter when it comes to the methods section. In a retrospective study you should be able to replicate the study by reading the methods. The Ramirez study had a paltry 11 sentences. </span></li>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt; text-align: center;">
<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">PERC</span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> - </span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><b>Love it but ignore it?</b></span></div>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">It’s well accepted that in a patient with low pretest probability (15% or less, i.e. Low Risk by Wells Criteria), we can rule out pulmonary embolism (PE) using the PERC criteria. The miss rate using this approach is <2%, which is the cut point where further workup and treatment would cause more harm than good (test-treatment threshold). Apparently, we suck at actually following this evidence based approach according to a prospective observational study by </span><a href="https://www.ncbi.nlm.nih.gov/pubmed/28787100" style="text-decoration: none;"><span style="background-color: white; color: #1155cc; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Buchanan et al </span></a><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">of patients with chest pain and/or shortness of breath looked at PE testing rates in PERC negative patients. Over 25% of patients who were PERC negative underwent further PE testing and 7.2% went straight to CTPA or V/Q, skipping the d-dimer.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYY61-RyCHLMJGmzBEI90FqPW4w1BB5wziRIPfKsazrX-9hBSBMzwNBO3kenE6rzsxL9cre9CnO2oSakmwhCDXMBhH5GK9tEHbyriWbg89wUGLSqkTXfl-ZOiTz4tmadTQu0dnSy55nbw/s1600/Screen+Shot+2017-09-13+at+1.38.04+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1138" data-original-width="1298" height="280" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYY61-RyCHLMJGmzBEI90FqPW4w1BB5wziRIPfKsazrX-9hBSBMzwNBO3kenE6rzsxL9cre9CnO2oSakmwhCDXMBhH5GK9tEHbyriWbg89wUGLSqkTXfl-ZOiTz4tmadTQu0dnSy55nbw/s320/Screen+Shot+2017-09-13+at+1.38.04+PM.png" width="320" /></a></div>
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<li dir="ltr" style="background-color: white; color: #333333; font-family: 'Times New Roman'; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Bottom Line:</span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> If you think of working up PE, consider the patient’s risk of PE, then think of PERC, and then d-dimer before you jump to CTPA. In low-risk patients (ex: meets Wells Low Criteria) with possible PE that are PERC negative, do not do further testing to assess for PE.</span></div>
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<li dir="ltr" style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><b>Stats/Study Design Pearl</b></span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">: The test-treatment threshold is important. This is the idea that there is a point at which the harms of further workup and treatment of a disease process equal or become greater than harm of not pursuing the test. For PE this has been established at about 1.8%.</span></li>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt; text-align: center;">
<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The End of Apneic Oxygenation?</span></div>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Placing a nasal cannula at 15 LPM (or more) during RSI has become pretty standard practice in many ED rapid sequence intubations (RSI), often deemed apneic oxygenation (ApOx). The ENDAO trial randomized 206 ED patients undergoing RSI who had at least 3 minutes of preoxygenation to ApOx or no ApOx. Nobody was blinded. The study was looking for a difference in lowest mean oxygen saturation before groups, which they did not find (92% vs 93%).</span></div>
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<li style="background-color: white; color: #333333; font-family: 'Times New Roman'; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Bottom Line</span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">: This study, and others like it, are negative, probably because the desaturations we are looking to prevent with ApOx are rare. ApOx may be helpful in difficult intubations or those with poor physiologic parameters who are likely to desaturate, unfortunately, we sometimes don’t know who these people are.</span></div>
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<li><span style="color: #333333; font-family: "times new roman"; font-size: 12pt; vertical-align: baseline; white-space: pre-wrap;"><b>Stats/Study Design Pearl</b></span><span style="color: #333333; font-family: "times new roman"; font-size: 12pt; vertical-align: baseline; white-space: pre-wrap;">: Choice of primary outcome is important. It may seem like a difference in oxygen saturation is clinically important but when oxygen saturations are globally high, this is not going to make a difference to the patient.</span></li>
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<span id="docs-internal-guid-238e8121-7cb7-73b1-f0b9-14d1719f3119"><div style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt; text-align: center;">
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<span style="background-color: white; color: #333333; font-family: "Times New Roman"; font-size: 12pt; font-weight: 700; vertical-align: baseline; white-space: pre-wrap;">Steroids for all that wheezes?</span></div>
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<span style="background-color: white; color: #333333; font-family: "Times New Roman"; font-size: 12pt; vertical-align: baseline; white-space: pre-wrap;">Many patients with lower respiratory tract infections (LRTI), particularly with wheezing, receive empiric steroids, inhaled beta-agonists, and possibly antibiotics (such as azithromycin), yet the evidence behind this is scare in patients without underlying lung disease (asthma/COPD). </span><a href="http://jamanetwork.com/journals/jama/article-abstract/2649201" style="text-decoration-line: none;"><span style="background-color: white; color: #1155cc; font-family: "Times New Roman"; font-size: 12pt; text-decoration-line: underline; vertical-align: baseline; white-space: pre-wrap;">Hay et al</span></a><span style="background-color: white; color: #333333; font-family: "Times New Roman"; font-size: 12pt; vertical-align: baseline; white-space: pre-wrap;"> randomized 401 patients presenting to outpatient clinics with cough and signs of LRTI who had no history of asthma or COPD to either 40 mg prednisolone daily for 5 days or placebo. They found no difference in duration of moderately bad or worse cough (~5 days in each group) or severity of symptoms on days 2-4. Of note, about 40% of the patients in this study were wheezy.</span></div>
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<li dir="ltr" style="background-color: white; color: #333333; font-family: "Times New Roman"; font-size: 12pt; list-style-type: disc; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-size: 12pt; font-weight: 700; vertical-align: baseline; white-space: pre-wrap;">Bottom Line</span><span style="font-size: 12pt; vertical-align: baseline; white-space: pre-wrap;">: Just because a patient with a cough wheezes, it doesn’t mean they will benefit from steroids. Keep giving steroids to patients with flares of asthma and COPD but we can be much more selective in the those without these lung diseases.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt; text-align: center;">
<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Bonus Throwback(Cutting Edge from 2010) - Stop the pulse checks in codes</span></div>
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<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We are <a href="https://shortcoatsinem.blogspot.com/2016/11/slaying-prehistoric-practice-killing.html" target="_blank">terrible at pulse checks</a> - they are inaccurate and insensitive. The pulse check during a code (i.e. after the initial <10 sec pulse check by a healthcare provider to establish arrest) is nowhere in </span><span style="background-color: white; color: #1155cc; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;"><a href="http://circ.ahajournals.org/content/132/18_suppl_2/S444" style="text-decoration: none;">ACLS</a>.</span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> Nada. The </span><a href="http://circ.ahajournals.org/content/122/18_suppl_3/S685" style="text-decoration: none;"><span style="background-color: white; color: #1155cc; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">2010 AHA Guidelines state</span></a><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">: </span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 13pt; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">"Because of difficulties with pulse assessments, interruptions in chest compressions for a pulse check should be minimized during the resuscitation, even to determine if ROSC has occurred." </span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 13pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The </span><a href="http://circ.ahajournals.org/content/122/18_suppl_3/S729" style="text-decoration: none;"><span style="background-color: white; color: #1155cc; font-family: "times new roman"; font-size: 13pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">ACLS guidelines</span></a><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 13pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> recommend pulse checks during CPR only if an organized rhythm is seen</span></div>
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<li dir="ltr" style="background-color: white; color: #333333; font-family: 'Times New Roman'; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Bottom Line</span><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">: Continue to assess for rhythm changes during CPR - this can take place in 2-3 seconds. There’s no need to stop for a pulse check but you may if you see ETCO2 rise significantly (just be aware it’s not very accurate). You can take a few second ultrasound clip during a rhythm check to assess for cardiac contractility.</span></div>
</li>
</ul>
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<span id="docs-internal-guid-238e8121-7bac-d487-96bf-97074668920f"></span><br />
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<span id="docs-internal-guid-238e8121-7bac-d487-96bf-97074668920f"><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; font-weight: 700; vertical-align: baseline; white-space: pre-wrap;">Bonus Non-Clinical Paper - Boys > Girls?</span></span></div>
<span id="docs-internal-guid-238e8121-7bac-d487-96bf-97074668920f"> </span><br />
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span id="docs-internal-guid-238e8121-7bac-d487-96bf-97074668920f"><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; vertical-align: baseline; white-space: pre-wrap;">There’s been a lot of talk about the gender pay gap, but surely it doesn’t apply to academic emergency medicine, right? Wrong. </span><a href="https://www.ncbi.nlm.nih.gov/pubmed/28779488" style="text-decoration-line: none;"><span style="background-color: white; color: #1155cc; font-family: "times new roman"; font-size: 12pt; vertical-align: baseline; white-space: pre-wrap;">Masden et al</span></a><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; vertical-align: baseline; white-space: pre-wrap;"> used 2015 survey data from full-time faculty academic emergency physicians and found that women made > $19,000 less than men. You may say that doesn’t account for rank, fellowship status, administrative roles, location, clinical hours, etc. But again, that would be incorrect. That gap was after adjusting for all of these potential confounders.</span></span></div>
<ul style="text-align: left;"><span id="docs-internal-guid-238e8121-7bac-d487-96bf-97074668920f"><span style="background-color: white; color: #333333; font-family: "times new roman"; font-size: 12pt; vertical-align: baseline; white-space: pre-wrap;">
<li><span style="color: #333333; font-family: "times new roman"; font-size: 12pt; font-weight: 700; vertical-align: baseline;">Bottom Line</span><span style="color: #333333; font-family: "times new roman"; font-size: 12pt; vertical-align: baseline;"><span style="font-weight: 700;">: </span>Women make less than men in academic emergency medicine. Transparency and awareness may help so share the paper with your colleagues and chairs and don’t be afraid to negotiate.</span></li>
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Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com5tag:blogger.com,1999:blog-6248057085226614935.post-76515078889417942862017-05-29T21:05:00.000-05:002017-05-29T21:05:01.391-05:00An ED Model for Shared Decision Making<div dir="ltr" style="text-align: left;" trbidi="on">
<u><b>The Gist</b></u>: Shared decision making (SDM) is increasingly common in the ED, yet most people, particularly trainees, are untrained in this area. A proposed framework in an <i>Annals of Emergency Medicine</i> article by <a href="http://www.annemergmed.com/article/S0196-0644(17)30359-1/fulltext" target="_blank">Probst et al</a> proposes a framework to guide clinicians (or train them) in the implementation of SDM in the busy ED and combats common misconceptions regarding SDM.<br />
<ol style="text-align: left;">
<li>Ask yourself: is this clinical scenario appropriate for SDM - is there clinical uncertainty or equipoise, is the patient capable of engaging in SDM, and is there time?</li>
<li>Have the conversation - Acknowledge that a decision needs to be made and share information about the risks and benefits of each option. Explore the patient's values and circumstances to help come to a decision.</li>
</ol>
<b><u>The Case</u></b>: The nurses give you a heads up the next patient to be seen is in a lot of pain. You see a 25-year-old healthy male who is doing the “kidney stone dance” – pacing around the room while holding an emesis basin. He's had left flank pain for the past two hours, nausea, but has a reassuring abdominal exam with minimal tenderness. His urinalysis shows red cells in the urine and he's feeling better after analgesia. What's next - CT scan? Ultrasound? Discharge with neither?<br />
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<div style="text-align: center;">
<b>An SDM in the Emergency Department Framework from the <a href="http://www.annemergmed.com/article/S0196-0644(17)30359-1/fulltext" target="_blank">Probst et al <i>Annals</i> article</a></b></div>
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<b>1. Is this scenario appropriate for SDM? </b><br />
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<ul style="text-align: left;">
<li><b>Is there more than one reasonable option at this time?</b></li>
</ul>
The current literature regarding renal colic in the ED supports multiple options as the next reasonable<br />
<b></b><br />
<div style="display: inline;">
step [1-5].<span style="background-color: white; font-family: Times, serif; font-size: 13.5pt; vertical-align: super;"> </span>Non-contrast CT scan is the historic option; yet, recent evidence supports ultrasound as a reasonable next step, and an ultrasound-first diagnostic plan might decrease radiation exposure for this young patient [2]. Experts have also argued that renal colic can be diagnosed clinically, and imaging is not necessary in classic cases with low probability of dangerous alternative diagnoses [1]. The trade-offs between these options might be important to this patient; if he’s feeling better or concerned about lifetime radiation risk, he may not want to wait for a CT scan, and conversely, if he’s about to set off hiking the Appalachian Trail, he may want to know the location and size of his stone. </div>
<b>
</b>Obviously, there are clinical reasons why some cases of suspected renal colic warrant CT scans – fever, concern for an alternate diagnosis, or solitary kidney [6].<br />
<ul style="text-align: left;">
<li><b>Is the patient able to make his own medical decisions? </b></li>
</ul>
While this patient may know little about the trade-offs involved in the clinical question, research has<br />
shown that patients do want to be told about the risks of radiation prior to CT scans [7]. This patient isn't altered or otherwise incapacitated - he can participate in decision making.<br />
<ul style="text-align: left;">
<li><b>Do you have time? Does your patient have time?</b></li>
</ul>
The latter question is easy to answer: unless he’s eloped because he’s feeling better, your patient<br />
clearly has time to have this conversation. Whether you have time depends on the severity of other patients’ conditions and your ability to explain the trade-offs in a manner that he can understand. The more you practice this skill, the better you will be at it, and it’s worth noting that the results of your conversation may speed up his discharge, creating space for another patient and increasing throughput.<br />
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<div style="text-align: left;">
<b>2. Have the conversation (if the answers to the above questions are yes)</b></div>
<ul style="text-align: left;">
<li><b>Acknowledge that a decision needs to be made - </b></li>
</ul>
<i>“I suspect that you have a kidney stone – kidney stones cause severe pain, vomiting, and blood in the urine, all of which you had. At this point, we have to decide if it makes sense to do some more imaging.”</i><br />
<ul style="text-align: left;">
<li><b>Share Information in Regard to Management Options and the Potential Harms, Benefits, and Outcomes of Each - </b></li>
</ul>
<i>“For some people, we do a CT scan – the benefit of a CT is that we know exactly how big the stone is, which helps us know if you’re going to need a procedure from a urologist to get it out. Most people with kidney stones pass the stone by themselves, and the CT isn’t helpful. The downside of a CT is that it takes time and it exposes you to radiation – and we know that every time you get exposed to radiation it increases your future risk of cancer ever so slightly. Also, if your pain comes back and doesn’t go away, it might make more sense to get a CT later – and we wouldn’t want to have to do two CT scans. Most people who have one kidney stone will have another one in the next 10 years – so you could end up with multiple CT scans over your lifetime. The other option is an ultrasound: it gives us some information and sometimes we get a CT scan if we see a lot of swelling in your kidney, but it doesn't show us how big the stone. Because I can do the ultrasound right now, people often go home sooner when they have an ultrasound, if they don’t need a CT. If we decide on the ultrasound, it’s important that you have a doctor you can follow-up with if you are feeling worse.”</i><br />
