ED Rounds – Competency By Design

ED Rounds – September 2018

Dr. Jo-Ann Talbot

 


 


Competency-based medical education (CBME) is an outcomes-based approach to the design, implementation, assessment, and evaluation of a medical education program using an organizing framework of competencies.

Competence by Design (CBD) is the Royal College’s version of CBME. It is a transformational change initiative designed to enhance CBME in residency training and specialty practice in Canada.

The first stage in residency is known as Transition to discipline. It emphasizes the orientation and assessment of new trainees. Foundations of discipline, the second stage, covers broad-based competencies that every trainee must acquire before moving on to the third stage, which is known as Core of discipline. The third stage covers more advanced, discipline-specific competencies. As part of CBD, the Royal College is also exploring moving the Royal College exam to the end of this stage.5 The fourth and final stage of residency education is known as Transition to practice. During this stage the trainee demonstrates readiness for autonomous practice

RCPSC 2016


 

Dr. Talbot’s Presentation

Competence by Design – Are You Ready?

Competency by Design Are You Ready? Dr. Jo-Ann Talbot – 2018

Click link above to view


Further Reading

CBD Cheatsheet

Download (PDF, 128KB)


Emergency Medicine – Entrustable Professional Activities 

Download (PDF, 71KB)


 

Entrustable Professional Activity Guide: Emergency Medicine

EPA-guide-emergency-medicine RCPSC 2018

Click link above to view


 

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Fall ECCU Conference Workshop – 28th September

We still have availability for delegates wanting to attend the Fall ECCU Conference Workshop on the 28th September at the beautiful Algonquin Resort in St. Andrews, New Brunswick.


  • International PoCUS experts from South Africa, USA and Canada
  • PoCUS hot topics and updates
    • PoCUS in Rural Health
    • Why aren’t you doing THIS with PoCUS?
    • How to be a leader in PoCUS
  • Top PoCUS research
  • IP2 Diagnostic stream lectures
  • Hands-on scanning workshops


  • Choose your own workshop
    • Pediatrics, Cardiac, Lung, IVC, DVT, Gallbladder, DVT, Aorta, FAST, Obstetric
  • CPoCUS approved
  • CCFP CME approved
  • Bring the family and stay for the weekend
    • Top golf resort, whale watching, explore the islands

 

Click Here for More information and Booking

 


 

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ED Rounds – Oncologic Emergencies and Emerging Treatments

ED Rounds – May 2018

Dr. Paul Frankish

 

Take Home Points

  1. In patients on Immunotherapy for cancer beware of diarrhea or dyspnea, as it may represent an autoimmune side effect.

  2. LMWH is the treatment of choice for the duration of Malignancy associated PE.

  3. SVC obstruction is “sneaky” and new dyspnea is far more common than facial swelling.

 

Immunotherapy

 

 

 

 


Febrile Neutropenia

A single oral temperature >38.3 deg C

or

A sustained oral temperature >38 deg C

with

An absolute neutrophil count (ANC) less than 500 cells per microliter (0.5 x 109/L)

 

*Far and away one of the most common oncologic presentations to the ED

*70% hematologic and 30% solid organ malignancies

*Treatment Timelines (as per IDSA):

1.STAT CBC within 10 minutes

2.Broad empiric antibiotics within 60 minutes

 

History

1.Diagnosis

2.Date and type of last Chemo

3.Use of G-CSF

4.Use of antimicrobials

5.History of prior infection

6.PMH/surgical history

7.Medications/Allergies

 

Exam

1.Mental Status

2.Volume Status

3.Oral Mucosa

4.Skin/Catheter Sites

5.Respiratory

6.Cardiovascular

7.Abdomen

 

Treatment

*Imipenem 500 mg IV Q6H or

*Pip/Tazo 3.375 gram IV Q6H or

*Cipro 400 mg IV and Vanco 1 gram IV Q12H if penicillin allergic

*Consider adding Vanco to monotherapy if:

1.IV Catheter Infection

2.Gram positive organism not yet identified

3.MRSA Colonization

4.Hypotension/Shock

 


SVC Obstruction

*Subacute SVCO results in milder symptoms like facial swelling, cough, dyspnea, facial redness, dilated superficial veins.

*Acute SVCO is more severe and can result in altered LOC, increased ICP, airway obstruction.

