Jock Murray

Constance LeBlanc

Jennie Leverman

Caitlin Wolfe

Disclosures

ARTICLE #1

Background

• Physicians are reluctant to use IV

contrast for CT scans in patients with

impaired renal function

• We feel that we can not order the optimal

test in an emergent situation due to the

risk of kidney injury

• This study helps determine if this

concern is justified

Methods

• Objective: To determine if IV contrast

administration for CT Scans is

independently associated with acute

kidney injury

Methods

Design: The Largest study on this topic.

• Single- Centre retrospective cohort analysis over 5 years. Serum creatinine levels were recorded within 8 hours before and 48-72 hours after CT scanning

• There was propensity matching with patients who had a CT without contrast or no CT at all.

Funding and

Conflicts

• Funding: John Hopkins University

• Conflicts: None Reported

Results

Results

• The risk of Acute Kidney Injury as 7.5

% in all three groups

Limits

• Retrospective

• Study Single centre study

• Ideally a DBRTC study would be performed but this is unlikely to be approved by any Research Ethics Board.

• Creatinine range from 40-400. Some critics (who do their work in the dark) suggest that a study focusing on patient with borderline renal function is needed

Discussion

• This is likely the best done and

largest study we will every get

addressing the association between

kidney Injury and intravenous contrast

• There was no difference in kidney

Injury between groups

Discussion

• If you need a Contrast study to

answer an important question then

get it.

• Work with your Radiologist for a more

permissive approach to CT Scanning

with contrast in patients with impaired

renal function.

References

• Risk of Acute Kidney Injury After

Intravenous Contrast Media

Administration. Hinson, J. S., et. al.,

2016. Annals of Emergency Medicine

. Vol. 69, no. 05. page 577- 586

Contrast: NO PROBLEM

ARTICLE #2

Background

• Early Goal Directed Therapy (EDGT) as described by Manny Rivers has been promoted as the standard of care for treatment of sepsis

• This approach was promoted in the “Surviving Sepsis campaign”.

• This approach was eventually recognized to be inappropriate for most Emergency Departments.

• Which Components of EDGT matter?

Methods

• Objective: To determine if Early Goal Directed Therapy (EDGT) is superior to standard care.

• Design: A Preplanned Patient Level Meta-Analysis of Three large prospective Double Blind trials. 3732 patients at 138 hospitals in seven countries. (ProCess, ARISE, and ProMISe)

Funding and

Conflicts

• Funding: Funding by Multiple large

National and International funding

organizations in Australia, the UK and

North America

• Conflicts: Several investigators have

financial ties to Drug companies. None

had ties to device makers

Results

Results

Results

Results

Results

• Mortality at 90 days- EDGT 24.9% vs.

25.4% (P=0.68)

• EDGT was associated with greater

mean use of Intensive care (5.3+7.1

vs. 4.9+/-7.0 days ) (P=0.04)

• Inotrope use (1.9+/-3.7 vs. 1.6+/- 2.9

days) (P=0.01)

Results

• Cost Effectiveness

• No difference in Quality Adjusted Life

Years

• 4 times as likely that Usual Care is

more cost effective than EDGT

Discussion

• EDGT provides no mortality benefit at

increased cost

Conclusion

• Physicians should not feel that they need to follow a complicated protocol for patients with sepsis

• Standard care with early early antibiotics and aggressive fluid is equivalent to a much more complicated protocol

• Central lines, special catheters and complicated inotrope management are not valuable and can be left to the ICU

Just Do It!!!

ARTICLE #3

• Mensour

No need to intubate

peds patients with IHCA

P: Inclusions - IHCA age <18 yrs

Exclusions - had invasive airway or being ventilated at the time of starting chest compressions

I: Endotracheal intubation

C: Those not tracheal intubated

O: Survival to hospital discharge (primary)

ROSC & favorable neurologic outcome at D/C (secondary)

Peds intubation IHCA

• n = 2294, 57% were male, age~7 months (21 days- 4 yrs)

• 1555 were intubated during the cardiac arrest

• Propensity score matched cohort 2270

• Survival was lower in those intubated 36% vs 41%

What do I do?