<ul style="text-align: left;">
<li><b>Explore Patient Values, Preferences, and Circumstances - </b>Probing the patient about what's important to them is key - they may not disclose difficulties with transportation, their activities of daily living, or their travel plans.</li>
</ul>
<i>“How are you feeling? Do you have a doctor you can see in the next week or so? Would you be able to get back to the ED if you had a problem? Kidney stones usually pass in a week or two – do you have any travel planned?”</i><br />
<ul style="text-align: left;">
<li><b>Decide Together on the Best Option for the Patient, Given His or Her Values, Preferences, and Circumstances</b></li>
</ul>
If a patient has a preference, this part is easy – maybe they’re in a hurry, worried about the cost of a CT, or have had multiple CT scans, or maybe they have an upcoming trip and want certainty.<br />
Many patients won't have a preference, and they may ask you for advice. Share your opinion but recognize that there is a huge power differential.<br />
<br />
<i>“If I had a kidney stone, and the pain medication worked, I wouldn’t be in a rush to get a CT scan – but might get one in a week or two if I still had alot of pain. </i><i>If I had some reason that I felt like I needed more information right now, like I was going on a cruise, then I might get the scan.”</i><br />
<br />
Presenting both sides in the explanation of your opinion empowers the patient to choose either the<br />
option you endorsed or the other option without feeling like they are disagreeing with the expert.<br />
<span style="font-size: x-small;"><br /></span>
<span style="font-size: x-small;">References:</span><br />
<span style="font-size: x-small;">1.<span class="Apple-tab-span" style="white-space: pre;"> </span>Wang RC. Managing Urolithiasis. Annals of Emergency Medicine 2016;67(4):449–54.</span><br />
<span style="font-size: x-small;">2.<span class="Apple-tab-span" style="white-space: pre;"> </span>Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. N Engl J Med 2014;371(12):1100–10.</span><br />
<span style="font-size: x-small;">3.<span class="Apple-tab-span" style="white-space: pre;"> </span>Brisbane W, Bailey MR, Sorensen MD. An overview of kidney stone imaging techniques. Nat Rev Urol 2016;:1–9.</span><br />
<span style="font-size: x-small;">4.<span class="Apple-tab-span" style="white-space: pre;"> </span>Fiore M. A proposal algorithm for patients presenting to the Emergency Department with renal colic. Eur J Emerg Med 2016;23(6):456–8.</span><br />
<span style="font-size: x-small;">5.<span class="Apple-tab-span" style="white-space: pre;"> </span>Xiang H, Chan M, Brown V, Huo YR, Chan L, Ridley L. Systematic review and meta-analysis of the diagnostic accuracy of low-dose computed tomography of the kidneys, ureters and bladder for urolithiasis. J Med Imaging Radiat Oncol 2017;:1–9.</span><br />
<span style="font-size: x-small;">6.<span class="Apple-tab-span" style="white-space: pre;"> </span>Türk C, Petřík A, Sarica K, et al. EAU Guidelines on Diagnosis and Conservative Management of Urolithiasis. European Urology 2015;:1–7.</span><br />
<span style="font-size: x-small;">7.<span class="Apple-tab-span" style="white-space: pre;"> </span>Robey TE, Edwards K, Murphy MK. Barriers to computed tomography radiation risk communication in the emergency department: a qualitative analysis of patient and physician perspectives. Acad Emerg Med 2014;21(2):122–9.</span></div>
Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com3tag:blogger.com,1999:blog-6248057085226614935.post-32765433437205978332016-11-13T19:53:00.001-06:002019-03-07T10:31:35.244-06:00Slaying Prehistoric Practice - Killing off the Routine Pulse Check<div dir="ltr" style="text-align: left;" trbidi="on">
<b><u>The Gist</u></b>: It's time to kill off the routine pulse check every two minutes. While some providers and systems have moved away from routine pulse checks, perfunctory cessation in compression to identify pulses happens as 'the norm' across the United States. Perform rhythm checks, which take far less time, taking less than 10 seconds to do so. Pulse checks may be indicated if there is a perfusing rhythm and/or other signs of ROSC. <br />
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Most of us recognize that, to the best of our knowledge, interruptions in chest compression may be deleterious to return of spontaneous circulation and, theoretically, neurologic outcome [2]. We may even devise complicated ways of reducing time without compressions including mechanical compressions and hands-on defibrillation. These interventions are not evidence-based and the yield is minimal. A more simple fix exists - stop checking for pulses routinely. This isn't some novel wild idea.<br />
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The American Heart Association guidelines do not recommend any specific interval for pulse check after the first initial pulse check for healthcare providers [3]. Beginning in 2010, however, the AHA guidelines begin discouraging routine pulse checks:<br />
<i>"Because of difficulties with pulse assessments, interruptions in chest compressions for a pulse check should be minimized during the resuscitation, even to determine if ROSC has occurred"</i> [4].<br />
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<b><br />It's really difficult to identify pulselessness in < 10 seconds</b>. Few people can determine the presence of pulselessness in 10 seconds. <a href="https://www.ncbi.nlm.nih.gov/pubmed/11098941" target="_blank">Dick et al</a> performed a study of patients placed on cardiopulmonary bypass, and providers were blinded to the presence of pulsatile flow. Only two percent of experienced providers (n=209) were able to determine that a patient was pulseless in under 10 seconds [5].<br />
Enforcement of time between compressions may be mitigated by having someone count down from 10 during the rhythm analysis. We often have the individual performing chest compressions do this and they are trained and reminded at the beginning of the resuscitation to resume compressions when they reach zero.<br />
<br />
<b>Pulse checks are inaccurate</b>. A study by Tibaballs et al again had providers assess for a pulse in patients on bypass with and without pulsatile flow. They found 78% accuracy in identification of the presence or absence of a pulse [6]. While an accuracy of 78% may seem high, this means that approximately one in four times we are wrong. This means we may feel the reverberation of our own pulse and the truly pulseless patient may have an unnecessary and perhaps deleterious delay in chest compressions. Cardiac ultrasound and arterial line tracings demonstrate contractility and flow with superior diagnostic characteristics, although each has their limitations [7].<br />
<br />
<b>Why would we undertake a diagnostic strategy if we know it it is inaccurate and insensitive</b>? Changing practice is difficult. In critical situations, we default to what is familiar, what we know. It is time to move away from the pulse check. We may still need to check for rhythm analysis at periodic intervals, and this is supported by the AHA guidelines. Some monitoring systems allow for this concurrently with compressions (filter out the baseline), while others do not. Many of us are also compelled to search for reversible causes of arrest with ultrasound, many of which do not require an interruption in compressions.<br />
<br />
<b>How do we determine ROSC, then?</b><br />
The AHA recommends arterial lines, ultrasound, rise in end-tidal capnography to 35-45 mmHg, or pulse AND blood pressure. In the emergency department, we often have access to ultrasound, arterial lines, and ETCO2.<br />
<b><br /></b>
If you're curious about why we are so stubborn to let go of our practices, check out <a href="http://shortcoatsinem.blogspot.com/2016/11/unlearning-yoga-for-your-brain.html">this post on unlearning practices we adore</a>.<br />
<br />
References:<br />
1. Soar J et al. "<a href="http://ercguidelines.elsevierresource.com/european-resuscitation-council-guidelines-resuscitation-2015-section-3-adult-advanced-life-support/fulltext">European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support.</a>" Resuscitation, October 2015, Pages 100 - 1472.<br />
2. Eftestøl T, Sunde K, Steen PA. Effects of Interrupting Precordial Compressions on the Calculated Probability of Defibrillation Success During Out-of-Hospital Cardiac Arrest. Circulation.2002; 105: 2270-2273.<br />
3. Link MS, Berkow LC, Kudenchuk PJ et al. Part 7: Adult Advanced Cardiovascular Life Support. Circulation. 132(18 suppl 2):S444-S464. 2015<br />
4.Berg RA, Hemphill R, Abella BS et al. Part 5: Adult Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 122(18_suppl_3):S685-S705. 2010.<br />
5. Dick WF, Eberle B, Wisser G, Schneider T. The carotid pulse check revisited: what if there is no pulse? Crit Care Med. 2000 Nov;28(11 Suppl):N183-<br />
6. Tibballs J, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation. Resuscitation. 81(6):671-5. 2010.<br />
7. Gaspari R et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation 2016 Sep 27<br />
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Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com6tag:blogger.com,1999:blog-6248057085226614935.post-67238266718624143092016-11-13T14:50:00.001-06:002016-11-18T12:52:52.448-06:00Unlearning - Yoga For Your Brain<div dir="ltr" style="text-align: left;" trbidi="on">
<b><u><br /></u></b> <b><u>The Gist</u></b>: Knowledge translation is a problem in medicine and, at the individual level, unlearning likely contributes to the knowledge translation gap. It may also exist as part of the solution. Akin to yoga, unlearning requires flexibility, training or deliberate practice, and is enhanced by a community open to skepticism and growth.<br />
<ul style="text-align: left;">
<li>Note: These musings are not evidence based but are more of a cognitive framework to understand why we have such difficulty individually changing practice.</li>
</ul>
For an introduction to unlearning, check out <a href="http://shortcoatsinem.blogspot.com/2014/02/the-unlearning-process.html" target="_blank">this post</a>. In brief, unlearning, while really an aspect of truly understanding and learning, is complicated. Most of us find it relatively easy to stuff more information into our brains, a process we perceive as "learning." Nasal cannula with oxygen at 15 liters per minute plus may help prolong safe apnea time and reduce hypoxia during intubation? Cool, we can do that. However, when we are told that something that we routinely do or believe may not necessary or even harmful, we often have more difficulty changing out behavior or "unlearning." Intubating patients with out of hospital cardiac arrest may not be helpful? Preposterous! Unlearning a bit of information is unnatural, it may feel awkward whereas learning, as it often does not put our knowledge or ego in jeopardy.<br />
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<b>Flexibility </b>- Unlearning requires cognitive flexibility. When we stretch our bodies, we reach a point where we feel a burn; our body telling us we are approaching our limit. We can push further safely, it just burns slightly more. Unlearning is essentially the same and is often accompanied by “the burn.” When we come across information counter to the way we practice, it stings. We may feel defensive. This is “the burn.” We experience discomfort when we stretch our thinking beyond this. This may be, in part, because we are emotionally tied to our knowledge. We work hard for what we know. We act quickly in emergency care and must have confidence in what we know, as emergent situations do not typically allow for debate or significant time to think.<br />
<br />
<ul style="text-align: left;">
<li><b>A fix</b>: When one feels “the burn” when confronted with new information that runs counter to our practice, recognize that this is a warning sign that knowledge may be changing. Recognize that the sting comes from our ego, protecting what we know. This does not mean that one should change practice whenever we come across a piece of novel information. Rather, we should we aware that in order to practice evidence based, up to date medicine, we may feel discomfort. When our beliefs are challenged, instead of becoming defensive, we should thoughtfully consider the information.</li>
</ul>
<b>Training</b> - Mastering a yoga pose requires training and deliberate practice. In order to unlearn ways of thinking, we must also engage in mental preparation and practice. It is easy, particularly in emergency settings when adrenaline dominates, to think and execute in a perfunctory manner. We default to what we know and what is familiar.<br />
Some fixes:<br />
<br />
<ul style="text-align: left;">
<li><b>Early Exposure</b> - The earlier we begin training, the more prepared we are. If one has an upcoming race, we may expect we will perform better if we begin preparing earlier rather than the week before the race. Similarly, when it comes to unlearning a habit or a way of thinking, the sooner we are exposed to the contrary argument, the more prepared we may be to unlearn. This may serve as a preconditioning so that we may react less strongly upon repeat exposure. </li>
<li><b>Repeat Exposure</b> - Practice is central to most athletic endeavors. The more repetitions we do, the stronger we become. The more we practice a yoga pose, the more likely we are to be successful, the more comfortable it will feel. Unlearning is easier when we are exposed to the target bit of knowledge more frequently. Spaced repetition exists as one of the most evidence-based means of learning and this probably applies to unlearning. </li>
</ul>
<b>Community</b> - Yoga and CrossFit are associated with strong communities, as are many team sports. Communities may motivate us, hold us accountable, and push the bounds of our perceived capability. Studies demonstrate that physicians practice similarly to the institution where they trained and show a wide array of geographic variation in practice patterns. A network of peers and colleagues, particularly outside of own’s main “system” or hospital, may increase our cognitive flexibility by exposing us to a wide array of practice pattern. The Free Open Access Medical Education (FOAM) community may expose to novel and controversial information.<br />
<br />
<div style="text-align: center;">
<b><u>Unlearning in the Prehospital Arena: The Workout</u></b></div>
<b>Needle Decompression for Tension Pneumothorax</b> (see <a href="http://shortcoatsinem.blogspot.com/2016/01/a-needle-in-chest-evidence-based-failure.html" target="_blank">this post</a> or <a href="http://foamcast.org/2016/03/19/episode-36-pneumothorax/" target="_blank">this podcast</a>). The second intercostal space at the midclavicular line (2nd ICS MCL) has been taught as the ideal spot for needle decompression. This, however, is changing. New recommendations are to use a catheter at least 8cm in length if needle decompression is attempted at the 2nd ICS MCL or decompress at the fourth or fifth intercostal space at the anterior axillary line (4/5th ICS AAL).<br />
The chest wall is thick at the 2nd ICS MCL [1,2]. Radiographic studies of chest wall thickness demonstrate increased thickness at the 2nd ICS MCL compared with the 4/5th ICS AAL (4.78 cm vs 3.42 cm). Even ATLS states that needle decompression in the 2nd ICS MCL will fail more than 50 percent of the time. This is an intervention undertaken in extreme circumstances in critically ill patients. A chance of failure of 1 in 2 is unacceptable.<br />
The 2nd ICS MCL is difficult to identify [3,4]. The clavicle extends further than most people think. As a result, providers are less accurate in identifying the 2nd ICS MCL compared with the 4/5th ICS AAL.<br />
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<b>The pulse check</b>. If one were to survey cardiac arrest resuscitation across the United States, in and out of hospital, we would probably see that the majority of people pause every two minutes for a “pulse check” despite decreased emphasis on the pulse check by the AHA guidelines over the past 10 years. The guidelines recommend minimal interruptions for pulse check and detail the problematic sensitivity and specificity of pulse identification [6]. After the initial pulse check prior to CPR, the guidelines don’t actually specify any time frame for repeat pulse checks. Yet, many of us do. Sure, we can pause for rhythm analysis; however, many systems and the European guidelines now recommend pulse assessment upon observation of an organized rhythm or increase in end tidal capnography [7].<br />
Few people can determine the presence of pulselessness in 10 seconds. Dick et al of patients placed on cardiopulmonary bypass and providers blinded to whether or not the patient actually had a pulse. Only 2% of this cohort of experienced providers were able to identify a pulseless patient in 10 seconds [8]. With increased emphasis on compression fraction, this may result in a delay in resumption of compressions.<br />
The accuracy of the pulse identification by providers is suboptimal, noted to be 78% in one study [9]. While an accuracy of 78% may seem high, this means that approximately one in four times we will be wrong. We may feel the reverberation of our own pulse and the truly pulseless patient may have an unnecessary and perhaps deleterious delay in chest compressions.<br />
For more on this topic check out <a href="http://shortcoatsinem.blogspot.com/2013/06/house-of-gods-law-3-revised.html" target="_blank">this post</a> and/or <a href="http://shortcoatsinem.blogspot.com/2016/11/slaying-prehistoric-practice-killing.html" target="_blank">this post</a>.<br />
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<b><br /></b> <b>Left Bundle Branch Block (LBBB) as a STEMI Equivalent</b> (<a href="http://shortcoatsinem.blogspot.com/2013/06/the-foam-forecast-better-than-weather.html" target="_blank">check out this post</a>)- Prior to the 2013 iteration of the AHA guidelines for ST-elevation myocardial infarction (STEMI), new or presumed new LBBB existed as a “STEMI equivalent.” This often activated the cath lab and STEMI teams. In 2013, the AHA removed this from the guidelines yet these patients are often referred to the emergency department for “rule out MI.”<br />