*Test of choice is a contrast enhanced CT chest

 

 

Treatment

1.Elevate HOB

2.Dexamethasone 10 mg IV

3.Symptom control

4.Airway management if indicated

5.Urgent Radiation Oncology Consult

6.If known Small Cell Lung Cancer, then worth a call to Medical Oncology

 

 


 

Pulmonary Embolus

*New dyspnea of unknown etiology in patient with active malignancy is a PE until proven otherwise

*Alternate explanations for new dyspnea are pericardial effusion, SVCO, lung tumor burden, anemia.

*Preferred treatment is LMWH indefinitely

 

Investigation of choice is CTPA

 

ECG may show S1QT3 – But don’t rely on this sign

PoCUS may also be helpful for initial triage of acute dyspneic patient – look for dilated RV and IVC

 

Treatment

*Dalteparin 200 units/kg sc for 1 month

then

*Dalteparin 150 untis/kg sc thereafter

*Main evidence for LMWH over warfarin comes from CLOT trial

*50% reduction in recurrent VTE with LMWH vs. warfarin

*Presumed to be because of poor tolerance of PO meds in patients with cancer nauseated from chemo

*May not be relevant in era of modern anti-emetics and anticoagulants, data pending

 


 

Epidural Spinal Cord Compression

1.Back pain (90% of cases)

2.Motor weakness

3.Sensory impairment

4.Autonomic dysfunction

5.Perianal numbness

6.Conus medullaris syndrome

 

Investigations and Treatment

*Dexamethasone 10-20 mg IV immediately if SCC is suspected

*MRI is preferred (generally T/L spine)

*Radiation Oncology if previously diagnosed malignancy

*Neurosurgery if new diagnosis of malignancy

 


 

 

 


SJRH Oncology Services – On Call Consults

 

 

 


Full Presentation

 

Download (PDF, 43.05MB)

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SJRHEM Journal Club – March 2018

DEM Journal Club Report

 

  1. Host/Presenter/Date:

    Dr. Talbot /Dr. Chandra/ March

  2. Title of paper/citation:

Sergey Motov, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: an RCT. Ann Emerg Med. 2017; 70:177-84.

  1. Research question/PICOD

Question: Does increasing the dose of intravenous Ketorolac improve analgesia in emergency department patients with a variety of pain syndromes?

Population: 240 patients, 80 allocated to each group

Adult patients (18-65) who presented to the emergency department with acute (less than 30 d) moderate to severe (intensity of 5 or greater on a standard 0-10 pain scale) flank, abdominal, musculoskeletal, or headache pain, who would routinely be treated with ketorolac by the attending emergency physician.

(Exclusion criteria: Older than 65 yrs, pregnancy or breastfeeding, active PUD, acute GI hemorrhage, history of renal or hepatic disease, allergy to NSAIDs, unstable vitals systolic BP <90 or > 180 mmHg or HR < 50 or > 150, and patients that had already received analgesic.

Intervention (1): Ketorolac 10 mg IV  (given over 1-2 minutes)

Intervention (2): Ketorolac 15 mg IV (given over 1-2 minutes)

Intervention (3):  Ketorolac 30 mg IV (given over 1-2 minutes)

Patients who still desired pain medications after 30 minutes were offered Morphine 0.1 mg/kg IV as a rescue analgesic.

Outcome:  Primary: Reduction in the numeric pain scale score at 30 minutes from medication administration

Secondary: Rates and percentage of subjects experiencing adverse events or requiring rescue analgesia.

Design: Randomized control trial

  1. Results

Ketorolac dose Pain Score

Initial

Pain Score

30 min

Difference
10 mg 7.73 5.13 2.6
15 mg 7.54 5.05 2.5
30 mg 7.8 4.84 3.0

 

Patients in all dosing regimens had clinically significant improvement in their pain scores after 30 min. The reduction in pain persisted through to 120 minutes.

There was no difference in the rate of rescue morphine use by group over time.

There was no difference in the common adverse effects (dizziness 18% vs 20% vs 15%, nausea 11% vs 14% vs 10%, headache 10% vs 2.5% vs 3.8%, itching 0% vs 1.3% vs 1.3%, or flushing 0% vs 1.3% vs 0%).

Other more serious side effects were not documented (gastrointestinal bleeding, renal impairment, changes in bleeding times). There are other studies that suggest that some of these adverse effects are dose related and therefore lower doses would be expected to reduce these complications.

 

 

  1. Authors conclusions

Ketorolac had similar analgesic efficacy profiles at doses of 10 mg, 15 mg and 30 mg IV for short term treatment of acute moderate to severe pain in the Emergency Department.  The results of the study provide a basis for changes in practice patterns and guidelines in the Emergency Department supporting the use of the 10 mg IV ketorolac dose.