• Put in an LMA to ventilate and measure the quality of CPR using ETCO2

• Although the study design does not eliminate the potential for confounding, findings do not support the current emphasis on early tracheal intubation for peds in-hospital cardiac arrest

JAMA. 2016;316(17):1786-1797. doi:10.1001/jama.2016.14486

ARTICLE #4

Introduction

• Asthma accounts for more than 2.1

million unscheduled emergency

department (ED) visits annually, with

a prevalence that includes 8.4% of

the population

OBJECTIVE

• Oral dexamethasone demonstrates bioavailability similar to that of oral prednisone with a longer half-life

• Evaluate whether a single dose of oral dexamethasone plus 4 days of placebo is not inferior to 5 days of oral prednisone in treatment

• Adults with mild to moderate asthma exacerbations to prevent relapse

Non-Inferiority

Prednisone x 5 Dex + placebo x 4

Methods

• Adult ED patients (18 to 55 years)

• Randomized to receive either

single dose of 12 mg of oral dexamethasone with 4 days of placebo

5-day course of oral prednisone 60 mg a day

Follow-up phone interview at 2 weeks

Results

Dexamethasone

• 173 completed

• Relapse rates within 14

days 12.1%

• Hospitalization for relapse

dexamethasone 3.4%

Prednisone

• 203 completed

• Relapse rates within 14

days 9.8%

• Relapse rates within 14

days 2.9%

Adverse effect rates were the same in the 2 groups

Conclusion

One dose of oral dexamethasone did not

demonstrate non-inferiority to prednisone

for 5 days by a very small margin for

treatment of adults with mild to moderate

asthma exacerbations

Enhanced compliance and convenience

may support the use of dexamethasone

regardless

Discussion

Technically a negative trial

These data support, rather than refute, the use of a single dose of dexamethasone in the treatment of asthma with acute exacerbation

Statistically, this non-inferiority trials’ results mean there simply weren’t enough patients enrolled to meet their predefined criteria

Choice of single-dose dexamethasone is likely as safe as the typical prednisone burst

Take Home!

• Single oral doses of longer-acting

corticosteroids might be just as effective

as multi-day short courses of prednisone

• A single dose of oral dexamethasone 12

mg is either similar to or slightly inferior

to a 5-day course of prednisone 60 mg

for asthma

Steroids

ARTICLE #5

Why bother?

• ED visits for skin infections have increased with the emergence of MRSA

• In cellulitis without purulent drainage, β-hemolytic streptococci are presumed to be the predominant pathogens

• Do antimicrobial regimens possessing in vitro MRSA activity improve outcomes compared with treatments lacking MRSA activity

Question

Does cephalexin + TMP-SMX yield a

higher clinical cure rate of

uncomplicated cellulitis than cephalexin

alone

Methods

• Multicenter, double-blind, RTC superiority

• 5 US EDs among outpatients

• Over 12 years of age

• Cellulitis and no wound, purulent drainage, or abscess

• April 2009 to June 2012

• All had soft tissue US

• Follow-up August 2012

Groups

Cephalexin + TMP-SMX

7 days

(n = 248)

Cephalexin + placebo

7 days

(n = 248)

Outcomes

• Primary outcome determined a priori as clinical cure

• Absence of clinical failure criteria

Fever

increase in erythema (>25%)

swelling, or tenderness (days 3-4)

no decrease in erythema, swelling

tenderness (days 8-10)

More than minimal erythema, swelling, or tenderness (days 14-21)

A clinically significant difference was >10%

Limitations

• US use

• Rechecked frequently

• Generalizable?

Conclusions

• For uncomplicated cellulitis

• Cephalexin plus trimethoprim-

sulfamethoxazole compared to

cephalexin alone did not result in

higher rates of clinical resolution

No Pus = No MRSA

ARTICLE #6

Problem

• Patients want/

need this

• Sometime take it

• Toxic to cornea

• Put out an APB?

Methods

• Outcomes were compared between

patients who did or did not received

tetracaine

• Retrospective study

• Simple corneal abrasions

• Allow EPs to prescribe topical 1%

tetracaine drops q 30 minutes prn for

24

Groups

• 1,576 initial ED presentations

532 simple abrasions

1,044 non-simple corneal abrasions

• Tetracaine was dispensed at the initial visit

303 simple abrasions (57%)

141 non-simple corneal abrasions (14%)

Results

• No serious complications or uncommon adverse events attributed to tetracaine in either group (0/459; upper 95% confidence interval [CI] 0.80%)

• Relative risks of ED recheck and fluorescein staining were increased overall among patients who received tetracaine (RR 1.67, 95% CI 1.25 to 2.23; and RR 1.65, 95% CI 1.07 to 2.53)

• Relative risks for only SIMPLE ABRASIONS receiving tetracaine was 1.16 (95% CI 0.69 to 1.93) and 0.77 (95% CI 0.37 to 1.62)

Results

• Referrals to ophthalmology were

significantly decreased for all patients

dispensed tetracaine (relative risk

0.33; 95% CI 0.19 to 0.59)

• The number of complications was too

small to permit modeling

Limitations

• Not blinded

• Retrospective

• No harm found

• Large review

Conclusions

• There was no evidence that up to 24-

hour topical tetracaine for the

treatment of pain caused by SIMPLE

CORNEAL ABRASIONS was unsafe

• CIs were wide

• Increased risks in NOT SIMPLE

Tetracaine OK

ARTICLE #7

Why is it Important?