Further, STEMI may often be diagnosed on ECG, using the Sgarbossa or modified Sgarbossa criteria (<a href="http://www.mdcalc.com/sgarbossa-criteria-mi-left-bundle-branch-block/" target="_blank">link</a>) [10].<br />
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<b>Backboards</b> - fortunately protocols in many states and systems have dispensed with long backboards. Long thought to be protective, despite known harms, the American College of Emergency Physicians released a guideline in 2016 explicitly stating that long backboards should not be used as a therapeutic or precautionary measure. They cause harm and don’t help. [11]<br />
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<b>Oxygen in Acute Coronary Syndromes</b> - Aspirin, oxygen, and nitroglycerin have long been the initial interventions for patients with suspected ACS. Recent studies have found no clear benefit for oxygen in patients with normal oxygen saturations. Further, one study found oxygen was associated with markers of larger myocardial infarctions (although this is not a patient-oriented outcome) [12]. The AHA recommends oxygen is appropriate for patients who are hypoxemic (oxygen saturation < 90%) [6].<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWUPBWPVTvkJ6dlyZWShSUjMyP0daSxDsoTEX9HhMXAhhrS0sEbt04-BITsc3gqr0TfRE7jEyR0d0MJyESs7lSBKP-59dsgpAsmBpFYVURIJ1qw0Ak7mjsSchVVHJUd5_yphonvpTECp8/s1600/Screen+Shot+2016-11-14+at+7.50.48+AM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="236" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWUPBWPVTvkJ6dlyZWShSUjMyP0daSxDsoTEX9HhMXAhhrS0sEbt04-BITsc3gqr0TfRE7jEyR0d0MJyESs7lSBKP-59dsgpAsmBpFYVURIJ1qw0Ak7mjsSchVVHJUd5_yphonvpTECp8/s320/Screen+Shot+2016-11-14+at+7.50.48+AM.png" width="320" /></a></div>
<br />
<br />
References:<br />
1. Laan D V., Vu TDN, Thiels CA, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2015:14–16.<br />
2. Advanced Trauma Life Support, 9th edition.<br />
3. Ferrie EP et al. The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J 2005;22(11):788–9.<br />
4. Inaba K et al. Cadaveric comparison of the optimal site for needle decompression of tension pneumothorax by prehospital care providers<br />
5. ACS COT<br />
6. Berg RA, Hemphill R, Abella BS et al. Part 5: Adult Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 122(18_suppl_3):S685-S705. 2010.<br />
7. Resuscitation. 81(6):671-5. 2010.<br />
8. Dick WF, Eberle B, Wisser G, Schneider T. The carotid pulse check revisited: what if there is no pulse?Crit Care Med. 2000 Nov;28(11 Suppl):N183-5<br />
9. Tibballs J, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation.<br />
10. O'Gara PT, Kushner FG, Ascheim DD et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Journal of the American College of Cardiology. 61(4):e78-e140. 2013<br />
11. "EMS Management of Patients with Potential Spinal Injury." ACEP Board of Directors. Available at: https://www.acep.org/clinical---practice-management/ems-management-of-patients-with-potential-spinal-injury/<br />
12. Stub D et al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 131(24):2143-2150. 2015.</div>
Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com4tag:blogger.com,1999:blog-6248057085226614935.post-1352032854090164452016-05-28T14:35:00.002-05:002016-06-12T03:34:28.413-05:00Risky Business: Framing Statistics<div dir="ltr" style="text-align: left;" trbidi="on">
<b><u>The Gist:</u></b> Medical literature frequently frames effect size using relative and absolute risks in ways that intentionally alter the appearance of an intervention, an example of framing bias. Effect sizes seem larger using relative risk and smaller using absolute risk [1,2]. <br />
<br />
<div style="text-align: center;">
Part of our 15 Minutes - 'Stats are the Dark Force?' residency lecture series</div>
<iframe allowfullscreen="" frameborder="0" height="360" mozallowfullscreen="" src="https://player.vimeo.com/video/168472489" webkitallowfullscreen="" width="640"></iframe>
<a href="https://vimeo.com/168472489">Risk</a> from <a href="https://vimeo.com/user20312246">Lauren Westafer</a> on <a href="https://vimeo.com/">Vimeo</a>.<br />
<span style="background-color: white; font-family: "times new roman" , "times" , "freeserif" , serif; font-size: 17.6px; line-height: 24.64px; text-align: center;"><br /></span>
Perneger and colleagues surveyed physicians and patients about the efficacy of 4 new drugs. They were presented with the following scenarios:<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhukpUtGK_qVlmy-ajMMEPnK5ZkjtK6YfprhyYs-6RYUL7lDAN1ClRFzD63I3Ga3lmiNaY-hZ6d99YvxqLN9gfzemjb0i9CSLIRQK78G0tpeegS4DQLfvy1ERFO_uRKxw21WF8_VADXlvE/s1600/Screen+Shot+2016-05-28+at+3.09.48+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="125" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhukpUtGK_qVlmy-ajMMEPnK5ZkjtK6YfprhyYs-6RYUL7lDAN1ClRFzD63I3Ga3lmiNaY-hZ6d99YvxqLN9gfzemjb0i9CSLIRQK78G0tpeegS4DQLfvy1ERFO_uRKxw21WF8_VADXlvE/s400/Screen+Shot+2016-05-28+at+3.09.48+PM.png" width="400" /></a></div>
<div class="separator" style="clear: both; text-align: left;">
While these numbers reflect the same data, patients and physicians selected that the drug that "reduced mortality by 1/3" was "clearly better" [3]. This indicates both parties are susceptible to the cognitive tricks statistics, particularly the way that relative risk make numbers <i>appear</i> larger and the ways absolute risk makes numbers <i>appear</i> smaller. Authors can consistently switch between relative and absolute risk to maximize the appearance of benefit and minimize risks, as seen in the following abstract:</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJmEi07nNR0QIIzrho2OsziBesiHnspjceACsTpdxJnlnfrYZT1Cv7h8rEKRtwz8022vvairbm9Mu2waqEBdqW4QVMtplDy0dxV4sON70GN3TNNaTu9x3YlhoGnno22IyLNu-5gLGIqyY/s1600/Screen+Shot+2016-05-28+at+3.24.34+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="238" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJmEi07nNR0QIIzrho2OsziBesiHnspjceACsTpdxJnlnfrYZT1Cv7h8rEKRtwz8022vvairbm9Mu2waqEBdqW4QVMtplDy0dxV4sON70GN3TNNaTu9x3YlhoGnno22IyLNu-5gLGIqyY/s320/Screen+Shot+2016-05-28+at+3.24.34+PM.png" width="320" /></a></div>
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<br /></div>
<div class="separator" style="clear: both; text-align: left;">
Perhap authors should be encouraged to report statistics consistently, using relative OR absolute rather than switching between the two to give the appearance of maximum benefit and minimal risk.</div>
<br />
<div style="text-align: left;">
<span style="font-size: x-small;">References:<br />1. Barratt A. Tips for learners of evidence-based medicine: 1. Relative risk reduction, absolute risk reduction and number needed to treat. Canadian Medical Association Journal. 171(4):353-358. 2004<br />2. Malenka DJ, Baron JA, Johansen S, Wahrenberger JW, Ross JM. The framing effect of relative and absolute risk. Journal of general internal medicine. 1993;8(10):543-8.<br />3. Perneger TV, Agoritsas T. Doctors and patients' susceptibility to framing bias: a randomized trial. Journal of general internal medicine. 26(12):1411-7. 2011.</span></div>
</div>
Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com3tag:blogger.com,1999:blog-6248057085226614935.post-51466128951299676722016-05-21T13:06:00.002-05:002016-05-23T08:09:55.343-05:00P Values: Everything You Know Is Wrong<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="p1">
<span class="s1"><b><u>The Gist</u></b></span><span class="s2"><b><u>:</u></b> P values are probably the most “understood” statistic amongst clinicians yet are widely misunderstood. P values should not be used alone to accept or reject something as “truth” but they may be thought of as representing the strength of evidence against the null hypothesis [1].</span></div>
<div class="p1">
<span class="s2"><br /></span></div>
<div class="p1">
<div style="text-align: center;">
Part of our 15 Minutes - 'Stats are the Dark Force?' residency lecture series</div>
</div>
<div class="p2">
<span class="s2"></span><br /></div>
<iframe allowfullscreen="" frameborder="0" height="360" mozallowfullscreen="" src="https://player.vimeo.com/video/167688922" webkitallowfullscreen="" width="640"></iframe>
<a href="https://vimeo.com/167688922">P: Everything You Know Is Wrong</a> from <a href="https://vimeo.com/user20312246">Lauren Westafer</a> on <a href="https://vimeo.com/">Vimeo</a>.<br />
<br />
<div class="p1">
<span class="s2"><br /></span>
<span class="s2">At various times in my life I, like many others, have believed the p value to represent one of the following (none of which are true):</span></div>
<ul>
<ul>
<li class="li1"><span class="s3"></span><span class="s2"><b>Significance</b></span></li>
<ul>
<li class="li1"><span class="s3"></span><span class="s2">Problem: Significance is a loaded term. A value of 0.05 has become synonymous with “statistical significance.” Yet, this value is not magical and was chosen predominantly for convenience [3]. Further, the term “significant” may be confused with clinical importance, something a statistic cannot answer.</span></li>
</ul>
<li class="li1"><span class="s3"></span><span class="s2">T<b>he probability that the null hypothesis is true</b>.</span></li>
<ul>
<li class="li1"><span class="s3"></span><span class="s2">Problem: The calculation of the p value includes the assumption that the null hypothesis is true. Thus, a calculation that assumes the null hypothesis is true cannot, in fact, tell you that the null hypothesis is false.</span></li>
</ul>
<li class="li1"><span class="s3"></span><span class="s2"><b>The probability of getting a Type I Error </b></span></li>
<ul>
<li class="li1"><span class="s3"></span><span class="s2">Background: Type I Error is the incorrect rejection of a true null hypothesis (i.e. a false positive) and the probability of getting a Type I Error is represented by alpha. Alpha is often set at 0.05 so that there is a 5% chance you are wrong if you reject the null hypothesis. This is a PRE test calculation (set before the experiment)</span></li>
<li class="li1"><span class="s3"></span><span class="s2">Problem: Again, the calculation of the p value assumes the null hypothesis is true. The p value only tells us the probability of getting the data we did, it does NOT speak to the underlying truth of whatever is being tested (i.e. efficacy). The p value is also a POST test calculation.</span></li>
<li class="li1"><span class="s2">The error rate associated with various p values varies, depending on the assumptions in the calculations, particularly prevalence. However, it's interesting to look at some of the estimates of false positive error rates often associated with various p values: p=0.05 - false positive error rate of 23-50%; p=0.01 - false positive error rate of 7-15% [5].</span></li>
</ul>
</ul>
</ul>
<div class="p1">
<span class="s2"><b>P value is</b> the probability of getting results as extreme or more extreme, assuming the null hypothesis is true. Originally, this statistic was intended to serve as a gauge for researchers to decided whether or not a study was worth investigating further [3]. </span></div>
<ul>
<li class="li1"><span class="s3"></span><span class="s2"><b>High P value</b> - data are likely with a true null hypothesis [Weak evidence against the null hypothesis]</span></li>
<li class="li1"><span class="s3"></span><span class="s2"><b>Low P value</b> - data are UNlikely with a true null hypothesis [Stronger evidence against the null hypothesis]</span></li>
</ul>
<div class="p2">
Example: A group is interested in evaluating needle decompression of tension pneumothorax and proposes the following:<span class="s2"></span></div>
<ul>
<ul>
<li class="li1"><span class="s3"></span><span class="s2">Hypothesis - Longer angiocatheters are more effective than shorter catheters in decompression of tension pneumothorax.</span></li>
<li class="li1"><span class="s3"></span><span class="s2">Null hypothesis - There is no difference in effective decompression of tension pneumothorax using longer or shorter angiocatheters.</span></li>
</ul>
</ul>
<div class="p2">
A group, Aho and colleagues, did this study and found a p value of 0.01 with 8 cm catheters compared with 5 cm catheters. How do we interpret this p value? <span class="s2"></span></div>
<ul>
<li class="li1"><span class="s3"></span><span class="s2">We would expect the same number of effective decompressions or more in 1% of cases due to random sampling error. </span></li>
<li class="li1"><span class="s2">The data are UNLIKELY with a true null hypothesis and this is decent strength evidence against the null hypothesis.</span></li>
</ul>
<div class="p1">
<span class="s2"><b>Limitations of the Letter “P”</b></span></div>
<ul style="text-align: left;">
<ul>
<li class="li1"><span class="s3"></span><span class="s2"><b>Reliability.</b> P values depend on the statistical power of a study. A small study with little statistical power may have a p value greater than 0.05 and a large study may reveal that a trivial effect has statistical significance [2,4]. Thus, even if we are testing the same question, the p value may be "significant" or "nonsignificant" depending on the sample size.</span></li>
<li class="li1"><b>P-hacking.</b> Definition: "<i>Exploiting –perhaps unconsciously - researcher degrees of freedom until p<.05"</i> Alternatively: <i>"Manipulation of statistics such that the desired outcome assumes "statistical significance", usually for the benefit of the study's sponsor</i>s" [7].</li>
<ul>
<li class="li1">A recent study of abstracts between 1990-2015 showed 96% contained at least 1 p value < 0.05. Are we that wildly successful in research? Or, are statistically nonsignificant results published less frequently (probably). Or, do we try to find something in the data to report as significant, i.e. p-hack (likely).</li>
</ul>
</ul>
</ul>
<div>
<b>P values are neither <i>good</i> nor <i>bad</i></b>. They serve a role that we have distorted and, according to the American Statistical Association: <b style="font-style: italic;">The widespread use of “statistical significance” (generally interpreted as “p ≤ 0.05”) as a license for making a claim of a scientific finding (or implied truth) leads to considerable distortion of the scientific process </b>[1]. In sum, acknowledge what the p value is and is not and, by all means, do not p alone.</div>
<div>
<br /></div>
<div class="p1">
<span class="s2">References:</span></div>
<ol class="ol1">
<li class="li1"><span class="s3"></span><span class="s2">Wasserstein RL, Lazar NA. The ASA’s statement on p-values: context, process, and purpose. Am Stat. 2016;1305(April):00–00. doi:10.1080/00031305.2016.1154108.</span></li>
<li class="li1"><span class="s2">
<div class="p1">
<span class="s1">Goodman S. (2008) <a href="http://www.ncbi.nlm.nih.gov/pubmed/18582619" target="_blank">A dirty dozen: twelve p-value misconceptions</a>. Seminars in hematology, 45(3), 135-40. PMID: 18582619 </span></div>
</span></li>
<li class="li1"><span class="s3"></span><span class="s2">Fisher RA. Statistical Methods for Research Workers. Edinburgh, United Kingdom: Oliver&Boyd; 1925.</span></li>
<li class="li1"><span class="s3"></span><span class="s2">Sainani KL. Putting P values in perspective. PM R. 2009;1(9):873–7. doi:10.1016/j.pmrj.2009.07.003.</span></li>
<li class="li1">Sellke T, Bayarri MJ, Berger JO. Calibration of p Values for Testing Precise Null Hypotheses. The American Statistician, February 2001, Vol. 55, No. 1</li>
<li class="li1"><span class="s3"></span><span class="s2">Chavalarias D, Wallach JD, Li AHT, Ioannidis JPA. Evolution of Reporting P Values in the Biomedical Literature, 1990-2015. Jama. 2016;315(11):1141. doi:10.1001/jama.2016.1952.</span></li>
<li class="li1"><span class="s2">PProf. "P-Hacking." Urban Dictionary. Accessed May 1, 2016. Available at: http://www.urbandictionary.com/define.php?term=p-hacking</span></li>
</ol>
</div>
Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com7tag:blogger.com,1999:blog-6248057085226614935.post-51711231439632132802016-01-26T00:34:00.003-06:002016-01-26T00:34:25.777-06:00Percutaneous Chest Tubes: The Humane Choice<div dir="ltr" style="text-align: left;" trbidi="on">
<b><u>The Gist:</u></b> Small bore percutaneous catheters, often referred to as "pigtail" catheters, should be the initial means of treating many pneumothoraces and select other drainable thoracic pathologies as they cause less pain and capitalize on the commonly used seldinger technique [1-10].<br />
<br />
Traditional tube thoracostomy is an invasive procedure. For the past several years, international guidelines, individuals in the Free Open Access Medical education (FOAM) community, and various institutions have moved towards placing more pigtail catheters for urgent thoracic pathology. Yet, this practice is still not ubiquitous. I recently gave a talk on this to my program and, in the spirit of FOAM, have shared it:<br />
<div style="text-align: center;">
<iframe allowfullscreen="" frameborder="0" height="375" mozallowfullscreen="" src="https://player.vimeo.com/video/153063750" webkitallowfullscreen="" width="500"></iframe>
</div>
<div style="text-align: center;">
<a href="https://vimeo.com/153063750">Percutaneous Chest Tubes: The Humane Choice</a> from <a href="https://vimeo.com/user34193972">Lauren Westafer</a> on <a href="https://vimeo.com/">Vimeo</a>.</div>
<b><br /></b>
<b>Technique - </b><a href="https://www.youtube.com/watch?v=ExAKcElqCDo" target="_blank">Watch this video by Dr. Larry Mellick </a><br />
<ul style="text-align: left;">
<li><b>Seldinger style: </b>uses a technique with which we are intimately familiar. The majority of emergency providers have likely done far more central lines than open tube thoracostomies. As such, a technique mentally and mechanically familiar to providers may be preferable.</li>
<li><b>Pearls for placement </b>- Kulvatunyou and colleagues suggest "POW" pearls for placement.</li>
<ul>
<li><b>P </b>-Perpendicular: Ensure the finder needle is perpendicular to the rib during placement</li>
<li><b>O</b> -Over the rib: Like chest tubes, pigtails go over the rib to avoid injury to the neurovascular bundle</li>
<li><b>W</b> -Wary of wire kinking: The wire may be prone to kinking, particularly upon dilation through the tough intercostal muscles.</li>