 

  1. Discussion at Journal Club

    1. Strengths
      1. Randomized control blinded design
      2. Excellent data collection for primary outcome (99%)
  • Groups were treated the same
  1. Weakness
    1. Single center
    2. Although randomized, the patients were also only recruited between 8 am and 8 pm Monday to Friday as a convenience sample. This could lead to selection bias.
  • Although the patient, nurse, research coordinator, research fellow and the physicians were blinded to the group allocation, the pharmacist, research manager and the statistician were aware of patient allocation.

 

  1. Bottom line/suggested change to practice/actions

 

Patients presenting to the emergency department with moderate to severe pain receiving a single dose of intravenous Ketorolac had a significant reduction in pain with no difference between the dosing regimens of 10mg, 15 mg and 30 mg IV.

We recommend a change to our renal colic protocol and our ED Assessment order set to administer Ketorolac 10 mg IV instead of 30 mg IV of the treatment of a variety of conditions with moderate to severe pain. Unfortunately, the Ketorolac used in the emergency department comes in a 30 mg/ml vial. It is more efficient to draw up the full dose for each individual patient than be taking 1/3 of a ml out and possibly throwing the remainder out. Recommend asking Emergency Department pharmacist to determine if other solution strengths are available. Ketorolac could be a narcotic sparing analgesic, where in the opinion of the attending physician, appropriate patients can be given ketorolac and then reassessed at 30 minutes and rescue mediation given as required.

 

 

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ED Rounds – Epistaxis

ED Rounds – March 2018

Dr Christopher Chin MD FRCSC

Rhinology, Anterior Skull Base, Head and Neck Oncology

Otolaryngology- Head & Neck Surgery

Saint John Regional Hospital

 

Objectives

  • Cover basic and advanced techniques to obtain hemostasis in the ER
  • Review what options are available if that fails

Agenda

  • Review of anatomy
  • Management algorithm
  • What options are available when traditional packing fails
  • What’s new in epistaxis?
  • Special scenarios

 

Download (PPTX, 11.86MB)

 

Download (PDF, 16.26MB)

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EM Reflections – March 2018

Thanks to Dr. Paul Page for leading the discussions this month

Edited by Dr David Lewis 

 


 

Top tips from this month’s rounds:

Abdominal Aortic Aneurysm – Size matters, but it isn’t everything

CME QUIZ

 

 


Abdominal Aortic Aneurysm – Which patients require urgent consult / transfer ?

AAA is a disease of older age. The prevalence of AAA among men aged 65 to 80 is 4 to 6 times higher than in women of the same age. The Canadian Task Force on Preventative Healthcare have recently (2017) made the following recommendations on screening:

Recommendation 1: We recommend one-time screening with ultrasound for AAA for men aged 65 to 80. (Weak recommendation; moderate quality of evidence)

Recommendation 2: We recommend not screening men older than 80 years of age for AAA. (Weak recommendation; low quality of evidence)

Recommendation 3: We recommend not screening women for AAA. (Strong recommendation; very low quality of evidence)

 

Emergency Physicians are trained to recognize the signs and symptoms of ruptured AAA (hypotension, tachycardia, pulsatile abdominal mass, back pain) and are always on the lookout for those curveball presentations e.g renal colic mimic, syncope, sciatica etc.

With the organization of centralized vascular services predominating in the majority of developed national health systems, patients with ruptured AAAs are now being transferred for specialist care. Recent evidence from the UK suggests that this practice is safe with no observed increased mortality or length of stay. and other studies have shown a benefit, with reduced mortality post service-centralization.

While there maybe benefits of centralization for patients, vascular surgeons and health economies, the initial management of the patient with AAA disease can be increasingly challenging for the Emergency Physician, especially if they are located in a peripheral hospital.

Let us consider a few scenarios:

  • A 70yr old man presents to a peripheral hospital (without CT), 120km from the vascular centre, with severe back pain and hypotension. Point of Care Ultrasound (PoCUS) confirms the diagnosis of a 7.5cm AAA.

This scenario is relatively straightforward. The patient is judiciously resuscitated (avoiding aggressive fluid infusion), and transferred, after discussion with on-call vascular surgery, as quickly as possible directly to the receiving hospital’s vascular OR.

