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October 2016 New in EM

Authors: Andy Neill, Simon Laing, Nikki Abela, Chris Connolly, Craig Davidson, Ken Milne / Codes: CAP1, CAP7, CMP2, PAP9 / Published: 05/10/2016

Clinical Question to be answered

  • Which drug is best for stable VT?

Title of paper

Journal and year

  • European Heart Journal, 2016

Lead Author

  • Ortiz

Name of contributor

  • Andy Neill

Patients studied

  • wide QRS tachycardia, presumed VT, stable by fairly reasonable criteria

Intervention (if therapeutic)

  • Procainamide 10mg/kg

Comparison

  • Amiodarone 5mg/kg

Primary outcome

  • Major Adverse Events (not conversion success)

Summary of results

  • stopped early after 6 years and 70 pts in 29 hospitals due to lack of enrollment
  • 62 pts analysed
  • roguemedic had a nice comment about how long it took them to start the meds (90 mins!!) and that they had time to watch most of casablanca while in VT
  • 90% VT in each group (on a later review of ECGs)
  • much more hypotension and poor prerfusion in the amio group (9v 40%) but this was 3 v 12 patients
  • 50% success rate overall (67% in the procainamide group v 38% in the amio group)”

Strengths

  • randomised, power calc (however dodgy), important outcomes (safety a good outcome given both level II by AHA guidelines already)

Weaknesses

  • open label, slow time to treatment, poor recruitment, randomisation by envelopes. perhaps unfair on amio given the larger does – 300 over 20 as opposed to 300 over 60n in the UK guidelines and 150 in the US guidelines. note the fragility index for the primary outcome was 3 patients illustrating just how little statistical power they had

Clinical Bottom Line

  • While we’d like to say that the evidence is now strongly in the favour of procainamide the evidence here is really weak so make your own call on this one…

Any other FOAM sites where you found it or who have discussed it already so that we can be sure to give kudos

Clinical Question to be answered

  • Can the MACS rule be altered to utilise single troponin (rather then H-FAB) to rule out ACS in the Emergency Department?

Title of paper

Journal and year

  • EMJ 2016

Lead Author

  • Body

Name of contributor

  • Simon Laing

Patients studied

  • ED patients with chest pain that the treating clinician suspected to be cardiac in origin and requiring further investigation (excluding patients with ECG changes)

Comparison

  • The percentage of patients who had a diagnosis of ACS who score very low risk on T-MACS

Primary outcome

  • The diagnosis of Acute Coronary Syndrome

Summary of results

  • 40% of patients were identified as very low risk with T-MACS, of these less than 1% of patients were diagnosed with ACS.

Strengths

  • Large patient group, pragmatic trial and appropriate clinical outcomes

Weaknesses

  • This is a retrospective validation of T-MACS and not a study prospective study looking to derive and validate a decision rule

Clinical Bottom Line

  • T-MACS shows promise to rapidly evaluate those at low risk of ACS when attending ED. Further prospective evaluation would be beneficial and healthcare providers also need to determine their acceptance of risk for a missed diagnosis of ACS before considering its implementation.
  • The rule also gives a valuable nod to those features that clinicians could use in their day to day evaluation of patients with possible ACS to evaluate their risk whilst not necessarily employing T-MACS as a binary tool.

Any other FOAM sites where you found it or who have discussed it already so that we can be sure to give kudos

Clinical Question to be answered

  • Can the EDACS-ADP (Emergency Department assessment of chest pain and accelerated diagnostic pathway) rule out Acute MI in ED patients with chest pain?

Title of paper

Journal and year

  • EMJ 2016

Lead Author

  • Flaws et al

Name of contributor

  • Chris Connolly

Patients studied

  • Consecutive adult patients at a Vancouver Hospital

Intervention (if therapeutic)

  • Calculated EDACS score in addition to TnT at 0 and 2 hours and ECG assessment.

Primary outcome

  • MACE (Major adverse cardiac event) at 30 days including at index presentation.

Summary of results

  • EDACS-ADP demonstrated good Sensitivity 100% (95% Confidence intervals 94-100) and Negative predictive value 100% (95% CI 98.51-100) for 30 day MACE including index presentation.

Strengths

  • Prospectively recruited patients (data was then retrospectively collected).
  • Researchers blinded to 30 day outcomes.
  • Test and ‘gold standard’* was applied to all patients.
    • * This was diagnosis of MI according to that given in Annals of Emergency Medicine”

Weaknesses

  • Single Centre Retrospective data analysis that led to some subtle differences in the validation cohort to the derivation group (e.g. family history of IHD)
  • Patient data collected in 2000-03 for the Vancouver chest pain study. (Would a modern data set produce different results?)
  • No data for patients who present between 2200 and 0700 (Are they different in some way or can we assume they’re the same – probably)
  • Not a ‘rule out’ for cardiac cause as was the aim of the population studied (Vancouver Chest pain score)”

Clinical Bottom Line

  • Application of the EDACS-ADP appears to risk stratify those at low risk of 30 day and MACE and therefore those that can be discharged from ED with a view to further outpatient testing.

Clinical Question to be answered

  • Can we manage low risk infants with fever as outpatients without antibiotics?

Title of paper

Journal and year

  • Archives of Disease in Childhood July 2016

Lead Author

  • Santiago Mintegi et al

Name of contributor

  • Nikki Abela

Patients studied

  • 1472 infants (<91 days) with fever without a focus were included. However 767 were finally analysed after they were deemed low risk of Serious Bacterial Illness – SBI as per the Step by Step criteria (criteria published &validated by the same group of authors a few months before).
  • LOW RISK =
    • Well appearing
    • Aged >21 days
    • No leukocytes in urine
    • Procalcitonin <0.5 ng/mL
    • Absolute Neutrophil Count <10,000/mm3
    • CRP < 20 mg/L”
  • The end result is NO intervention- so really, this “low risk” group were managed with no antibiotics, LP or admission.

Primary outcome

  • The primary outcome was the proportion of infants managed as outpatients who returned to the ED due to a clinical deterioration.
  • The secondary outcome measure was the proportion of infants managed as outpatients later diagnosed with a SBI. (though we thought this should have been the primary ouctome)

Summary of results

  • Of 586 patients found to be at “”low risk”” for SBI:
  • 2 had “”definite SBI””:
  • 1 – Staph a. – treated with IV abx
  • 1- Salmonella – no antibiotics
  • 29 had “”possible SBI”” – all had a positive urine culture (i.e. “”possible UTI)- 3 got antibiotics and 2 were admitted.

Strengths

  • New approach which challenges “old thinking” on approach of infants with fever.
  • Good study, good number of patients, well followed up.

Weaknesses

  • Uses definition of “”well appearing”” infant in defining risk, which is a bit “”wooly””- could this still be applied in EDs which do not see as many infants as PEM clinicians in tertiary hospitals?
  • No real power calculation – but still had good numbers.
  • Bit of confusion in primary and secondary outcomes.”

Clinical Bottom Line

  • Unlikely to change current practice, but with some more validation, the “Step by Step” approach seems promising.

Any other FOAM sites where you found it or who have discussed it already so that we can be sure to give kudos

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