</ul>
</ul>
<b>Indications</b><br />
<ul style="text-align: left;">
<li><b>Pneumothorax</b></li>
<ul>
<li>Spontaneous pneumothorax: The British Thoracic Society has recommended small bore tubes over traditional chest tubes since 2010.</li>
<li>Traumatic pneumothorax: Use of pigtail catheters have increased in many trauma communities, with success rates comparable to large bore chest tubes [8-11].</li>
</ul>
<li><b>Effusions</b> - pigtail catheters are frequently used to drain effusions, particularly simple effusions. Most of the primary literature on this topic has been conducted in children with parapneumonic effusions and has demonstrated that this technique is successful and safe [13].</li>
</ul>
<b>Cautions/Contraindications</b><br />
<ul style="text-align: left;">
<li><b>Hemothorax/Complex fluid -</b> Larger bore tubes (28F and larger) are typically used to drain hemothorax due to the feared complication of retained hemothorax. A prospective review of 36, 14F pigtail catheters placed for hemothorax in trauma patients found no significant differences in complications or success between pigtails or chest tubes but wasn't powered to find important, infrequent complications [11]. An animal study found</li>
</ul>
<b>The Good</b>:<br />
<ul style="text-align: left;">
<li><b>Less Painful </b>- In addition to the procedure not requiring large, forceful separation of the and unsurprisingly, placing a smaller tube in the chest causes less pain, even 2 days after the procedure [10].</li>
<ul>
<li>Pain in pigtail vs chest tube patients: Day 0 3.2 vs 7.7; p<0.001, Day 1 1.9 vs 6.2; p<0.001, Day 2 2.1 vs 5.5; p=0.04 (note: no power calculation performed)</li>
</ul>
<li><b>Easy/Familiar Procedure </b>- as above under "Seldinger technique"</li>
<li><b>May reduces some complications </b>- The literature suggests that complications are typically at least equivalent between larger chest tubes and pigtails. More serious complications are difficult to quantify given the infrequency.</li>
<ul>
<li>One study did show that infections were reduced in the pigtail group, possibly due to technique or a larger nidus for infection [2].</li>
</ul>
<li><b>Outpatient treatment possible</b> - In select patient groups with spontaneous pneumothorax and excellent follow up, a pigtail catheter may be connected to a heimlich valve and the patient may be discharged [7].</li>
</ul>
<b>The Bad</b>:<br />
<ul style="text-align: left;">
<li><b>More predisposed to kinking</b> - Due to the small, flexible tubing, these tubes may kink and obstruct the lumen. The trauma literature suggests these complications may occur in 2-8% of cases [8-10].</li>
<li><b>Clogging </b>- Drainage of some complex fluids (loculated effusion/hemothorax) may be more problematic through pigtail catheters as the small lumen may be easier obstructed with clot.</li>
<li><b>Time? </b>The belief exists that open thoracostomy more expediently relieves pneumothorax compared with the percutaneous technique and is thus preferred in emergent, life-threatening situations. To date, there's no literature to support or refute this and the time a tube takes is likely provider dependent.</li>
<li><b>It's less cool </b>- A certain pride and thrill exists with performing invasive procedures. In discussions with individuals regarding barriers to uptake of the percutaneous technique the theme arose that performing this technique would demonstrate some sort of weakness by the provider. Note: this notion is not supported or addressed by the literature and is merely a thought about subconscious provider bias</li>
</ul>
<div>
<span style="font-size: xx-small;">References:</span></div>
<div class="p1">
<span style="font-size: xx-small;"><span class="s1"><span style="font-size: xx-small;">1. </span></span><span style="font-size: xx-small;">Laws D et al. BTS guidelines for the insertion of a chest drain. Thorax. 2003 May;58 Suppl 2:ii53-9.</span></span></div>
<div class="p1">
<span style="font-size: xx-small;">2. Benton IJ, Benfield GF. Comparison of a large and small-calibre tube drain for managing spontaneous pneumothoraces. Respir Med. 2009 Oct;103(10):1436-40.</span></div>
<div class="p1">
<span style="font-size: xx-small;">3. Dull KE, Fleisher GR. Pigtail catheters versus large-bore chest tubes for pneumothoraces in children treated in the emergency department. Pediatr Emerg Care. 2002 Aug;18(4):265-7.</span></div>
<div>
<div class="p1">
<span class="s1"><span style="font-size: xx-small;">4. Gammie JS et al. The pigtail catheters for pleural drainages: a less invasive alternative to tube thoracostomy. JSLS. 1999 Jan-Mar;3(1):57–61.</span></span></div>
<div class="p1">
<span class="s1"><span style="font-size: xx-small;">5. Kuo HC, et al. Small-bore pigtail catheters for the treatment of primary spontaneous pneumothorax in young adolescents. Emerg Med J. 2013 Mar;30(3):e17.</span></span></div>
<div class="p1">
<span class="s1"><span style="font-size: xx-small;">6. Repanshek ZD, Ufberg JW, Vilke GM, Chan TC, Harrigan RA. Alternative Treatments of Pneumothorax. J Emerg Med. 2013 Feb;44(2):457-466.</span></span></div>
<div class="p1">
<span class="s1"><span style="font-size: xx-small;">7. Hassani B, Foote J, Borgundvaag B. Outpatient management of primary spontaneous pneumothorax in the emergency department of a community hospital using a small-bore catheter and a Heimlich valve. Acad Emerg Med. 2009 Jun;16(6):513-8.</span></span></div>
<div class="p1">
<span style="font-size: xx-small;"><span class="s1"><span style="font-size: xx-small;">8. </span></span><span style="font-size: xx-small;">Kulvatunyou N, Vijayasekaran A, Hansen A, et al. Two-year experience of using pigtail catheters to treat traumatic pneumothorax: a changing trend. J Trauma. 2011 Nov;71(5):1104-7.</span></span></div>
<div class="p1">
<span style="font-size: xx-small;"><span class="s1"><span style="font-size: xx-small;">9. </span></span><span style="font-size: xx-small;">Rivera L, O’Reilly EB, Sise MJ, et al. Small catheter tube thoracostomy: effective in managing chest trauma in stable patients. J Trauma. 2009 Feb;66(2):393–9</span></span></div>
<div class="p1">
<span style="font-size: xx-small;"><span class="s1"><span style="font-size: xx-small;">10. </span></span><span style="font-size: xx-small;">Kulvatunyou N, et al. A prospective randomized study of 14-French pigtail catheters vs 28F chest tubes in patients with traumatic pneumothorax: impact on tube-site pain and failure rate. EAST Annual Surgical Assembly, Oral paper 12, Jan 17, 2013.</span></span></div>
<div class="p1">
<span style="font-size: xx-small;"><span style="text-indent: -32pt;">11. </span><span style="text-indent: -32pt;">Kulvatunyou N, Joseph B, Friese RS, et al. 14 French pigtail catheters placed by surgeons to drain blood on trauma patients. </span><i style="text-indent: -32pt;">J Trauma Acute Care Surg</i><span style="text-indent: -32pt;">. 2012;73(6):1423–1427. </span></span></div>
<div class="p1">
<span style="font-size: xx-small;"><span style="text-indent: -32pt;">12. </span><span style="text-indent: -32pt;">Russo RM, Zakaluzny SA, Neff LP, et al. A pilot study of chest tube versus pigtail catheter drainage of acute hemothorax in swine. </span><i style="text-indent: -32pt;">J Trauma Acute Care Surg</i><span style="text-indent: -32pt;">. 2015;79(6):1038–1043. </span></span><br />
<span class="s1"><span style="font-size: xx-small;">13. Liu YH, et al. Ultrasound-guided pigtail catheters for drainage of various pleural diseases. Am J Emerg Med. 2010 Oct;28(8):915-21</span></span><br />
<span style="font-size: xx-small;">14. Inaba K, Lustenberger T, Recinos G. Does size matter? A prospective analysis of 28-32 versus 36-40 French chest tube size in trauma. The journal of trauma and acute care surgery. 72(2):422-7. 2012. </span></div>
</div>
</div>
Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com10tag:blogger.com,1999:blog-6248057085226614935.post-1253673281770134822016-01-07T03:10:00.002-06:002016-11-15T12:26:47.830-06:00We Don't Know the Midclavicular Line<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="p1">
<span class="s1"><b><u>The Gist</u></b>: Needle decompression for tension pneumothorax should be taught at the fourth or fifth intercostal space at the anterior axillary line (4/5ICS AAL). </span></div>
<h3>
<ul style="text-align: left;">
<li><span style="font-size: xx-small; font-weight: normal;">Note: This post will not detail critiques that needle decompression may be overused or the needle vs thoracostomy debate.</span></li>
</ul>
</h3>
<div class="p1">
<span class="s1">Historical teaching instructs providers to place a needle in the second ICS at the mid-clavicular line (2ICS MCL) for tension pneumothorax [1,2]. Free Open Access Medical Education (FOAM) sources such as <a href="http://emergencymedicineireland.com/2012/11/stop-putting-iv-cannulae-in-the-2nd-ics-for-tension-ptx/" target="_blank">Emergency Medicine Ireland</a> have preached the more lateral approach for years; yet this teaching has not spread widely (outside of military circles where there seems to be better adoption). Change is difficult, particularly when it involves re-educating thousands of providers and it seems like this is the primary driver behind the 2ICS MCL remaining as the typical site for needle decompression.. However, several potential problems exist with the mid-clavicular approach that warrant consideration for assuming 4/5ICS AAL as the primary initial placement for needle decompression.</span></div>
<div class="p1">
<span class="s1"><br /></span></div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSnhKGTyeRqMZj4m-7QSdJ5QTzlNIkSEx7Uu9eLS1WV-8-l8f3rqlfQhJTyHV65FC9iU8RogjVX1NpB8BFBzSlH39R5LxWGMaNTKyiHNXQZ93XKVAph22CbDUuSX3_ahGqC2CyE5UXQ2c/s1600/Screen+Shot+2016-01-06+at+7.24.55+PM.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="241" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSnhKGTyeRqMZj4m-7QSdJ5QTzlNIkSEx7Uu9eLS1WV-8-l8f3rqlfQhJTyHV65FC9iU8RogjVX1NpB8BFBzSlH39R5LxWGMaNTKyiHNXQZ93XKVAph22CbDUuSX3_ahGqC2CyE5UXQ2c/s320/Screen+Shot+2016-01-06+at+7.24.55+PM.png" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">A: Where I see most needles placed, B: 2ICS MCL, C: 5ICS AAL</td></tr>
</tbody></table>
<div class="p1">
<span class="s1"><b>We may not be able to reach the pleura </b>[3-5]. The chest wall may be particularly thick at the 2ICS MCL, particularly as the average BMI in many nations grows. Researchers have looked at this question for years through a couple of means - measuring the depth at the 2ICS MCL on CT scans of trauma patients compared with alternative sites. The </span>2ICS MCL is generally 1.3 cm thicker than 5ICS AAL. </div>
<div class="p1">
</div>
<ul style="text-align: left;">
<li>This discrepancy was not solely seen in the morbidly obese. In fact, it was seen consistently across all four BMI quartiles tested, and at the traditional insertion site, needle decompression would have been extremely difficult with any eccentric placement using a standard needle in all but the lowest BMI quartile [3].</li>
</ul>
<u>How often would the needle fail</u>? A systematic review and meta-analysis in Injury 2015 by Laan et al looked at 17 studies, generally cadaveric or radiographic, and found that a standard 5 cm catheter used for needle decompression at the 2ICS MCL would fail 38% (24–54%) of the time compared with only 13% (8–22%) at ICS4/5-AAL (p= .01) [5].<br />
<div>
<ul style="text-align: left;">
<li>The British Thoracic Society Guidelines (2010) even remark “a standard 14 gauge (4.5 cm) cannula may not be long enough to penetrate the parietal pleura..with up to one-third of patients having a chest wall thickness >5 cm in the second interspace.”</li>
<li>In some places, the failure rate may be even higher secondary to obesity [5].</li>
</ul>
<div>
<u>What about a longer needle</u>? Many catheters used for needle decompression are 5 cm in length; however, some have access to 8 cm angiocatheters. A analysis by Clemency and colleagues found that in order to achieve a success rate of 95%, we would need a catheter at lease 6.4 cm in length [8]. Similarly, Laan and colleagues conducted a pre-post retrospective study in an EMS system that switched from using 5 cm catheters to 8 cm catheters with an increase in success rate (48% vs 83%) [6]. For a life saving, last ditch effort, I'm not sure that 95% success rate is adequate when alternatives exist.</div>
<div>
<div class="p2">
<span class="s1"></span><br /></div>
<div class="p1">
<span class="s1"><b>We don’t identify this site well </b>[10,11]. </span>A 2005 paper by Ferrie and colleagues had 25 emergency physicians name the correct side for needle thoracentesis and label this site with a pen on a male volunteer (erased between providers). Nearly all participants were ATLS certified within the past 10 years. </div>
<div class="p1">
</div>
<ul style="text-align: left;">
<li>88% (n=22) named the correct site (one additional person did name the 5ICS AAL).</li>
<li>Only 15 of the 25 participants (60%) could correctly identify the 2ICS MCL [10]. </li>
</ul>
<div class="p1">
<span class="s1">In another study, Inaba and colleagues trained 25 US Navy corpsmen on needle decompression, using both the 2ICS MCL and the 5ICS AAL. The corpsmen then performed needle decompression at both sites on randomly selected cadavers, bilaterally. </span></div>
<div class="p1">
</div>
<ul style="text-align: left;">
<li>Mean distance from the correct location: 3.1 cm 2ICS MCL vs 1.2 cm 5ICS AAL</li>
<li>Correct placement (ICS +/- 5 cm): 15/50 (30%) 2ICS MCL vs 41/50 (82%) 5ICS AAL</li>
<li>Limitations: This study had multiple outcomes and no power analysis was performed [11]</li>
</ul>
<div>
<div class="p1">
<span class="s1">I think much of this is because we underestimate the length of the clavicle. It's easier when you can see the chest wall bones but we don't have this advantage in the clinical setting. On a person, the midclavicular line often seems fairly lateral. </span></div>
</div>
<div>
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-nSo2TeS05HpZU28yVvmaBqPEEt-2AGq_S2p2u-dusX_APIxM8BgTVSiN5Z1tTwBPuVwWdlMLoM7n2LqDv3m1HBntZEbpLoUBx9KJr2vRsZZPIIHJvS2iD2kQ37Dg72mUpVv9MZ0RWRw/s1600/Screen+Shot+2016-01-07+at+9.37.55+AM.png" imageanchor="1"><img border="0" height="248" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-nSo2TeS05HpZU28yVvmaBqPEEt-2AGq_S2p2u-dusX_APIxM8BgTVSiN5Z1tTwBPuVwWdlMLoM7n2LqDv3m1HBntZEbpLoUBx9KJr2vRsZZPIIHJvS2iD2kQ37Dg72mUpVv9MZ0RWRw/s320/Screen+Shot+2016-01-07+at+9.37.55+AM.png" width="320" /></a></div>
<div>
<br /></div>
<br />
<div class="p1">
<span class="s1"><b>Important structures surround the 2ICS MCL.</b> As mentioned above, we seem to have a tough time finding the 2ICS MCL [8,9]. There are important structures in this vicinity, particularly if the tendency is to go more medial than the actual midclavicular line, including the internal mammary artery and contents of the superior mediastinum. Naturally, should an individual placing a needle in the 4/5ICS AAL go too caudal the possibility exists for the needle to enter the liver or spleen but the study by Inaba and colleagues suggest we may be better able to identify this space [9].</span></div>
<div class="p1">
<span class="s1"><br /></span></div>
<div class="p1">
<span class="s1">Given the literature, it seems that at this time should a needle be placed aiming for the 2ICS MCL for needle decompression and fail, this is a failure of education and changing our knowledge base rather than a patient-based failure. We should know better.</span></div>
<div class="p2">
<br /></div>
<div class="p2">
<span class="s1"></span></div>
<div class="p1">
<span class="s1"><span style="font-size: x-small;">References:</span></span></div>
<br />
<ol class="ol1">
<li class="li1"><span style="font-size: x-small;"><span class="s2"></span><span class="s1">MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(Suppl 2):ii18–ii31.</span></span></li>
<li class="li1"><span style="font-size: x-small;">Advanced Trauma Life Support, 9th ed. </span></li>
<li class="li1"><span class="s1"><span style="font-size: x-small;">Inaba K, Ives C, McClure K, Branco BC, Eckstein M, ShatzD, Martin MJ, Reddy S, Demetriades D. Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. Arch Surg. 2012;147(9): 813Y818.</span></span></li>
<li class="li1"><span class="s1"><span style="font-size: x-small;">Inaba K, Branco BC, Eckstein M, Shatz DV, Martin MJ, Green DJ, Noguchi TT, Demetriades D. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. JTrauma. 2011;71(5):1099Y1103; discussion 103.</span></span></li>
<li class="li1"><span style="font-size: x-small;"><span class="s2"></span><span class="s1">Laan D V., Vu TDN, Thiels CA, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2015:14–16. </span></span></li>
<li class="li1"><span style="font-size: x-small;"><span style="text-indent: -32pt;"> </span><span style="text-indent: -32pt;">Laan D, Berns KS, Habermann EB. Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter. 2015. doi:10.1097/TA.0000000000000889.</span></span></li>
<li class="li1"><span style="font-size: x-small;">Hecker M, Hegenscheid K, Völzke H, et al. Needle decompression of tension pneumothorax. J Trauma Acute Care Surg. 2016;80(1):119–124. doi:10.1097/TA.0000000000000878.</span></li>
<li class="li1"><span style="font-size: x-small;">Carter TE, et al. Needle Decompression in Appalachia Do Obese Patients Need Longer Needles? West J Emerg Med, 2013; 14(6): 650–2</span></li>
<li class="li1"><span class="s1"><span style="font-size: x-small;">Clemency BM, Tanski CT, Rosenberg M, May PR, Consiglio JD, Lindstrom HA. <a href="http://www.ncbi.nlm.nih.gov/pubmed/25857267" target="_blank">Sufficient catheter length for pneumothorax needle decompression: a meta-analysis</a>. Prehospital and disaster medicine. 30(3):249-53. 2015.</span></span></li>
<li class="li1"><span style="font-size: x-small;"><span class="s2"></span><span class="s1">Ferrie EP, Collum N, McGovern S. The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J. 2005;22(11):788–789.</span></span></li>
<li class="li1"><span style="font-size: x-small;"><span class="s2"></span><span class="s1">Inaba K, Karamanos E, Skiada D, et al. Cadaveric comparison of the optimal site for needle decompression of tension pneumothorax by prehospital care providers.</span></span></li>
</ol>
</div>
</div>
</div>
Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com96tag:blogger.com,1999:blog-6248057085226614935.post-37893945967049427412015-06-03T23:55:00.001-05:002015-06-05T06:16:57.591-05:00GCS: Saying What We Mean<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="p1">