• Ketorolac is a NSAID analgesic that is widely

used in the ED

• It is one of few (? the only) medication(s) that

has a higher parenteral dose than the oral form

• Why is that?

• Is it necessary? Do the benefits outweigh the

harms?

Methods

• Single centre randomized double blind study of 240 subjects

• Compared 3 doses (10mg, 15mg, 30mg) of IV Ketorolac in the treatment of moderate to severe pain (NRS ≥5)

• Convenience sample, presenting to ED with predominantly flank, abdominal pain or headache M-F 9-5 enrolled by research team

Methods

• Recorded pain scores at 15, 30, 60,

90 and 120 minute mark

• Rescue analgesia morphine if still

requesting analgesia 30 minutes after

study dose

Outcome Measures

• Primary:

Reduction in NRS pain scale at 30 minutes from medication administration

• Secondary:

1. Rates and numbers of patients experiencing adverse effects

2. Numbers of patients requiring rescue analgesia

Results at 30 Min.

10 mg Ketorolac

NRS 7.75.2

15 mg Ketorolac

NRS 7.55.1

30 mg Ketorolac

NRS 7.84.8

NO SIGNIFICANT DIFFERENCE between the groups with all having a significant reduction in pain

Results by Time

• No significant difference in pain scores

across the time points

• All pts who reported complete resolution

of pain DID NOT receive morphine

• There was no difference in the number of

patients requesting “rescue” morphine

across the doses

Results

by

Time

Adverse Effects

• No patients developed unstable vitals

• Nausea, dizziness and headache

were main adverse effects

• Again no differences between the

groups

• Not powered to look at safety

Limitations

• Small study, one centre

• No follow up to assess delayed AE

such as GI bleeding

• Not long enough to assess if higher

doses give lasting analgesia beyond

120 minutes

Conclusions

• There appears to be little to no benefit

of higher parenteral doses of

ketorolac

• A new standard of 10 mg dosing will

provide equivalent analgesia and may

decrease adverse events

Ketorolac

ARTICLE #8

Why is it Important

• Uncontrolled atrial fibrillation/flutter is a relatively common condition in the ED

• Although similar mortality for rate versus rhythm control in long term management… acute management is left to clinical judgment, with little evidence to guide either way

Questions

• For patients presenting with acute Afib/ flutter, if choosing a rhythm control strategy, what are the outcomes after ED discharge?

• Are there certain patients who are higher risk for negative outcomes with this approach?

Methods

• Prospective cohort study

• Identified all pts (except 29) presenting with acute Afib/flutter at 6 academic EDs in Canada over 2 years

• Looked at ED management then followed pts for 30 days post discharge

• Afib/flutter was primary issue (i.e.: excluded ACS, sepsis, PE, pneumonia etc.)

Methods

• Composite outcome: death, stroke,

ACS, CHF, subsequent Afib/flutter

related hospitalization or subsequent

ED cardioversion

• Logistic regression to look at

independent risk factors associated

with the composite outcome

Results

• Patients were most likely (72.8%) to be

treated with electrical or chemical

cardioversion (procainamide most

common chemical choice)

• Only 9% were admitted

• Eighty percent were in sinus at d/c

• Only 4.8% were rx’d anticoagulant from

ED

Results

• MD follow up was recommended but

only 50.7% had seen MD by 30 days

• Only 9.6% of those who did follow up

were on some form of anticoagulation

Results

• Overall 10.5% had an adverse event

6.5% required repeat cardioversion

3.2% required admit for Afib/flutter

• NO DEATHS related to AFib/flutter

• One ischemic stroke (in anti-coagulated

patient)

Results

• Patients leaving ED in sinus rhythm were less likely to have adverse outcome

• Independent predictors of adverse outcome:

Longer duration of Afib/flutter (OR 1.03/hr)

Hx stroke/ TIA (OR 2.09)

Pulmonary congestion on CXR (OR 7.37)

Patients who were chemically cardioverted hadlowest risk (OR 0.23) for adverse events

Results

Conclusions

• Cardioversion of acute Afib/flutter is associated with few adverse events at 30-day follow up

• Pts with CHF, Stroke hx and longer duration before ED presentation are higher risk for adverse events

• Rates of ED and follow up anti-coagulation are low

• Need head to head trial of rate vs. rhythm to assess for superiority

Atrial Fibrillation

ARTICLE #9

• Mensour

Why does it matter?