 

  • A 70yr old man presents to a peripheral hospital (without CT), 120km from the vascular centre, with moderate flank pain and normal vital signs. They are known to have a 3.7cm AAA (last surveillance scan 6 months ago). PoCUS confirms the presence of an AAA measuring approx. 3.7cm. Urinalysis is negative.

This scenario is also relatively straightforward. While the cause of the flank pain has not been determined, the risk of AAA rupture is highly improbable. For men with an AAA of 4.0 cm or smaller, it takes more than 3.5 years to have a risk of rupture greater than 1%. Given the stable vital signs, low pain score and lack of significant change in AAA size, this patient can be safely worked-up initially at the peripheral hospital pending transfer for abdominal CT if diagnosis remains unclear or symptoms change.

 

  • A 70yr old man presents to a peripheral hospital (without CT), 120km from the vascular centre, with moderate flank pain and normal vital signs. They have no past medical history. PoCUS confirms the presence of a new 4.7cm AAA.  

This scenario starts to become more challenging. Is the AAA leaking? Is the AAA rapidly expanding? Has PoCUS accurately measured the AAA size, Is the AAA causing the symptoms or is there another diagnosis? While this AAA is still below the elective repair size (5.5cm), the rate of growth is not know (and this is important), 4.7cm AAAs do occasionally rupture and rapidly expanding AAA’s can cause pain (the phenomena is more common in inflammatory and mycotic aetiologies). In this scenario the safest approach would be to organize transfer for an urgent CT and to arrange for Vascular Surgey consult immediately thereafter.

 

 

Salmonella aortitis may appear after a febrile gastroenteritis. The common location of primary aortitis and aneurysm formation is at the posterior wall of the suprarenal or supraceliac aorta – . 2010; 3(1): 7–15.

 

Aortitis is the all-encompassing term ascribed to inflammation of the aorta. The most common causes of aortitis are the large-vessel vasculitides including GCA and Takayasu arteritis. The majority of cases of aortitis are non-infectious, however an infectious cause must always be considered, as treatment for infectious and non-infectious aortitis is significantly different.

This article provides a detailed summary of the diagnosis and management of Aortitis

 


CME QUIZ

EM Reflections - March 2018 - CME Quiz

EM Reflections – March 2018 – CME Quiz

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CPoCUS Independent Practitioner Certification Workshop

 CPoCUS Independent Practitioner Certification Workshop

Halifax, Nova Scotia

June 22-24, 2018

This intensive workshop will give participants the opportunity to obtain all of the required observed scans PLUS complete the three-part examination series towards CORE Independent Practitioner certification with the Canadian Point of Care Ultrasound Society (formerly the Canadian Emergency Ultrasound Society). This includes the addition of basic lung (hemothorax and pneumothorax) certification. There will be many instructors, ultrasound machines and many models available while you are here.

A CPoCUS approved introductory ultrasound course is strongly recommended prior to taking this workshop but is not required.

Cost for this workshop: 

$4600 + GST (Space is limited so register early)

Eligible for 25 Royal College Section 3 OR 60 CCFP Cert+ credits.

Registration fees are refundable (minus a $300 processing fee) up to one month prior to course dates. After this time, full course payments are non-refundable.

The course will take place at the Best Western Plus in Dartmouth.

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Fall ECCU Fest 2018 – PoCUS Conference Workshop and ECCU2 Course

September 27th – 28th 2018

The Algonquin Resort in St. Andrews by-the-Sea, New Brunswick, Canada

 

Atlantic Canada’s top PoCUS event

 

Now open for applications/booking

 

 

The ECCU Conference is being held in conjunction with the ECCU2 Advanced Applications Course in order to provide those attending the course and other delegates with an opportunity to access an update in the hottest clinical PoCUS topics. The focus will be on presenting the best emerging evidence, strategies for developing a local PoCUS program and developing competencies.

Includes:

  • International PoCUS experts
  • Clinical PoCUS hot topics and updates
  • Top PoCUS research
  • IP2 Diagnostic stream lectures

Conference delegates will have access to the Diagnostic stream lectures of the ECCU2 Advanced Applications Course, which will include an Gallbladder, Renal, DVT and Ocular

Invited Faculty – 2018

Dr. Hein Lamprecht – South Africa – (ECCU Fest 2018) – PoCUS Educator Extraordinaire – IFEM – WinFocus

Dr. Darryl Wood – UK/South Africa – (ECCU Fest 2018) – PoCUS bushcraft on the frontline