<span class="s1"><b><u>The Gist</u></b>: The Glasgow Coma Scale (GCS) is widely used, yet complicated by clunkiness and poor inter-rater reliability (<a href="http://foamcast.org/2015/03/13/foamcastini-kappa/" target="_blank">explanation of kappa</a>). The Simplified Motor Score (SMS) is easier to use and equivalent, although this is prone to similar limitations. Until a better means of communicating mental status comes, it may be best to communicate what the patient is doing (opening eyes to voice, moaning incomprehensibly, localizing pain). See <a href="http://www.scancrit.com/2011/11/28/why-the-glasgow-coma-scale-has-got-to-go/" target="_blank">this ScanCrit post</a>.</span></div>
<div class="p2">
<span class="s1"></span><br /></div>
<div class="p1">
<span class="s1"><b><u>The Case</u></b>: A 29 year old male involved in a MVC with multiple traumatic injuries resulting in a prolonged ICU course at <a href="http://janusgeneral.com/">Janus General </a>had a tracheostomy placed for respiratory failure. The patient was responding appropriately to questions, following commands, opening his eyes spontaneous and lacked any signs of confusion or delirium, mouthing words, but was awaiting tracheostomy exchange for a fenestrated trach with a Passy-Muir valve. What's the patient's GCS? Does this patient's GCS reflect their mental status?</span><br />
<ul style="text-align: left;">
<li>Documented at as 10NT, 11T, and 15 by various providers. The arguments behind each: 10NT - cannot test verbal, 11T -one point for showing up, 15 -patient oriented, and saying appropriate words, just without phonation.</li>
</ul>
In medicine, we communicate through abbreviations, codes, and numbers. When we see heart rate or blood pressure values we can place these numbers in the context of our knowledge of the patient’s peers. These numbers become actionable. </div>
<div class="p2">
<span class="s1"></span><br /></div>
<div class="p1">
<span class="s1">Other critical components to the physical exam and evaluation are less easily quantified. The mental status, for example, is a key component to evaluating a patient. The GCS was developed to communicate the mental status of a head injured individual among providers during continuing care in a neurosurgical unit [1]. It is often used to track neurologic status when transferring care or over time. A particular GCS in the prehospital setting may also qualify a patient for a trauma activation in some settings. </span><br />
<span class="s1"><br /></span>
<span class="s1"><b><u>Limitations</u></b>:</span>
<span class="s1">Unfortunately, unlike other vital signs, scores don't have explicit meaning. The total GCS is often reported, yet this 13 point scale (3-15) actually has 120 different possible combinations. A patient with a GCS of 10 may be completely oriented but totally paralyzed or be moaning incomprehensibly with their eyes own and a withdrawal reflex present. Further, the sum of the GCS does not equal the parts, with regard to mortality. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12707528">Healey et al</a> used the National Trauma Database to model mortality predictions based on GCS and found that the same total sum score could be associated with double the mortality (ex: from 27% to 52%) depending on the individual components. Further, the mortality associated with scores is not linear [3]. So a GCS of 11, for instance may mean very different things for two different patients.</span></div>
<div class="p2">
<span class="s1"></span><br /></div>
<div class="p1">
<span class="s1">Yet, even if the numbers <i>did </i>mean something, the GCS has been found to have abysmal inter-rater reliability. In one study, 19 emergency physicians rated 131 patients within five minutes of each other found a concordant GCS 32% of the time (Spearson's rho 75, weighted kappa 0.40) [4]. Even in the rather protected setting of case based written scenarios, emergency providers the overall GCS accuracy was 33.1% (95% CI, 30.2-36.0) [5]. In a written mock scenario, EMS personnel (n=178) generated an accurate GCS one-quarter of time without a scoring aid and a shocking 57% with the use of a scoring aid [7].</span><br />
<br />
<b><u>Alternatives</u></b>: Given the inaccuracy of the GCS, <a href="http://www.ncbi.nlm.nih.gov/pubmed/21803448">Thompson et al</a> set out to determine whether the performance of the SMS, a truncated version of the GCS was equivalent to the GCS in a retrospective cohort of out of hospital head injured patients. In the SMS, points are awarded for obeying commands (2), localizing pain (1), and withdrawing to pain or worse (0). They found that the predictive nature of the SMS paralleled that of the GCS, although the GCS seemed to predict mortality slightly better, 0.90 using GCS (0.88-0.01) vs 0.87 using SMS (0.86-0.88) [7].</div>
<div class="p2">
<span class="s1"></span></div>
<div class="p2">
<span class="s1"></span><br /></div>
<div class="p1">
<span class="s1"><b><u>So, what do we do?</u></b></span></div>
<div class="p1">
<span class="s1">Trashing the GCS is simply not an option for most of us; yet, score cards don't seem to do us any favors. </span> For example, during a trauma activation, the expectation (at least at Janus General) is to communicate to the room the patient’s GCS. This may seem to convey more neurologic information than the actual exam discriminates. <span class="s1">R</span>ecognizing the limitations to the GCS is important in discerning both what we do with this information and how we communicate what we mean, whether it's in documentation, to other providers, or family members.<br />
<br />
<ul style="text-align: left;">
<li><span class="s1">Describe the exam. </span>With the knowledge of the subjectivity and poor reliability of the GCS, one may give the breakdown of points rather than a simple total GCS and describe the neurologic examination. Documenting descriptors in medical records this may aid other teams in tracking the patient's exam. </li>
<li>We may also engage in interdisciplinary discussions about use of simplified scoring systems such as the SMS or about the ways we communicate and document neurologic exams. </li>
</ul>
</div>
<div class="p1">
<span class="s1" style="font-size: xx-small;">References:</span></div>
<div class="p1">
<span class="s1" style="font-size: xx-small;">1. Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale. Ann Emerg Med. 2011;58(5):427–30. doi:10.1016/j.annemergmed.2011.06.009.</span></div>
<div class="p1">
<span class="s1"><span style="font-size: xx-small; text-indent: -42.6666679382324px;">2. Singh B, Murad MH, Prokop LJ, et al. Meta-analysis of Glasgow Coma Scale and Simplified Motor Score in predicting traumatic brain injury outcomes. 2013;27(March):293–300. </span></span></div>
<div class="p1">
<span style="font-size: xx-small;"><span style="text-indent: -32pt;">3. Healey C, Osler TM, Rogers FB, et al. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12707528">Improving the Glasgow Coma Scale score: motor score alone is a better predictor.</a> </span><i style="text-indent: -32pt;">J Trauma</i><span style="text-indent: -32pt;">. 2003;54(4):671–678; discussion 678–680. </span></span></div>
<div class="p1">
<span class="s1" style="font-size: xx-small;"></span></div>
<div class="p1">
<span style="font-size: xx-small;"><span style="text-indent: -32pt;">4. Beveridge R, Ducharme J, Janes L, Beaulieu S, Walter S. Interrater reliability of Glasgow Coma Scale scores in the emergency department. </span><i style="text-indent: -32pt;">Ann Emerg Med</i><span style="text-indent: -32pt;">. 2004;43(February):215–223. </span></span><br />
<span style="font-size: xx-small;"><span style="text-indent: -32pt;">5. </span><span style="text-indent: -32pt;">Bledsoe BE, Casey MJ, Feldman J, et al. Glasgow Coma Scale Scoring is Often Inaccurate. </span><i style="text-indent: -32pt;">Prehosp Disaster Med</i><span style="text-indent: -32pt;">. 2014. doi:10.1017/S1049023X14001289.</span></span></div>
<div class="p1">
<span class="s1" style="font-size: xx-small;">6. </span><span style="font-size: xx-small;">Feldman A, Hart KW, Lindsell CJ et al. Randomized controlled trial of a scoring aid to improve glascow coma scale scoring by emergency medical services providers. Ann Emerg Med. 2015 Mar;65(3):325-329.e2.</span></div>
<div class="p1">
<span style="font-size: xx-small;">7. Thompson DO, Hurtado TR, Liao MM, Byyny RL, Gravitz C, Haukoos JS. </span><a href="http://www.ncbi.nlm.nih.gov/pubmed/21803448" style="font-size: x-small;">Validation of the Simplified Motor Score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury</a><span style="font-size: xx-small;">. Ann Emerg Med. 2011;58(5):417–25. </span></div>
</div>
Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com1tag:blogger.com,1999:blog-6248057085226614935.post-59079956457008250312015-05-15T13:19:00.004-05:002015-05-15T13:19:44.861-05:00FOAM on the Spot - A Needle in a Haystack?<div dir="ltr" style="text-align: left;" trbidi="on">
<div dir="ltr" trbidi="on">
At the SAEM conference, I had the privilege of partaking in a didactic with Dr. Anand Swaminathan, Dr. Ryan Radecki, and Dr. Matt Astin entitled, "FOAM on the Spot - Integration of Online Resources into Real-Time Education and Patient Care."<br />
<br /><div style="text-align: left;">
The cornucopia of free open access medical education (FOAM) resources may be overwhelming and I get frequent requests for guidance sorting through the cornucopia of FOAM. People often have the question, "I remember hearing about this technique but I can't recall which site and want to review it..." As such, I've posted a recording of my portion of the didactic here.</div>
<div style="text-align: left;">
<br /></div>
<div style="text-align: left;">
<b><u>The Gist</u></b>:</div>
<div style="text-align: left;">
<ul style="text-align: left;">
<li>Filter FOAM by searching relevant information - <a href="http://www.foamsearch.net/">FOAMsearch</a> [<span style="text-indent: -32pt;">1</span>].</li>
<ul>
<li>Customized Google search engine of 300+ blogs related to EM/critical care plus journal articles.</li>
</ul>
<li>Engage in the community of personal librarians - <a href="https://twitter.com/@foamstarter">Twitter</a> (<a href="http://shortcoatsinem.blogspot.com/2012/05/med-student-perspective-twittermore.html" target="_blank">a few pearls on Twitter</a>)</li>
<ul>
<li>Tag others when you have a question</li>
<li>Participate in discussions and "be the librarian" for others.</li>
</ul>
<li>Use a system to stay organized and collate resources - <a href="https://itunes.apple.com/us/app/agilemd/id660518286?mt=8">AgileMD</a>.</li>
<ul>
<li>Pro - Can collate several FOAM blogs, <a href="http://www.aliem.com/pv-cards/">PV card</a>s from Academic Life in Emergency Medicine, <a href="http://www.wikem.org/wiki/Main_Page" target="_blank">WikEM</a>, and podcast notes all in one application on a smart phone/tablet.</li>
<li>Con - Presently can only build a "library" from a limited number of resources.</li>
</ul>
</ul>
</div>
<div style="text-align: left;">
As a rather junior individual, selfishly, always welcome constructive feedback on my talks. This is my experiment in crowdsourcing feedback from the FOAM community to become a better presenter.</div>
<br /></div>
<div style="text-align: center;">
<iframe allowfullscreen="" frameborder="0" height="375" mozallowfullscreen="" src="https://player.vimeo.com/video/127952521" webkitallowfullscreen="" width="500"></iframe> </div>
<div style="text-align: center;">
<a href="https://vimeo.com/127952521">FOAM on the Spot - Finding a Needle in a Haystack?</a> from <a href="https://vimeo.com/user20312246">Lauren Westafer</a> on <a href="https://vimeo.com/">Vimeo</a>.</div>
<div style="text-align: center;">
<br /></div>
<div style="margin-left: 32pt; text-indent: -32.0pt;">
1. Raine T, Thoma B, Chan TM, Lin M. FOAMSearch.net: A custom search engine for emergency medicine and critical care. <i>Emerg Med Australas</i>. 2015;(March):n/a–n/a. doi:10.1111/1742-6723.12404.</div>
</div>
Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com4tag:blogger.com,1999:blog-6248057085226614935.post-82058245228107855262014-12-29T10:41:00.002-06:002015-01-07T05:56:21.790-06:00Medicine's Third: Polypharmacy<div dir="ltr" style="text-align: left;" trbidi="on">
<b><u>The Gist</u></b>: Polypharmacy, the concurrent use of multiple medications (5+) or use of unnecessary medications, is problematic in medicine. Consider “medication related problem” on the differential diagnosis and review the patient’s medications. When prescribing a medication, consider the unwanted reactions and tailor therapy, recalling that medications frequently have subtle or additive effects that may be especially problematic in the elderly. When in doubt, send a communication to a patient's PCP.<br />
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<b><u>The Case</u></b>: A 58 y/o with a history of hypertension and diabetes presented with weakness, vomiting, and fatigue. A basic chemistry panel returned with a creatinine of 3.8 mg/dL (last value, 0.9 mg/dL). While initially it seemed as though the gentleman had prerenal acute kidney injury from vomiting, the patient revealed he had been taking both ibuprofen and naproxen for worsening arthritis, in addition to his prescribed ace-inhibitor and thiazide diuretic. See another case in <a href="http://shortcoatsinem.blogspot.com/2012/09/never-trust-your-patients-med-list.html" target="_blank">this post on medication reconciliation.</a><br />
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Newton's Third Law states:<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span><i>"For every action there is an equal and opposite reaction.” </i><br />
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We ponder this frequently looking at collisions or calculating billiard shots but I think this principle can be translated to medicine. In the medical realm we prescribe therapies for the primary action of that medication/intervention. Yet, unintended consequences abound. Despite the comically long “disclaimers” of side effects on advertisements, the additive effects, unintended as they may be, are often disguised in a patient’s presenting complaint. Further, patients are often prescribed medication to mask the side effects of another medication. Struck by this during medical school, I created my own version:<br />
Westafer’s Third Law of Medicine:<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span><i> “For every medication action there is an unequal and unintended reaction.” </i><br />
<i><br /></i>
This came up recently in a discussion on Twitter regarding a new medication for hyperkalemia, targeted to combat the side effect of elevated potassium in patients on ACE-inhibitors, <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1411487" target="_blank">ZS-9</a>. A medication for a medication side effect (with likely more broad application in reality).<br />
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<blockquote class="twitter-tweet" data-conversation="none" lang="en">
<a href="https://twitter.com/cabreraERDR">@cabreraERDR</a> <a href="https://twitter.com/EMNerd_">@EMNerd_</a> <a href="https://twitter.com/ZackRepEM">@ZackRepEM</a> <a href="https://twitter.com/EMSwami">@EMSwami</a> f/u is tough! convinced Newton's 3rd applies to laws of polypharm. meds to tx SE = problematic<br />
— Lauren Westafer (@LWestafer) <a href="https://twitter.com/LWestafer/status/537457354934341633">November 26, 2014</a></blockquote>
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Although prescriptions from the emergency department (ED) are likely a minority of offenders with regard to the volume of inappropriate medications, awareness of the role that medications may play in the patient’s complaint. Studies show that adverse drug events (ADEs) may be responsible for 10-12% of ED visits among patients > 65 years old, although the definition of adverse drug event and determination of causality vary based on the study [1-3]. A more recent Canadian database review demonstrated a lower prevalence of ADEs generating ED visits, 0.8%, but the methods leave something to be desired [4].</div>
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<span class="s1">A small study by Chin and colleagues identified ED prescriptions for analgesia, notably NSAIDs, muscle relaxants, and narcotics, as an area for future intervention [5].</span><span class="s2"><sup></sup></span><span class="s1"> Interestingly, this paper was published prior to the massive spike in opioid prescriptions; thus, this area may be even more crucial presently [6]. </span></div>
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<span class="s3"><b><u>Deleterious</u></b></span></div>
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<span class="s1">Polypharmacy, particularly in the elderly, is associated with an increase in the prevalence of falls, mortality, hospital admission, and hospital length of stay. The elderly are more susceptible to many of these effects as clearance and metabolism change with age, and elderly patients tend to be on more medications. </span></div>
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<u>Drug-drug interaction</u> - A medication alters the activity of another. Example: warfarin + ciprofloxacin -> supratherapeutic INR and may lead to increased bleeding.</div>
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<u>Drug-disease interaction</u> - Medications that should be avoided in patients with specific medical conditions. </div>
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</div>
<ul>
<li>Example: Use of aspirin 325 mg or non-steroid anti-inflammatories in patients with peptic ulcer disease.</li>
</ul>
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<u>Adverse effects</u> - Many medications have more pronounced adverse effects in elderly patients, often because the pharmacokinetics, such as renal excretion, are altered and may predispose patients to acute kidney injury, delirium, or orthostatic hypotension. Check out <a href="http://foamcast.org/2014/11/12/episode-18-falls-and-geriatrics/" target="_blank">this podcast</a> for more.</div>
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<ul>
<li>Example: Anticholinergic properties are abundant in medications, including antidepressants, antihistamines, and antipsychotics. In the elderly these effects are more pronounced and are associated with hallucinations, impaired memory, tachycardia, falls, constipation, etc.</li>