• Drive to continue improving outcomes

in cardiac arrest

• Training and dogma around need for

definitive airway

Vs many other tasks that need to

occur in early ACLS

• How should we prioritize our time?

Methods

• Retrospective analysis

• “Get-with-the-Guidelines-

Resuscitation registry”

Multicenter

Sponsored by AHA

All in-hospital cardiac arrests

Jan 1, 2000- Dec 31, 2004

Methods

• Inclusion: adult, in-hospital, CPR given, no DNR

• Exclusion: invasive airway at the time, data missing

• Definitions

Tracheal intubation if successful

Unsuccessful attempts not counted

Time to ROSC or ending CPR without ROSC

Methods

• Outcomes

Survival to hospital discharge

ROSC

Favourable functional outcome

Cerebral performance category 1-2

• Statistics

Matched patients being intubated with non-intubated (yet?) for each time score

Results

• 108,079 total patients

69.9% intubated at some point

94.8% of intubations in first 15

mins

Median time of 5 mins

Results

• 22.4% overall survived to discharge

Intubated patients had lower survival

17% vs 33.2% (RR 0.58, 95% CI 0.57-0.58, p< 0.001)

3% absolute reduction in survival

16% relative

Results

• 62.5% of patients attained ROSC

Intubated patients less likely to get ROSC…

59.2% vs 69% (RR 0.75, 95% CI 0.73-0.76, p<0.001)

2% absolute reduction

Similar results for functional outcome but some data missing

Subgroups etc.

• Effect of tracheal intubation lowering

survival:

most pronounced if initially had

shockable rhythm

32% relative decrease vs 9%

Not present if presented with

respiratory insufficiency!

Limitations

• Matched cases to others within data set who were potentially intubated later

• Indication for intubation, cause of arrest, and skill level not specifically recorded in registry

• Unsuccessful attempts not logged

But would have biased to null…

Conclusions

• In adults with in-hospital cardiac arrest….

Initiation of tracheal intubation at any point in first 15mins was associated with worse scores on all outcomes vs not intubating…

• Probably we shouldn’t be doing this early/as a matter of priority

Congruent with current guidelines

Conclusions

• In adults who arrest in hospital

70% got intubated within 15mins

¼ survived to hospital discharge

1/6 had good neurological status

Academic Emergency Medicine 2017;24:1258-1266

ARTICLE #10

Why does it matter?

• Traumatic intracranial bleeding is the feared complication of head injury

• How can we apply decision rules to our patients?

Are anti-platelets as scary as anti-coagulants?

“full” dose antiplatelet vs small?

Methods

• Consecutive patients at trauma center

• Prospective, observational, cohort

• Inclusion

Adult patients (>18)

Ground-level fall (or lesser mechanism)

On ASA, clopidogrel, warfarin, LMWH, DOACs, other antiplatelets

• Exclusion

Injury >24 hours

Patients transferred with known injury

Methods

• Treating clinician noted ground level fall + antiplatelet or anticoagulant

All received CT scan on first visit

• Outcomes

Primary: traumatic bleed

Subdural, epidural, subarachnoid, intraparenchymal

Secondary: clinical characteristics, intervention, disposition

Results

• 939 patients enrolled

78% were on ASA

71% alone

24% on Warfarin

3.3% on DOAC

Some on multiple agents

• Mean age: 78 (+/-11.9 years)

Results

• 33 intracranial hemorrhages

3.5% of all cases reviewed

99% were “awake and alert”, only 30% had LOC

Antiplatelets: rate of 4.3% (3-6.2% CI)

And 82% of those who bled on ASA were on 81mg alone

Anticoagulants: 1.7% (0.4-4.5%)

Mean INR on warfarin 3.3

Results

• Medical interventions in several

Vit K, FFP, platelets…

• 0.4% rate of surgery or death

2 craniotomies

4 deaths

3 on ASA alone

Limitations

• Fair approximation of patient population, although all low risk

First presentation, well at triage

• Needed CT head for age alone

• Numbers in the non-ASA groups were small, less reliable

• No control group

• Can’t confirm if were taking Rx

• Could bleeds have preceded fall?

Conclusions

• No statistical difference between tICH rate on anti-platelet or anti-coagulants

Including low dose ASA!

Because platelets are important earlier in clotting cascade?

Because “strength” of inhibition not measureable?

• Beware both yourself and patients being falsely reassured about risk