Dr. Peter Croft – USA – (ECCU Fest 2018) – New England PoCUS disrupter –past MGH PoCUS Fellow

Dr. David Mackenzie – USA – (ECCU Fest 2018) – Canadian New Englander, PoCUS innovator – past MGH PoCUS Fellow

 

Also our top Dalhousie Faculty of PoCUS Experts

 


 

Open for applications and booking: More Information Here

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EM Reflections – February 2018

Thanks to Dr. Paul Page for leading the discussions this month

Edited by Dr David Lewis 

 


 

Top tips from this month’s rounds:

Pleuritic Chest Pain – Don’t forget the Abdomen

Headache – Not always Migraine

Epistaxis – Posterior Bleed

CME QUIZ

 


Pleuritic Chest Pain – Don’t forget the Abdomen

The commonest causes of pleuritic chest pain (pleurisy) presenting to the ED include:

  • Pulmonary embolus
  • Pneumonia
  • Pericarditis
  • Myocardial infarct
  • Pneumothorax

Once these have been ruled out consider the following differential diagnosis:

ref: American Family Physician (May 2007)

 

Another differential to consider is:

Perforated peptic ulcer

This can result in localized sub-diaphragmatic peritonitis that can result in pleuritic chest pain

 

Tips:

  • If a CT Chest has been performed – look for free air under the diaphragm
  • Always document an abdominal exam when assessing a patient with pleuritic chest pain
  • Although radiologists are highly skilled, like any physician, they are not infallible. Conservative estimates suggest an error rate of 4%. See this excellent article: The Epidemiology of Error in Radiology and Strategies for Error Reduction
  • Wherever possible physicians should always review the images from CT and X-Ray prior to reading the formal radiology report.

Arrows depicting free air on erect CXR – note the double stomach bubble sign on the left

Free air seen on lower slice of CT Chest. Easily mistaken for bowel

 

 


Headache – Not always migraine

The commonest cause of headache presenting to the ED is migraine

The features of migraine headache are well documented in this article – The diagnosis and treatment of chronic migraine

 

The differential diagnosis for patients presenting with headache is large. This excellent website (https://ddxof.com/) provides algorithms to help consider the differential diagnosis in the cardinal EM presentations.

From: DDxof.com

 

Another differential to consider is:

Anemia

Sub-acute onset anemia secondary to chronic blood loss e.g menorrhagia, chronic GI bleed, etc can present with fatigue, visual disturbance and headache.

Tips:

  • Patients who present to ED with a new headache (no previous hx of primary headache syndrome or change in symptoms) should have baseline investigations including CBC and Glucose.
  • Always review the paramedic and triage notes for supplementary information and the presence of additional symptoms that may broaden or narrow the differential.
  • Patient ethnicity and skin colour may mask the presence of anemia.

 

 

 

 


Epistaxis – Posterior Bleed

Posterior epistaxis is a difficult condition to manage and is associated with a number of acute and serious complications. In this study, 3.7% required intubation.

The #FOAM Blog post provides an excellent outline to the management of posterior epistaxis – EMDocs.net

The Emergency Department Management of Posterior Epistaxis

 

Posterior Nasal Packing – video

 

 

Tips:

  • All cases of major bleeding, including epistaxis should be initially managed in the highest acuity areas of the ED. Patients can then be rapidly stepped down and relocated to lower acuity areas if determined to be lower risk after initial assessment.
  • Consider using a suction device to aid intubation in cases of massive obscuring oro/naso-pharynx haemorrhage.

PulmCrit: Large-bore suction for intubation: strategies & devices

 


 

 

CME QUIZ

EM Reflections - Feb 18 - CME Quiz

EM Reflections – Nov 17 – CME Quiz

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ED Rounds – Sexual Assault and the SJRH SANE Program

Sexually Assault and the SJRH SANE Program

ED Rounds Presentation by Dr. Robin Clouston and Maureen Hanlon RN, SANE Co-ordinator


The Sexually Assaulted Patient – Evaluation & Management in the Emergency Department

Dr. Robin Clouston

Download (PPTX, 479KB)

 


The Saint John SANE Program

Maureen Hanlon RN, SANE Co-ordinator

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EM Reflections – January 2018

Thanks to Dr Joanna Middleton for leading the discussion this month and providing these tips and references.