</ul>
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<u>Unnecessary</u> - Medications are frequently initiated and then continued without re-examination for appropriateness. A study of Veterans Association hospital discharges of patients age >65 y/o classified as "frail" found that 44% had at least one unnecessary medication at discharge [8]. These medications contribute to increase cost and may play a role in further drug interactions or adverse effects. </div>
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</div>
<ul>
<li>Example: A H2 blocker such as ranitidine may be prescribed for prophylaxis but the anticholinergic effects can contribute to diminished cognition, constipation, etc (see above).</li>
</ul>
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<span class="s3"><b><u>Under-recognized</u> </b></span>A prospective observational study by Hohl and colleagues of ED patients > 65 y/o in Canada found ADEs in 8.3%-12.3%, depending on the breadth of the definition of ADEs. A prospective study by Hohl et al found that many ADEs in the ED were not attributed as medication related, particularly in the older population [9]. </div>
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<span class="s3"><b><u>ED Interventions</u></b></span></div>
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</div>
<ul>
<li>Consider the Third Law of Medication when pondering the differential diagnosis. For example, <a href="http://thesgem.com/2014/10/sgem89-preventing-falling-to-pieces/" target="_blank">geriatric fall patients</a> should probably be screened for polypharmacy (What medications is the patient on? Can the problem be explained by a medication?) and while prescribing medications (Is the medication truly necessary? Will it interact with any of their medications? Does the patient need a bowel regimen or other precautions?)</li>
<li>Medication review in the ED. The ED encounter can serve as an opportunity for an outsider to glance at the patients medications to gain a sense as to whether something may be dangerous or warrant further discussion with their primary physician.</li>
<li>Judicious prescription of medications. In the ED, we often write for short courses of medication and may be lulled into the sense that these prescriptions don't matter, yet they may carry an unintended reaction. Be familiar with medications that are common offenders.</li>
<ul>
<li>The <a href="http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf" target="_blank">Beers' List</a> has a long list of medications to avoid in the elderly, but often these aren't the biggest offenders (also note the <a href="http://www.ncbi.nlm.nih.gov/pubmed/25324330" target="_blank">STOPP criteria</a>). The most common medications associated with ADEs, implicated in 67% of hospital admissions according to a national survey database, were: </li>
<ul>
<li>warfarin (33.3%)</li>
<li>insulins(13.9%)</li>
<li>oral antiplatelet agents (13.3%)</li>
<li>oral hypoglycemic agents (10.7) [1,4]</li>
</ul>
</ul>
<li>Targeted feedback to general practitioners regarding potentially problematic medications. Many health systems and electronic medical records have easy ways to send messages to primary care physicians. In the ED haste, these communications frequently take a back seat but may be important. Yet, the ACEP Geriatric ED guidelines recommend referral to PCP for any concern for polypharmacy (>5 medications) or presence of any high risk medication [10].</li>
<li>ED pharmacists. Many study authors have called for increasing the role of ED pharmacists in identifying ADE related to medications [2].</li>
</ul>
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<span class="s1"><span style="font-size: xx-small;">References:</span></span></div>
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<span class="s1"><span style="font-size: xx-small;"><span class="s1">1.</span>Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365:(21)2002-12. </span></span></div>
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<span class="s1"><span style="font-size: xx-small;">2. Banerjee A, Mbamalu D, Ebrahimi S, Khan AA, Chan TF. The prevalence of polypharmacy in elderly attenders to an emergency department - a problem with a need for an effective solution. Int J Emerg Med. 2011;4(1):22.</span></span></div>
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<span class="s1"><span style="font-size: xx-small;"><span class="s1">3. </span>Budnitz DS, Shehab N, Kegler SR, Richards CL. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147:(11)755-65.</span></span></div>
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<span style="font-size: xx-small;"><span class="s1">4.</span>Bayoumi I, Dolovich L, Hutchison B, Holbrook A. Medication-related emergency department visits and hospitalizations among older adults. Can Fam Physician. 2014;60:(4)e217-22. </span></div>
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<span style="font-size: xx-small;"><span class="s1">5. </span><span style="text-indent: -32pt;">Chin MH, Wang LC, Jin L, et al. Appropriateness of Medication Selection for Older Persons in an Urban Academic Emergency Department. </span><i style="text-indent: -32pt;">Acad Emerg Med</i><span style="text-indent: -32pt;">. 2007;6(12):1232–1242.</span></span></div>
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<span style="font-size: xx-small;"><span style="text-indent: -32pt;">6. </span><span style="text-indent: -42.6666679382324px;">Ruscitto A, Smith BH, Guthrie B. </span><span style="text-indent: -42.6666679382324px;">Changes in opioid and other analgesic use 1995-2010: Repeated cross-sectional analysis of dispensed prescribing for a large geographical population in Scotland.</span>Eur J Pain. 2015 Jan;19(1):59-66. </span></div>
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<span style="text-indent: -42.6666679382324px;"><span style="font-size: xx-small;">7. Robitaille C, Lord V, Dankoff J, et al. Emergency Physician Recognition of Adverse Drug-related Events in Elder Patients Presenting to an Emergency Department. 2005;12(3). </span></span></div>
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<span style="text-indent: -42.6666679382324px;"><span style="font-size: xx-small;">8.Hajjar ER, Hanlon JT, Sloane RJ, et al. Unnecessary drug use in frail older people at hospital discharge. J Am Geriatr Soc. 2005;53:(9)1518-23. </span></span></div>
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<span class="s1"><span style="font-size: xx-small;">9. Hohl CM, Zed PJ, Brubacher JR, Loewen PS, Purssell RA. Do Emergency Physicians Attribute Drug-Related Emergency Department Visits to Medication-Related Problems? YMEM. 2009;55(6):493–502.e4. </span></span></div>
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<span class="s1"><span style="font-size: xx-small;">10.</span></span><span style="font-size: xx-small;">American College of Emergency Physicians. <a href="file:///Users/Westafer/Downloads/Geri_ED_Guidelines_FINAL.PDF" target="_blank">Geriatric emergency department guidelines 2013</a>. </span></div>
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Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com3tag:blogger.com,1999:blog-6248057085226614935.post-82421301597977387122014-11-22T11:33:00.002-06:002014-11-24T16:22:17.637-06:00Misrepresented: EBM<div dir="ltr" style="text-align: left;" trbidi="on">
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<span class="s1"><b><u>The Gist</u></b>: Evidence based medicine (EBM) is misunderstood; it's not a randomized control trial (RCT) or "the literature." Rather, EBM is</span> the intersection of the best available evidence, clinical expertise, and patient values [1-2]. Avoid BARF (Brainless Application of Research Findings), with tips from <span class="s1"><a href="http://emergencymedicinecases.com/episode-47-walter-himmel-evidence-based-medicine-nygh-emu-conference-2014/" target="_blank">Emergency Medicine Cases</a>. </span></div>
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<span class="s1">We have a cultural problem. Clinicians are increasingly called upon to practice EBM. Yet, the term EBM does not sit well on the palate of many physicians. Conversations involving a mention of EBM have resulted in some of the following refrains...</span></div>
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<blockquote class="tr_bq">
<i><span class="s1">"See, my patients are different..."</span> </i></blockquote>
<blockquote class="tr_bq">
<i><span class="s1">"We'll never get an RCT on that..."</span> </i></blockquote>
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<i><span class="s1">"The culture is different here, I don't want to get sued."</span> </i></blockquote>
<blockquote class="tr_bq">
<i><span class="s1">"Patients don't understand, but they do hold the power with satisfaction scores."</span> </i></blockquote>
<blockquote class="tr_bq">
<span class="s1"><i>"It's cookbook medicine."</i></span></blockquote>
</div>
<div class="p1">
<span class="s1">With these words and reactionary body language, the dialogue quickly shuts down - by both parties. First, this is a shame. We should learn from one another but there seems to be a "hard stop" between many who champion EBM and those who find EBM off-putting. Second, this is a misunderstanding. EBM is not an RCT. In fact, EBM is not the best statistical methods or the rationing of care. EBM is not nihilism. </span><br />
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EBM is the intersection of the best available evidence, clinical expertise, and patient values:</div>
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<span class="s1"></span></div>
<blockquote class="tr_bq">
<i>"the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research" [1].</i></blockquote>
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<div style="text-align: center;">
<span class="s1"><b>Why, then, the misunderstanding? </b></span></div>
<div style="text-align: center;">
<span class="s1">Here are some thoughts...</span></div>
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<span class="s1"><b>Misrepresentation</b>. EBM is often used to refer to literature or studies, rather than to the application of research and evidence to particular patients and situations, using one's clinical experience (example and discussion: "<a href="http://emrespodcast.org/blog/2014/11/19/episode-245-ebm-is-crap" target="_blank">EBM is Crap</a>"). As a result, EBM may be misunderstood as a cost-cutting venture or a cookbook for medicine [3]. I have been complicit in perpetuating this misrepresentation of EBM. </span> As a novice physician-in-training with limited clinical experience, I draw predominantly upon the literature base. I have unknowingly quoted the literature, thereby proudly proclaiming my practice of EBM, while unconsciously dismissing the other components of EBM. </div>
<ul style="text-align: left;">
<li>A remedy: Remind ourselves and others that the evidence is part of the trifecta of EBM, along with the patient's values and clinical expertise. We can be clear in what we mean by EBM and refrain from referring to a body of literature as EBM. </li>
</ul>
<span class="s1"><b>Zeal</b>. A religiosity exists amongst many champions of EBM, or people who believe they are championing EBM. We tout our pyramids of evidence and may scoff at a lack of evidence or rigorous trials. This may be off-putting as not all fields are amenable to RCTs and patient populations vary. Moreover, there's a human tendency to form a reactionary attitude when someone exerts a strong identity [4]. Hence, EBM zeal may engender an anti-EBM attitude and cause people to be wary of solid practice changing evidence.</span><br />
<ul style="text-align: left;">
<li>A remedy: While championing good research and employing the best available evidence, we can balance our enthusiasm with important caveats and understand the importance for tailored approaches for patients. Gentle education about EBM rather than diatribes may aid individuals in understanding the values of EBM beyond evidence.</li>
</ul>
</div>
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<span class="s1"><b>Fear</b>. People like to be right. We may reflexively become defensive when we are (possibly) wrong. EBM or "literature" can be used in an antagonizing way and, subconsciously, a way to exert a feeling of superiority. "You haven't read that study?"</span><br />
<ul style="text-align: left;">
<li>A remedy: Understand that unlearning in medicine is difficult. Aggressive assertions may push people further away. Think of it as a Kubler-Ross like grief cycle, as explained in <a href="http://shortcoatsinem.blogspot.com/2014/02/the-unlearning-process.html" target="_blank">this post</a>. This may help us become more cognitively flexible, understand the reticence of others, and perhaps make our points more effectively. </li>
</ul>
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<span class="s1"><br /></span></div>
</div>
<blockquote class="twitter-tweet" data-conversation="none" lang="en">
<a href="https://twitter.com/LWestafer">@LWestafer</a> <a href="https://twitter.com/sandnsurf">@sandnsurf</a>
Change as a grief reaction - Kubler Ross curve model of change/grief <a href="http://t.co/4w2I0BD74o">pic.twitter.com/4w2I0BD74o</a><br />
— Simon Carley (@EMManchester) <a href="https://twitter.com/EMManchester/status/441574702809489408">March 6, 2014</a></blockquote>
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<span class="s1"><b>Confusion</b>. Historically, researchers, clinicians, physicians in training, and allied health professionals have limited understanding of fundamental statistics [5,6]. As such, we may not understand what we're reading or how it applies to our patient population. We may have difficulty understanding why something we believed was proper at one time is no longer the case. Often, this is because the research was, in fact, initially wrong or misleading [7]. </span><br />
<ul style="text-align: left;">
<li>A remedy: Read. <a href="http://emrespodcast.org/blog/2014/11/14/episode-24-what-do-i-read-and-how-do-i-do-it" target="_blank">This podcast</a> proffers tips on getting started; however, even the most seemingly rigorous papers published in high impact journals are subject to bias (publication bias and otherwise), which can be difficult to parse through. For example, the oseltamivir (tamiflu) recommendations from Cochrane changed after they were allotted access to data, demonstrating the profound impact of publication bias [<a href="http://www.ncbi.nlm.nih.gov/pubmed/24718923" target="_blank">Jefferson et al</a>]. More on this <a href="http://shortcoatsinem.blogspot.com/2012/09/overestimates-underestimates-and-things.html" target="_blank">here</a>.</li>
</ul>
</div>
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<span class="s1"><b>Time</b>. The </span>number of journal articles needed to read (NNR) to obtain valid and relevant information is typically cited as 20-200, an insurmountable task [8]. The process of trolling through the literature is time consuming and may be overwhelming. Frustration can turn into apathy, confusion, and mistrust.<br />
<ul style="text-align: left;">
<li>A remedy: Use Free Open Access Medical education (FOAM) resources to complement regular reading. Sites such as <a href="http://thesgem.com/" target="_blank">The Skeptics Guide to Emergency Medicine</a>, the <a href="http://lifeinthefastlane.com/education/research-and-reviews/" target="_blank">Life in the Fastlane Research & Reviews</a>, and <a href="https://t.co/1jNJAbpsYi" target="_blank">HEFT EMcast</a> exist as ways to keep up to date on important literature. </li>
</ul>
<div>
<b>There are legitimate issues with EBM</b>. Evidence is often subject to the biases of industry and legislative bodies. Guidelines or recommendations billed as "EBM" may be hijacked by individuals with conflicts of interest or other agendas. Further, the grading of evidence isn't always objective or consistent, as seen by the grading of evidence for thromboylitics in acute ischemic stroke listed in the ACEP clinical policy. In addition, guidelines harness EBM and disseminate the body of evidence to practitioners. For example, the 2008 AHA/ACC guidelines are based largely on low levels of evidence and expert opinion, many of whom have financial conflicts of interest. Only 11% of the recommendations were based on high quality evidence [9]. </div>
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So, while EBM has imperfections in concept, representation, and implementation, the model incorporates the primary things we, as providers, care about - the evidence, the patient, and clinical experience. Let's understand what EBM means and apply the term and principles appropriately.</div>
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<div style="text-align: left;">
<span style="font-size: xx-small;"><br /></span></div>
<span style="font-size: xx-small;">References:</span><br />
<span style="font-size: xx-small;">1. Sackett DL, Rosenberg WM, Gray JAM, et al. E<a href="http://www.bmj.com/content/312/7023/71" target="_blank">vidence based medicine: what it is and what it isn’t</a>. BMJ. 1996;312(7023):71–72. </span></div>
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<span style="font-size: xx-small;">2. Greenhalgh T, Howick J<span style="background-color: white; font-family: arial, helvetica, clean, sans-serif; line-height: 17.9987869262695px;">,</span> Maskrey N. <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4056639/" target="_blank">Evidence based medicine: a movement in crisis</a>? BMJ 2014;348:g3725</span></div>
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<span style="font-size: xx-small;"><span style="text-indent: -32pt;">3. Straus SE, McAlister FA. <a href="http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=80509&tool=pmcentrez&rendertype=abstract." target="_blank">Evidence-based medicine: a commentary on common criticisms</a>. </span><i style="text-indent: -32pt;">CMAJ</i><span style="text-indent: -32pt;">. 2000;163(7):837–41. </span></span><br />
<span style="font-size: xx-small;"><span style="text-indent: -32pt;">4. Maalouf A. In the Name of Identity: Violence and the Need to Belong. New York: Penguin Books, 2000.</span></span><br />
