Archive | July, 2012

vasopressors in shock

31 Jul

De Backer D et al.:

Question: In the treatment of shock, is one vasopressor more efficacious than another?

Methods:

RCT all comers with shock were assigned to receive either dopamine or norepinephrine as first-line vasopressor therapy.

When hemodynamic monitoring could not be met, open label epi, norepi, or vasopressin was added.

The primary outcome was the rate of death at 28 days; secondary end points included the occurrence of adverse events.

Results:

There was no significant between-group difference in the rate of death at 28 days (52.5% in the dopamine group and 48.5% in the norepinephrine group; odds ratio with dopamine, 1.17; 95% confidence interval, 0.97 to 1.42; P=0.10).

However, there were more arrhythmic events among the patients treated with dopamine than among those treated with norepinephrine (207 events [24.1%] vs. 102 events [12.4%], P<0.001).

Teaching point: While both dopamine and norepi had no change in mortality, dopamine was associated with statistically more adverse effects (usually afib) and dopamine pts more often had to be put on open label second agent.

Submitted by W. Rushton.

Reference(s): De Backer D et al. “Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010 Mar 4;362(9):779-89.; picture

initial presentation of MI in women and older patients

30 Jul

Canto et al:

Question: Is there actually a difference in initial presentation of MI among women and older patients?

Methods: Observation study from the National Registry Myocardial Infarction of 1,143,513 patients from 1994-2006

Results: Proportion of female patients who presented without chest pain (42%) was significantly higher than men (30.7%) P<0.001. Absence of chest pain was also correlated with increased mortality (due to delay in recognition of MI).

Teaching points: Have a high index of suspicion for women with vague complaints as a ~40% of female MI patients will not have chest pain.

Submitted by W. Rushton.

Reference(s): Canto et al, “Association of Age and Sex with MI Symptom Presentation and In-Hospital Mortality” JAMA February 22 Vol 307 No 8; picture

elderly patients with a hip fracture

27 Jul

Hung, William “Hip Fracture Management”:

Question: In the acute setting, what actually improves the ADLs of elderly patients with a hip fracture

Methods: MEDLINE and Cochrane database search for hip fracture and then ranked the evidence

Results:

Operative management had a level 1B

–No difference vs early vs delayed surgery

VTE prophylaxis had a 1A

Early ambulation had a level 3

Biphosphates after fracture had a 1B

Teaching points: Elderly patients with hip fractures do better with surgery and likely better with early ambulation.  Don’t be shy calling your ortho colleagues from the ER to admit these patients. They can’t walk. They will likely need surgery. Surgery tends to help ADLs. There you go.

Submitted by W. Rushton.

Reference(s): Hung, William “Hip Fracture Management” JAMA May 23/30 Vol 307, No 20; picture

pediatric altered mental status

26 Jul

Article by Muniz AE:

Question: Pediatric patients level of consciousness can be difficult to detect and their etiologies differ from adults. What are the most common causes of AMS in pediatrics?

Methods: Prospective epidemological study of 145 children at VCU with AMS from 6/99 -12/03

Results: There were 31 different diagnoses:

  • overdoses 18 (12.4%)
  • ethanol intoxication 15 (10.3%)
  • seizures 13 (8.9%)
  • dehydration 13 (8.9%)
  • medication side effects 7 (4.8%)
  • hypoglycemia 6 (4.1%)
  • traumatic brain injury 6 (4.1%)
  • pyelonephritis 3 (2%),
  • viral meningitis 2 (1.3%),
  • CO poisoning 2 (1.3%)
  • viral infection 2 (1.3%)
  • pneumonia 2 (1.3%)

Teaching point: Differential is broad, obviously. Overdoses and side effects from medications are high on the differential for the altered peds patient.

Submitted by W. Rushton.

Reference(s): Muniz AE “Altered Mental Status Evaluation in Children Presenting to an Emergency Department” Annals of Emergency Medicine Vol. 46, Issue 3, Supplement, Page 72; picture

Appendicitis in children less than 3 years of age

25 Jul
Javed Alloo et al.:
Objectives: 
Discern common symptoms for young pediatric patients
Methods: 
Retrospective review of 28 patients less than three years of age seen by one pediatric surgeon at a childrens hospital in Toronto, ONT.
Results: 
Teaching points: 
Pediatric patients have a wide range of presentation. The inability to tolerate PO and fevers where the most common findings in young children under the age of three
Submitted by W. Rushton.
Reference(s): Javed Alloo et al. “Appendicitis in children less than 3 years of age: a 28-year review” Pediatr Surg Int (2004) 19: 777–779; picture from same article

Does lactate clearance and SVO2 goals have an effect on mortality?

24 Jul

RAGING HYPOTHETICAL:

A 41 yo male s/p lung transplant on immunosuppressants presents with dyspnea, fever, tachycardia, and SBPs in the 90s. His lactate is 6 and his SVO2 is 65%. What now?

Puskarich, Michael et al:

Question: Does lactate clearance and SVO2 goals have an effect on mortality?

Methods: 203 pts in septic shock. SVO2 and lactate clearance where checked and then followed.

Results: No agreement was found between reaching an SVO2 >70% or having lactate clear by 10% on mortality

Teaching point: Lactate and SVO2 cannot function alone as independent markers for ressucitation.

Submitted by W. Rushton.

Reference(s): Puskarich, Michael et al “Prognostic Value and Aggreement of Achieving Lactate Clearance or Central Venous Oxygen Saturation Goals During Early Sepsis Resuscitation” Society for Academic Emergency Medicine 2012; 19:25-258; picture

Can EKG abnormalities predict older adults with an increased risk of CHD events?

23 Jul

RAGING HYPOTHETICAL:

A 82 yo male presents with 3 hours of nausea. He has hyperlipidemia and hypertension, no hx CAD. He does not know his FMH. Vital signs are stable. His EKG shows a new RBBB. Pt never has any chest pain. What now?

Auer et al. “Association of Major and Minor ECG Abnormalities with CHD Events” JAMA April 11, 2012, Vol 37, No 14

Question: Can EKG abnormalities predict older adults with an increased risk of CHD events?

Methods: Population Based study of 2192 adults age 70-79. Baseline EKG was collected from 1997-1998. Repeat EKG done from 2006-2007. EKG were sent to central coders and classified as minor vs major abnormalities from baseline

Criteria for major prevalent ECG abnormalities:

  • Q-QS wave abnormalities
  • left ventricular hypertrophy
  • Wolff-Parkinson-White syndrome
  • complete bundle branch block or intraventricular block
  • atrial fibrillation or atrial flutter
  • major ST-T changes

Criteria for minor prevalent ECG abnormalities:

  • minor ST-T changes

Results: 351/2192 pts had a CHD event (death, MI, hospitalization). 782 pts had an abnormal EKG. Minor EKG changes had a hazarad ratio of 1.35 (95% CI 1.02-1.81) and Major EKG changes 1.51 (95% CI 1.2-1.9).

Teaching points: Risk stratification in elderly adults for CHD can be difficult as many can present without chest pain and do not have the traditional risk factors. A minimally abnormal EKG can help identify an elderly pt at risk for a serious cardiovascular disease.

Submitted by W. Rushton.

Reference(s): Auer et al. “Association of Major and Minor ECG Abnormalities with CHD Events” JAMA April 11, 2012, Vol 37, No 14; picture