Edited by Dr David Lewis 

 

  1. Occult Fractures of the Upper Limb

  2. Door to Needle/Balloon Times

  3. Mycotic Aneurysms

  4. CME Quiz


Occult Fractures of the Upper Limb

In patients (particularly the elderly)who present with upper limb pain following a fall or other trauma, be careful not to miss an occult fracture. Localization may be impaired by dementia, acute confusion or other soft tissue injuries. Commonly missed fractures of the upper limb include:

  • Clavicle fracture
  • Supracondylar fracture
  • Radial Head/Neck fracture
  • Buckle fractures of the radius/ulna
  • Scaphoid fracture
  • Carpal dislocation
  • Any impacted fracture

Impacted fractures of the humeral neck may still allow some shoulder joint movement. Pain can be referred to the elbow (just as some hip injuries have pain referred to the knee).

When a fracture is strongly suspected ensure that the entire bone is included in the radiograph. If localization is impaired consider obtaining radiographs of the entire limb, starting with the most symptomatic area. Also follow the old mantra – “include the joint above and below” when ordering radiographs for suspected fracture.

Commonly missed fractures in the ED

Misses and Errors in Upper Limb Trauma Radiographs

 


Strategies to reduce door to ballon time

Delays in door to balloon time for the treatment of STEMI have been shown to increase mortality.

 

 

JACC 2006 Click on here for full text

 

BMJ 2009 – Click here for full text

 

This evidence has led to an international effort to establish strategies that can reduce door to balloon times

This rural program in the USA published their strategy for reducing door to ballon times below 90mins over a 4 year period. https://www.sciencedirect.com/science/article/pii/S0735109710043810. Their strategies included the following:

2005
• Community hospital physicians visited by interventional cardiologist with recommendations to:

∘ Perform ECG within 10 min of arrival for chest pain patients

∘ Communicate with PCI center physicians via dedicated STEMI hotline

∘ Treat and triage patients without consulting with primary physicians

∘ Give aspirin 325 mg chewed, metoprolol 5 mg IV × 3 when not contraindicated, heparin 70 U/kg bolus without infusion, sublingual nitroglycerin or optional topical nitropaste without routine intravenous infusion, and clopidogrel 600 mg PO

∘ Eliminate intravenous infusions of heparin and nitroglycerin.

2006
• Nurse coordinator hired to oversee program and communicate with emergency department personnel at all referring hospitals.

• Recommendations for medications listed above were formally endorsed for all STEMI patients.

• Formal next-day feedback provided to referring hospitals, including diagnostic and treatment intervals and patient outcomes.

• Quarterly “report cards” issued to each referring hospital emergency department.

2007
• PCI hospital emergency physicians directly activated the interventional team (instead of discussing it first with the interventional cardiologist on call).

• A group page was implemented for simultaneous notification of all members of the interventional team and catheterization laboratory staff of an incoming STEMI patient.
ECG = electrocardiogram; IV = intravenous; PCI = percutaneous coronary intervention; PO = by mouth; STEMI = ST-segment elevation myocardial infarction.

 

However recent commentaries have highlighted the pitfall of this metric

 

The Challenges and Pitfalls of Door-to-Balloon Time as a Performance Metric

https://www.medscape.com/viewarticle/537538

 

and further evidence has shown no improvement in mortality despite reducing door to balloon times. However, it should be noted that these centres were already achieving < 90 min.

http://www.nejm.org/doi/full/10.1056/NEJMoa1208200

This may be a result of multiple confounding factors:

total ischemic time may be a more important clinical variable than door-to-balloon time

it has been suggested that the association between door-to-balloon time and mortality may be affected by an “immigration bias” – healthier patients are likely to have shorter door-to-balloon times than are sicker patients with more complex conditions, for whom treatment may be delayed because of the time needed for medical stabilization

 

Whilst strategies to ever reduce door to balloon times may not be the correct focus to reduce overall mortality, it is clear that the presence of significant delays (>90mins) is associated with increased mortality.

 


Mycotic Aneurysms

Any kind of infected aneurysm, regardless of its pathogenesis. Such aneurysms may result from bacteremia and embolization of infectious material, which cause superinfection of a diseased and roughened atherosclerotic surface.

 

Aneurysmal degeneration of the arterial wall as a result of infection that may be due to bacteremia or septic embolization 

  • Symptoms:  pulsatile mass, bruit, fever
  • Risk Factors:  arterial injury, infection, atherosclerosis, IV drug use
  • #1 cause = staph, #2 = salmonella

Download (PDF, 1.14MB)

 


 

CME QUIZ

EM Reflections - Jan 18 - CME Quiz

EM Reflections – Jan 18 – CME Quiz

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