<span style="font-size: xx-small; text-indent: -42.6666679382324px;">5. </span><span style="font-size: xx-small;">Windish D, Huot S, Green M. Medicine residents’ understanding of the biostatistics and results in the medical literature. Jama. 2007;298(9). </span><br />
<span style="font-size: xx-small; text-indent: -42.6666679382324px;">6. </span><span style="font-size: xx-small;">Mavros MN, Alexiou VG, Vardakas KZ, Falagas ME. Understanding of statistical terms routinely used in meta-analyses: an international survey among researchers. PLoS One. 2013;8(1):e47229. </span><br />
<span style="font-size: xx-small; text-indent: -42.6666679382324px;">7.</span><span style="font-size: xx-small;">Ioannidis JP a. How many contemporary medical practices are worse than doing nothing or doing less? Mayo Clin Proc. 2013;88(8):779–81.</span><br />
<span style="font-size: xx-small; text-indent: -42.6666679382324px;">8. McKibbon KA, Wilczynski NL, Haynes RB. What do evidence-based secondary </span><span style="font-size: xx-small; text-indent: -42.6666679382324px;">journals tell us about the publication of clinically important articles in primary </span><span style="font-size: xx-small; text-indent: -42.6666679382324px;">care journals? BMC Med. 2004;2:33. </span><br />
<span style="font-size: xx-small; text-indent: -42.6666679382324px;">9. </span><span style="font-size: xx-small; text-indent: -42.6666679382324px;">Tricoci P1, Allen JM, Kramer JM, et al. </span><span style="font-size: xx-small;"> </span><span style="font-size: xx-small; text-indent: -42.6666679382324px;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/19244190" target="_blank">Scientific evidence underlying the ACC/AHA clinical practice guidelines</a>. </span><span style="font-size: xx-small;">JAMA. 2009 Feb 25;301(8):831-41.</span></div>
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Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com0tag:blogger.com,1999:blog-6248057085226614935.post-49642158387279284892014-11-08T09:02:00.000-06:002014-11-08T09:02:09.515-06:00SBO Ultrasound<div dir="ltr" style="text-align: left;" trbidi="on">
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<b><u>The Gist</u>: </b>As mentioned in <a href="http://shortcoatsinem.blogspot.com/2013/12/small-bowel-obstruction-likely-story.html" target="_blank">this post</a>, the operating characteristics of historical and physical features are suboptimal in small bowel obstruction (SBO). Bedside ultrasound has better operating characteristics and is one of the easier scans to perform and read. Assuming others like to make their lives easier, I gave a talk on this; but professionals have created a tutorial at <a href="http://www.ultrasoundpodcast.com/2012/10/episode-36-small-bowel-obstruction/" target="_blank">The Ultrasound Podcast tutorial</a>.</div>
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I delivered a quick talk at the <a href="http://controversies-and-consensus.com/" target="_blank">Controversies and Consensus in Emergency Medicine Conference</a> on ultrasound for SBO, a modality that I've found great utility for in my developing practice. As a believer in Free Open Access Medical education (<a href="http://www.lifeinthefastlane.com/foam" target="_blank">FOAM</a>) and with hopes that, as a novice I might receive some constructive criticism to help me become better, I have posted the recording.<br />
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<iframe allowfullscreen="" frameborder="0" height="375" mozallowfullscreen="" src="//player.vimeo.com/video/111273084" webkitallowfullscreen="" width="500"></iframe> </div>
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<a href="http://vimeo.com/111273084">SBO</a> from <a href="http://vimeo.com/user20312246">Lauren Westafer</a> on <a href="https://vimeo.com/">Vimeo</a>.</div>
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<b><u>A Few Tidbits (some redundancy from <a href="http://shortcoatsinem.blogspot.com/2013/12/small-bowel-obstruction-likely-story.html" target="_blank">prior post</a>):</u></b> </div>
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<b>Time</b>. Ultrasound for SBO is quick and easy and can be performed in conjunction with the history and physical exam in appropriate patients. This may alleviate the time to definitive diagnosis (say CT or surgical evaluation), treatment, and/or disposition.* Furthermore, sometimes we see things we don't expect on ultrasound. Familiarity with US findings of SBO may make sense of dilated loops of bowel or altered peristalsis encountered during a gallbladder or aorta scan for abdominal pain. Conversely, there are times when SBO may be suspected and a quick ultrasound may reveal an alternative diagnosis that may grossly change management (examples in talk).</div>
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<b>X-rays are out for SBO</b>. Bedside ultrasound has better operating characteristics than plain films with fewer instances of equivocal results. Sometimes plain films are crucial to evaluate for pneumoperitoneum but most patients with abdominal pain don't fall in this category. Indeed, <a href="http://www.acr.org/~/media/832F100277004BC69A8C818C7C9BFF33.pdf" target="_blank">The American College of Radiology</a> conclusion on plain films in suspected SBO</div>
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"In light of these inconsistent results, it is reasonable to expect that abdominal radiographs will not be definitive in many patients with a suspected SBO. It could prolong the evaluation period and add radiation exposure while often not obviating the need for additional examinations, particularly CT" [5].</blockquote>
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<b>Limitations</b>.</div>
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<ul>
<li>Ileus vs. SBO - while US beats plain films with regard to percentage of ambiguous scans, ultrasounds can be equivocal as well.</li>
<li>Cause of obstruction/Transition point not well elucidated. In patients with recurrent SBO from malignancy or adhesions and this may be less important to the managing team and surgeons often stop ordering CT scans if the presentation is consistent with prior presentations. </li>
<li>Consultant access to images obtained at the bedside.</li>
</ul>
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Note: I have not included surgical consultants requiring a CT scan as part of the limitations. The surgical literature recognizes the capacity of US to diagnose SBO, although this is not yet widely adopted [6]. However, despite common assumptions, surgeons don't require a CT scan for every recurrent SBO. As a result, sometimes a positive ultrasound, followed by plain film, may be enough in these patients who will undergo conservative management. Have a chat with each consultant, they're not always as inflexible as we make them out to be. </div>
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*<a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0CCAQFjAA&url=http%3A%2F%2Fclinicaltrials.gov%2Fshow%2FNCT02190981&ei=qFpdVIOkKPjLsATbvYCgDA&usg=AFQjCNHV97LR_N29pVb8tLtY2MG9BX-MXg&sig2=-T_FWTTNIJXZBx0d_e6Zjw&bvm=bv.79189006,d.cWc" target="_blank">NCT02190981</a> pending with LOS as secondary outcome</div>
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<span style="font-size: xx-small;"><br /></span><span style="font-size: xx-small;">References:</span></div>
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<span style="font-size: xx-small;">1. Carpenter CR, Pines JM. The end of X-rays for suspected small bowel obstruction? Using evidence-based diagnostics to inform best practices in emergency medicine. Acad. Emerg. Med. 2013;20(6):618–20.</span></div>
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<span style="font-size: xx-small;">2. Taylor MR, Lalani N. Adult small bowel obstruction. Acad. Emerg. Med. 2013;20(6):528–44.</span></div>
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<span style="font-size: xx-small;">3. Böhner H, Yang Q, Franke C, Verreet PR, Ohmann C. Simple data from history and physical examination help to exclude bowel obstruction and to avoid radiographic studies in patients with acute abdominal pain. Eur. J. Surg. 1998;164(10):777–84. </span></div>
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<span style="font-size: xx-small;">4. </span><span style="font-size: xx-small;">Jang TB, Schindler D, Kaji AH. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J. 2011 Aug;28(8):676-8.</span></div>
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<span style="font-size: xx-small;">5. </span><span style="font-size: xx-small;">Katz DS, Baker ME, Rosen MP, Lalani T, et al, Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria® suspected small-bowel obstruction. Reston (VA): American College of Radiology (ACR); 2013. 10 p.</span><span style="font-size: xx-small;"><br />6. </span><span style="font-size: xx-small;">Maung AA, Johnson DC, Piper GL et al. Evaluation and Management of Small-Bowel Obstruction. J Trauma. 73(5):S362-S369, November 2012</span></div>
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Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com0tag:blogger.com,1999:blog-6248057085226614935.post-60674088182865848302014-10-11T07:30:00.002-05:002015-10-07T11:34:55.299-05:00Euboxia - Not Necessary (Or Necessarily Normal)<div dir="ltr" style="text-align: left;" trbidi="on">
<b><u>The Gist:</u></b> In medicine, we historically strive towards achieving values that fall within a reference range, or are normal, a phrase coined "euboxia" [1]. Targeting treatments to normalize values may not result in patient-oriented benefit and may cause harm. We must also consider that normal values may not necessarily be normal for our patients. Data fatigue, the exposure to copious data, may lead to ignoring values that are not flagged as abnormal, regardless of the appropriateness for a patient.<br />
<blockquote class="tr_bq">
"'<b>Euboxia</b>' (from the Greek 'eu' meaning good, normal or happy, and 'box' from the tradition of writing physiological variables in boxes) is a colloquial word used in many North American and other hospitals to describe the state of apparent perfection aimed at by residents by the time they present their patients on morning rounds" - MC Meade [2].</blockquote>
<b>Euboxia Is Not Always Necessary</b><br />
Chris Nickson's Free Open Access Medical education (<a href="http://www.lifeinthefastlane.com/foam" target="_blank">FOAM</a>) <a href="http://lifeinthefastlane.com/ccc/euboxia-abnormality/" target="_blank">post on Euboxia</a> highlights some of the pitfalls with this obsession with normalcy. He also delivered a talk Euboxia and (ab)Normality at <a href="http://smacc.net.au/" target="_blank">SMACC Gold</a> which will hopefully be available on the <a href="https://itunes.apple.com/us/podcast/smacc/id648203376?mt=2" target="_blank">SMACC podcast</a> in the near future. A few examples include:<br />
<ul style="text-align: left;">
<li><u><a href="http://shortcoatsinem.blogspot.com/2013/01/whats-your-trigger.html" target="_blank">Hemoglobin transfusion trigger in anemia</a></u> - Studies such as <a href="http://www.nejm.org/doi/full/10.1056/NEJM199902113400601" target="_blank">TRICC</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/14707558" target="_blank">CRIT</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/18156879" target="_blank">SOAP</a>, and <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1406617" target="_blank">TRISS</a> demonstrate that transfusion targets of more "normal" hemoglobin levels is not advantageous and may incur increased risks. As such, transfusion triggers, in the absence of active myocardial ischemia, have moved to <7 g/dL while uptake of this trigger remains low in some communities [4]. </li>
<li>Oxygen saturation in COPD - Unless patients are under duress, guidelines suggest patients with COPD have oxygen saturations targeted to 88-92% rather than the 98-100% more often associated with perfection [5]</li>
<li>Blood gas and saturations in ARDS - Guidelines for ventilation in patients with ARDS aim to protect the lungs using low tidal volumes and plateau pressures at the expense of allowing a pH of 7.20, permissive hypercapnia, and lower oxygen saturations of 88-95% (paO2 55-80 mmHg). Correction of these lab abnormalities may come at the cost of additional lung damage by means of higher pressures or volumes and are thus discouraged [6].</li>
</ul>
<b>Euboxia Is Not Necessarily Normal</b><br />
Euboxia, however, may fool also practitioners into a false sense of security. Failure to truly <i>see</i> a value that appears normal and isn't flagged, red, or outside of the box may be problematic. A few examples: <br />
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<b>Normotension - </b>Hypotension typically refers to systolic blood pressure <90 mmHg or a drop in systolic blood pressure >40 mmHg. The latter part of this definition is often unable to be determined (due to lack of information) or forgotten. The trauma literature seems to have solidified around the notion that the widely accepted definition of hypotension does not apply to many trauma patients, particularly those > 65 years old, and that 110 mmHg is probably a better cutoff [9-12]. While these recommendations have been out since 2011, 90 mmHg remains the common cut point for hypotension.<br />
<ul style="text-align: left;">
<li>The CDC triage guidelines/"National Trauma Triage Protocol" have suggested <110 mmHg as the new hypotension guideline in patients > 65 years of age as multiple registry studies have demonstrated that an SBP <110 mmHg is associated with increased mortality and has an improved AUC compared with other blood pressure cut offs [9]. </li>
<ul>
<li>An abstract presented at AAST in 2014 found that patients >65 y/o with an SBP 90-109 mmHg had an odds of mortality of 9.7 (95% CI 8.7-10.8, p<0.01). This survey study found improved, but terrible sensitivity for Trauma Center Need (ISS>15, ICU admit, urgent OR, or ED death) with the higher SBP cut-off [10].</li>
</ul>
</ul>
<b>Normal White Blood Cell Count (WBC)</b> - Leukocytosis is often used as a predictor of infection/inflammation and historically loved by surgical services, yet the operating characteristics don't perform that well. During a lecture as a medical student Dr. Sean Fox (<a href="http://pedemmorsels.com/" target="_blank">PEM Morsels</a>) shared the following perspective on the WBC, "WBC is the last bastion of the intellectually destitute." <br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifJteuNjoJx6y78rostnQB6z9wLna8AOoAQV4imXGL7u8lQNKpI81tsZ3J7bRVqEUs3ImYz2kO1YfzOig7ALUAecLV-ZGg8EazCxKxFH0X9SAvtuSFOLJkK20OKIdpmwkDg3A2WPLCZog/s1600/Screen+Shot+2014-10-11+at+12.11.08+AM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="513" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifJteuNjoJx6y78rostnQB6z9wLna8AOoAQV4imXGL7u8lQNKpI81tsZ3J7bRVqEUs3ImYz2kO1YfzOig7ALUAecLV-ZGg8EazCxKxFH0X9SAvtuSFOLJkK20OKIdpmwkDg3A2WPLCZog/s1600/Screen+Shot+2014-10-11+at+12.11.08+AM.png" width="640" /></a></div>
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I soon discovered that the sensitivity and specificity of leukocytosis, or the absence thereof, wasn't helpful in many situations.</div>
<ul style="text-align: left;">
<li>In acute cholecystitis, for example, the WBC proves unhelpful as demonstrated by the following operating characteristics for leukocytosis: +LR 1.5; -LR 0.6; Sensitivity 63%; Specificity 57% [13]. Thus, a normal WBC does not help rule out acute cholecystitis. Similarly, a normal WBC does not exclude acute appendicitis, although values <8 (a normal value) may have some utility in this regard according to <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=10.1001%2Fjama.298.4.438" target="_blank">Bundy et al</a>. </li>
</ul>
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<b>Normal Potassium in DKA</b> - The reference range for potassium runs approximately 3.5-5 mEq/L. Patients presenting in DKA may have low normal potassium concentrations but have severe total body potassium deficits. As a result, professional societies recommend withholding insulin if a patient has a potassium <3.5 and supplementing potassium even when values are well within the upper "normal" limit of 4-5 mEq/L [14]. Despite these teachings and nearly habitual practice, without mindful attention to the potassium the "normal" lab value could easily be ignored. </div>
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<b>Normal Lactate - </b>Lactate is beloved in Emergency Department (ED) care and it's well accepted that elevated lactate values predict mortality. Yet, normal lactate levels may be falsely reassuring. Lactate has been used as screening test in mesenteric ischemia as small, early reports yielded a sensitivity of 100% [15]. More recent analysis, however, show that the +LR 1.7 (1.4–2.1), -LR<span class="Apple-tab-span" style="white-space: pre;"> </span>0.2 (0–2.9) for L-lactate. The -LR for lactate crosses 1.0, demonstrating that a normal lactate is not useful in crossing mesenteric ischemia off the list [16]. While we may cognitively understand this notion, in practice I think we quite often feel reassured by normal lactates (or reassure the admitting teams).</div>
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<b><u>What to do?</u></b><br />
Data overload and obsession may engender a sort of "data fatigue." It is difficult to notice abnormalcy in data that may appear, for most individuals, normal. This may be particularly arduous in a sea of numbers. Furthermore, our attention is typically drawn to the red or flagged "abnormal" numbers. This is not to suggest that we should agonize over every value and cannot trust anything "normal." Rather, it seems that the signal in medicine is that tests and parameters are only as good as the context of the patient and the provider interpreting them. Here's what I'm trying, to combat my own data fatigue and subconscious euboxic thinking:<br />
<ul style="text-align: left;">
<li>Think about a patient's clinical context, which requires mindfulness in the fast pace and overwhelming environment we call an ED.</li>
<li>Order a test? Review the results (really), paying attention and process the results in the context of the patient.</li>
<li>If possible and appropriate, prevent data overload and data fatigue by ordering tests that will add value to the care of the patient.</li>
</ul>
<span style="font-size: xx-small;">References:</span><br />
<span style="font-size: xx-small;">1. Reade MC. <a href="http://www.ncbi.nlm.nih.gov/pubmed/23808501" target="_blank">The pursuit of oxygen euboxia</a>. Anaesth Intensive Care. 2013;41(4):453–5.</span><br />
<span style="font-size: xx-small;">2. <span style="text-indent: -32pt;"> </span><span style="text-indent: -32pt;"></span><span style="text-indent: -32pt;">Reade MC. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20001869" target="_blank">Should we question if something works just because we don’t know how it works? </a></span><i style="text-indent: -32pt;">Crit Care Resusc</i><span style="text-indent: -32pt;">. 2009;11(4):235–6. </span></span><br />
<span style="font-size: xx-small; text-indent: -32pt;">3. Nickson CN. <a href="http://lifeinthefastlane.com/dont-put-your-patient-in-a-box/" target="_blank">Don't Put Your Patient In A Box</a>. Life in the Fast Lane. </span><br />
<div style="text-indent: 0px;">
<span style="font-size: xx-small;"><span style="text-indent: -32pt;">4. </span><span style="text-indent: -42.6666679382324px;">Carson JL, Grossman BJ, Kleinman S et al. </span><a href="http://www.ncbi.nlm.nih.gov/pubmed/22751760" target="_blank">Red blood cell transfusion: a clinical practice guideline from the AABB.</a>*Ann Intern Med. 2012 Jul 3;157(1):49-58.</span></div>
<div style="text-indent: 0px;">
<span style="font-size: xx-small;">5. Abdo WF, Heunks LM. <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=23106947" target="_blank">Oxygen-induced hypercapnia in COPD: myths and facts.</a> Crit Care. 2012 Oct 29;16(5):323. </span></div>
<div style="text-indent: 0px;">
<span style="font-size: xx-small;">6.The Acute Respiratory Distress Syndrome Network (2000) </span><a href="http://www.nejm.org/doi/full/10.1056/NEJM200005043421801" style="font-size: x-small;" target="_blank">Ventilation with low volumes as compared with traditional tidal volumes for acute lung injury and acute respiratory distress syndrome</a><span style="font-size: xx-small;">.</span><span style="font-size: xx-small;"> N Engl J Med 342:1301-1308 </span></div>
<div style="text-indent: 0px;">
<span style="font-size: xx-small;">7. Putensen C, Theuerkauf N, Zinserling J et al. <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=19841457" target="_blank">Meta-analysis: ventilation strategies and outcomes of the acute respiratory distress syndrome and acute lung injury</a>. Ann Intern Med. 2009 Oct 20;151(8):566-76.</span></div>
<div style="text-indent: 0px;">
<span style="font-size: xx-small;">8. Petrucci N, Iacovelli W. <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=15106222" target="_blank">Ventilation with lower tidal volumes versus traditional tidal volumes in adults for acute lung injury and acute respiratory distress syndrome</a>. Cochrane Database Syst Rev. 2004;(2):CD003844.</span></div>
<div style="text-indent: 0px;">
<span style="font-size: xx-small;"><span style="text-indent: -42.6666679382324px;">9. <a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0CCAQFjAA&url=http%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fpreview%2Fmmwrhtml%2Frr6101a1.htm&ei=H6g4VMzJLo60yASKo4BQ&usg=AFQjCNHydDrpe4IKwdVD36vDG1R8-7UYzQ&sig2=tGm9q62eu-L80pU81UaeBw&bvm=bv.77161500,d.aWw" target="_blank">Guidelines for Field Triage of Injured Patients </a></span><span style="text-indent: -42.6666679382324px;"><a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0CCAQFjAA&url=http%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fpreview%2Fmmwrhtml%2Frr6101a1.htm&ei=H6g4VMzJLo60yASKo4BQ&usg=AFQjCNHydDrpe4IKwdVD36vDG1R8-7UYzQ&sig2=tGm9q62eu-L80pU81UaeBw&bvm=bv.77161500,d.aWw" target="_blank">Recommendations of the National Expert Panel </a></span><span style="text-indent: -42.6666679382324px;"><a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0CCAQFjAA&url=http%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fpreview%2Fmmwrhtml%2Frr6101a1.htm&ei=H6g4VMzJLo60yASKo4BQ&usg=AFQjCNHydDrpe4IKwdVD36vDG1R8-7UYzQ&sig2=tGm9q62eu-L80pU81UaeBw&bvm=bv.77161500,d.aWw" target="_blank">Field Triage, 2011</a>. MMWR 2012;61(1):14.</span></span></div>
<span style="font-size: xx-small;"><span style="text-indent: -42.6666679382324px;">10. Brown JB, Gestring ML, Forsythe RM et al. <a href="http://www.ncbi.nlm.nih.gov/pubmed/25757122" target="_blank">Systolic Blood PRessure Criteria in the National Trauma Triage Protocol for Geriatric Trauma</a></span><span style="text-indent: -42.6666679382324px;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/25757122" target="_blank">: 110 is the new 90</a>. Oral Abstracts, AAST July 2014.</span></span><br />
<span style="font-size: xx-small;"><span style="text-indent: -42.6666679382324px;">11. Eastridge BJ, Salinas J, McManus JG, et al.</span><a href="http://www.ncbi.nlm.nih.gov/pubmed/17693826" style="text-indent: -42.6666679382324px;" target="_blank"> Hypotension begins at 110 mm Hg: redefining “hypotension” with data</a><span style="text-indent: -42.6666679382324px;">. J Trauma. 2007;63(2):291–7; discussion 297–9.</span></span><br />
<span style="font-size: xx-small;"><span style="text-indent: -42.6666679382324px;">12. Oyetunji TA,</span><span style="text-indent: -42.6666679382324px;"> </span><span style="text-indent: -32pt;">Chang DC, Crompton JG, et al. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21768435" target="_blank">Redefining hypotension in the elderly: normotension is not reassuring</a>. </span><i style="text-indent: -32pt;">Arch Surg</i><span style="text-indent: -32pt;">. 2011;146(7):865–9.</span></span><br />
<span style="font-size: xx-small;"><span style="text-indent: -32pt;">13. </span><span style="text-indent: -32pt;"> </span><span style="text-indent: -32pt;">Trowbridge RL, Rutkowski NK, Shojania KG. Does This Patient Have Acute Cholecystitis? </span><i style="text-indent: -32pt;">JAMA</i><span style="text-indent: -32pt;">. 2003;289(1):80–86.</span></span><br />
<span style="font-size: xx-small;"><span style="text-indent: -32pt;">14. </span>Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335–43. </span><br />
<span style="font-size: xx-small;">15. </span><span style="font-size: xx-small;">Lange H, Jäckel R. </span><span style="font-size: xx-small;">Usefulness of plasma lactate concentration in the diagnosis of acute abdominal disease. </span><span style="font-size: xx-small;">Eur J Surg. 1994;160(6-7):381.</span><br />
<span style="font-size: xx-small;">16. Cohn B. <a href="http://www-ncbi-nlm-nih-gov.ezproxy.library.tufts.edu/pubmed/?term=10.1016%2Fj.annemergmed.2014.01.003" target="_blank">Does This Patient Have Acute Mesenteric Ischemia</a>? Ann Emerg Med. 2014 Jan 30</span><br />
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Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com0tag:blogger.com,1999:blog-6248057085226614935.post-50816971431476870812014-08-16T14:04:00.000-05:002014-08-17T15:59:59.503-05:00Open to Interpretation: Do Not ______<div dir="ltr" style="text-align: left;" trbidi="on">
<b><u>The Gist</u></b>: DNR (Do Not Resuscitate) orders are subject to variable interpretation by providers and patients whereas Physician Orders for Life Sustaining Treatments (POLST) are becoming increasingly common and have more specific, meaningful directives. As critical care providers, we should understand the meanings behind each of these documents, as well as the limitations. The <a href="http://podcasts.elsevierhealth.com/ymem/aug2014.mp3" target="_blank">Annals of Emergency Medicine August 2014 podcast</a> has a fantastic Free Open Access Medical education (<a href="http://www.lifeinthefastlane.com/foam" target="_blank">FOAM)</a> discussion of DNRs and POLSTs as they pertain to the physician in the Emergency Department (ED). Despite these helpful aids, nothing replaces discussions with patients and their family members or health care proxies about treatment that is clinically appropriate and congruent with the patient's goals.<br />
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<b><u>The Case</u></b>: A 82 y/o male presents to <a href="http://janusgeneral.com/" target="_blank">Janus General</a> in respiratory distress, 72% on 4L of oxygen via nasal cannula up to 92% on 15L non-rebreather from the rehab facility where he is recuperating from a fractured tibia. Previously in excellent health, he has been febrile and confused for the past two days with radiographic and clinical diagnosis of pneumonia and therapy with azithromycin and ceftriaxone at the facility. Patient has a signed DNR order and an advance directive stating that for an irreversible/terminal condition the patient would not want artificial support. The health care proxy is unavailable by phone and the patient lacks a clear sensorium but is in respiratory distress, appears septic, and has a chest x-ray with clear infiltrate and interstitial pattern that may indicate early ALI/ARDS.<br />
<ul style="text-align: left;">
<li>What should happen? BiPAP? Morphine? Intubation? What's this patient's disposition? At <a href="http://janusgeneral.com/" target="_blank">Janus General</a>, the providers in the ED and the inpatient team disagreed about what the patient's course should be, whether or not the condition was "reversible," and what the patient would want in this situation. </li>
</ul>
In a recent post I shared a talk on <a href="http://shortcoatsinem.blogspot.com/2014/07/critical-care-end-of-life-in-ed.html" target="_blank">tips for palliative care in the ED setting</a>. Despite our best efforts in the ED, uncovering documents such as DNRs and advance care directives may obscure the picture more than provide clarity. I discovered on rotations through critical care units that the presence of a DNR seemed to bias both myself and my colleagues regarding the care of patients that was unrelated to the performance of cardiopulmonary resuscitation. I believe we acted based on what we felt was clinically appropriate in the patient's situation but upon closer inspection, I think we were occasionally subject to a touch of another form of bias - The DNR bias.<br />
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<b><u>The Do Not Resuscitate (DNR)</u>: </b>A medical order that specifies one not initiate cardiopulmonary resuscitation (CPR) in a patient who has died (pulseless/apneic) [1].<br />
<ul style="text-align: left;">
<li>Technically, applies to a dead patient.</li>
<li>Does not indicate a patient's general wishes for medical care, only their preference regarding initiation of CPR. </li>
</ul>
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<b><u>The Problem With The DNR</u></b></div>
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DNR orders, which technically only speak to a patient's wishes to receive CPR, have variable interpretations amongst healthcare professionals and, likely, patients [2-4]. The issue lies in the word "resuscitate," which may be used to include fluids, antibiotics, vasopressors, advanced means of ventilation or, at the extreme, CPR.</div>
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<ul style="text-align: left;">
<li>The TRIAD II-IV studies surveyed EMS personnel, physicians, and medical students respectively and provided the participants with an advance care directive as well as case scenarios. The participants then indicated whether a patient was a DNR or full code and the appropriate action. Both physicians and EMS providers performed poorly and variably, indicating that the directives were not clear [2,4].</li>
</ul>
DNR orders may mean that patients receive care that differs from their wishes or standard medical practice. This demonstrates that the DNR bias may exist, even if it's partially a reflection of a patient's general clinical situation.</div>
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<ul style="text-align: left;">
<li>Aspirin is a non-intensive and relatively safe standard intervention in patients with acute myocardial infarction (AMI) (<a href="http://www.thennt.com/nnt/aspirin-for-major-heart-attack/" target="_blank">NNT=42, NNH=167</a>). In patients with an AMI, the Worcester Heart Attack study demonstrated a negative association between aspirin administration and those patients with a DNR [5]. Of note, the individuals in this study with a DNR were "sicker," meaning they had comorbidities or other poor prognostic signs such as shock. Other markers of more aggressive care such as PCI, thrombolytics, and cardiac catheterization, were also reduced in the DNR cohort. Therefore, it is possible that this association may represent the belief that these patients were not candidates for these interventions independent of their DNR status.</li>
<li>The Worcester Heart Failure study also demonstrated that patients with a DNR were less likely to receive any quality assurance intervention than those with no DNR (HR 0.52, adjusted HR 0.63- 0.4-0.99) [7]. This may have been appropriate given the clinical situation of the patients.</li>
</ul>
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But, it's not all about the co-morbidities:</div>
<ul style="text-align: left;">
<li>Residents in Missouri nursing homes with a DNR were less likely to be hospitalized following a LRTI (OR 0.69; 0.49-0.97). Compared with the Worcester Heart Attack study, patients with comorbidities were more likely to receive aggressive treatment (hospitalization) than those without a DNR (excluded patients with a Do Not Hospitalize order) [7]. </li>
</ul>
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<u style="font-weight: bold;">The Physician Order for Life Sustaining Treatment (POLST)</u><span style="font-weight: bold;"> - </span>Physician orders, on a standardized form, that are designed to transfer amongst settings, following an individual from home to hospital and nursing home/rehabilitation facilities. Most states have POLST programs or are in the process of developing them these programs (<a href="http://www.polst.org/programs-in-your-state/" target="_blank">map of programs</a>) and some have online registries for providers, mitigating issues with located print copies. <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=24743101" target="_blank">Jesus et al</a> give a good rundown of POLSTs in the ED in Annals of Emergency Medicine, August 2014 [8].<br />
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These may be more meaningful in the critical setting of the ED as they may indicate a patient's preference for a broad array of clinical conditions encountered. For example, in Massachusetts, the back portion of the <a href="http://molst-ma.org/sites/molst-ma.org/files/MOLST%20Form%20and%20Instructions%208.10.13%20FINAL.pdf" target="_blank">MOLST</a> resembles a sushi menu where individuals can opt to specify whether they would accept non-invasive ventilation, dialysis, artificial hydration or nutrition and, if yes, whether temporarily or permanently.<br />
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<b><u>Issues with POLSTs</u></b>:<br />
<ul style="text-align: left;">
<li>Require a physician signature and require either medical literacy or a good deal of physician explanation. </li>
<li>It is possible that only the sickest patients or those with terminal illnesses may be prompted to have a POLST.</li>
<li>Components are still open to interpretation by providers as the reversibility or predicted length of therapy are often difficult to determine upon initiation. </li>
<li>The FOAM blog, GeriPal, has an <a href="http://www.geripal.org/2011/10/some-days-i-hate-polst.html" target="_blank">interesting discussion on the semantics</a> prevalent in the POLST. For example, the connotation of the word "only" following Comfort Measures is not necessary and undermines the intensive work often required for end of life comfort. The blog offers some suggestions that may surface as POLSTs become increasingly adopted.</li>
</ul>
<span style="font-size: x-small;">References:</span><br />
<span style="font-size: x-small;">1. Dugdale DC. .<a href="http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000473.htm" target="_blank">Do Not Resuscitate Orders.</a>" MedlinePlus Medical Encyclopedia. </span><br />
<span style="font-size: x-small;">2. Mirarchi FL, Kalantzis S, Hunter D, McCracken E, Kisiel T. TRIAD II: do living wills have an impact on pre-hospital lifesaving care? J Emerg Med. 2009;36(2):105–15. doi:10.1016/j.jemermed.2008.10.003.</span><br />
<span style="font-size: x-small;">3. Mirarchi FL, Costello E, Puller J, Cooney T, Kottkamp N. TRIAD III: nationwide assessment of living wills and do not resuscitate orders. J Emerg Med. 2012;42(5):511–20. doi:10.1016/j.jemermed.2011.07.015.</span><br />
<span style="font-size: x-small;">4.</span><span style="font-size: x-small;">Mirarchi FL, Ray M, Cooney T.</span><span style="font-size: x-small;"> </span><span style="font-size: x-small;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/24583955" target="_blank">TRIAD IV: Nationwide Survey of Medical Students' Understanding of Living Wills and DNR Orders</a>. </span><span style="font-size: x-small;">J Patient Saf. 2014 Feb 27. </span><br />
<span style="font-size: x-small;">5. Gurwitz JH, Lessard DM, Bedell SE, Gore JM. Do-Not-Resuscitate Orders in Patients Hospitalized With Acute Myocardial Infarction. 2014;164.</span><br />
<span style="font-size: x-small;">6. </span><span style="font-size: x-small;">Chen JLT, Sosnov J, Lessard D, Goldberg RJ. Impact of do-not-resuscitation orders on quality of care performance measures in patients hospitalized with acute heart failure. Am Heart J. 2008;156(1):78–84. doi: 10.1016/j.ahj.2008.01.030.</span><span style="font-size: x-small;">4. </span><span style="font-size: x-small;">10.1002/jhm.2234</span><br />
<span style="font-size: x-small;">7. </span><span style="font-size: x-small;">Zweig SC, Kruse RL, Binder EF, Szafara KL, Mehr DR. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14687315." target="_blank">Effect of do-not-resuscitate orders on hospitalization of nursing home residents evaluated for lower respiratory infections</a>. J Am Geriatr Soc. 2004;52(1):51–8. </span><br />
<span style="font-size: x-small;">8</span><span style="font-size: x-small;">. Jesus JE, Geiderman JM, Venkat A, et al. </span><a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=24743101" style="font-size: small;" target="_blank">Physician Orders for Life-Sustaining Treatment and Emergency Medicine: Ethical Considerations, Legal Issues, and Emerging Trends</a><span style="font-size: x-small;">. Ann Emerg Med. 2014;64(2):140–144. doi:10.1016/j.annemergmed.2014.03.014.</span></div>
Lauren Westaferhttp://www.blogger.com/profile/10954779824260112126noreply@blogger.com0