Author Archives: Paul Atkinson

Congratulations @sjrhem resident researchers

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Congratulations to Dr Mandy Peach, PGY2 in the EM/FM program, on her success in receiving the Doug Sinclair Top Resident Research Award at the Dalhousie University Emergency Medicine Research Day 2018 and also Top Project at the Dalhousie Saint John FM/EM Project/Research Day 2018. Mandy presented her research on Sonography in Hypotension (SHoC-ED) diagnoses and shock categories.

Well done Derek Rollo and Luke Taylor for their joint runners up position. Derek presented his work on the ECPR/ED-ECMO feasibility study, and Luke presented on Sonography in Hypotension (SHoC-ED) resuscitation markers.

 

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Improving the economy, and our health with one simple action – reading.

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Improving the health and the wealth of the population can seem like a complex, almost impossible, task for governments. It may therefore seem somewhat surprising that a single inexpensive intervention could make a major impact on both. Believe it or not, the number of hours a child reads when young could significantly impact their health and wealth later in life, and also improve the economy.

Indeed, it seems that simply by ensuring kids read more before they start school, and most certainly in the early years at school, the economy and the lives of citizens could be impacted significantly for the better. How so?

In New Brunswick (NB), our students preform reasonably well on reading and mathematics when compared to other countries. NB reading scores for 15 year olds (PISA 2016) are just above the OECD average of 493 points at 505. However, they lag behind the rest of Canada, where the average score was 527 points. A similar pattern is seen with GDP, with New Brunswick showing a GDP per capita of CAN$45,187 (US$35,375) in 2016, compared with Canada at CAN$56,129 (US$43,938), and international rates as high as US$102,831 in Luxembourg (World Bank 2016).

Research from many countries has shown that the best predictor of future education achievement and life success regardless of socio-economic background is reading ability. And what is the best predictor of Grade 2 reading levels? That would be how much a child has read up to that age (Simplicity 2018). Not what they have read, just the total reading hours.

So the number of hours a child spends reading in their early years predicts their reading ability (learning to read), which in turn helps them read to learn through their school years. This in turn is associated with better earnings and better GDP per capita, which in turn is associated with improved health outcomes (Swift 2011).

So, if you want your child to be healthy, wealthy and wise, perhaps getting early to bed every day is important, but not before they have spent some time reading!

Let’s get our children reading early, and reading more!

 

 

 

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Great ideas and making things better

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I heard Dr. Dylan Blacquiere speaking on the radio while driving home after one of those busy D2 shifts on Friday, and it really cheered me up to hear him describe how we all in Saint John are leading the way in managing acute stroke care. http://www.cbc.ca/player/play/1152508483846
From EMS, through Emergency Medicine, diagnostic and intervention radiology, internal medicine and neurology, Saint John Regional Hospital (probably more appropriately Saint John University Hospital) provides a world class service for stroke patients in New Brunswick.
This got me thinking about many of the other innovations and ideas that we continue to push forward locally, especially relating to emergency medicine, and how important it is not to let ourselves become disillusioned by busy shifts, perceived administrative inertia, perceived injustices, crowding and many of the negatives we face, and will likely continue to face for sometime.
To name but a few, we can be proud of the integrated STEMI program we have from EMS to Cath Lab, the Point of Care Ultrasound program that leads in this nationally and beyond, the new Trauma Team leadership program, the patient wellness initiatives such as the photography competition corridor that make things just a little brighter for patients, the regionally dominant and growing simulation program, the regional and local nursing education programs, the nationally unique and hugely popular 3 year EM residency program, the impact of our faculty on medical education at DMNB, the leading clinical care provided by a certified faculty of emergency physicians, our website, our multidisciplinary M&M and quality programs, many of the research initiatives underway including development of an ECMO/ECPR program with the NB Heart Centre, improving detection of domestic violence, innovations around tackling crowding, preventing staff burnout, better radiology requesting, encouraging exercise prescriptions, and much more.
I was particularly impressed how Dylan explained the integrative approach that was required to improve stroke care, and how that was achieved here. There are many other areas that we can also improve, innovate and lead in. Every day we see ways to make things better.
I hope that at this point in our department’s journey, we can continue to make the changes that matter, for patients, our departmental staff, physicians, nurses and support staff alike.
I encourage all of us to think of one area we can improve, to plan for change and for us all to support each other to achieve those improvements. Some of our residents are embarking on very interesting projects, such as designing early pregnancy clinic frameworks, models to improve performance under stress, and simulating EMS ECPR algorithms – all new innovations, not just chart reviews of what we are already doing. I encourage us all to support them, and others with these projects, and to begin to create innovation priorities for the department.
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“At work, at home”

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As I began a new role with WorkSafeNB, alongside ongoing work in Emergency Care, I thought that perhaps it was timely to reflect on some of the best ways that we can all improve our health and the health of our patients, whether at work, or at home. Too often, we equate our health with how we feel, what pills we take, or how often we see a nurse or doctor. We all have a much greater influence and control over the quiet processes underpinning our physical and mental health than we are aware of.

How can we, as a society, achieve mindfulness that while some parts of our bodies (neurons) are as old as we are, others (skin, lungs, liver and even our heart) are replaced over time, cell by cell? That the food we eat is not just fuel for our bodies, but also supplies the building blocks – the replacement parts for our organs? To consider that when we drink that bottle of sugary pop to wash down the nachos or pizza, we should not be surprised if the body we build, over time, reflects those choices. If we sit all day, every day, and then suddenly need to run to catch a bus, or climb a flight of stairs, is it surprising that our leg muscles cry out in protest, and our heart pounds to alert us to its stress?

I believe that 2017 is as good a year as any for us as a society, and as individuals, to make some changes, so that in 2018, 2028 and beyond, we have a little bit more health, and a little less “health care” in our lives. How does that relate to work? Let’s look at a few scenarios: working, being unemployed, disability, going back to work and time spent at home.

Working: In general, going to work is good for us. Working is the most common way to make a living and attain financial independence. We know that long spells without work are harmful to physical and mental health. Earning enough money to eat well, to afford leisure, to reduce stress around meeting payments is likely to benefit our health. Work also meets many psychosocial needs including identity and providing a purpose in life.

However, many jobs pose both physical and psychological hazards that can risk health. These might include the dangers associated with construction, operating machinery or performing repetitive tasks, or may simply be the amount of sitting down at work. People who sit for prolonged periods of time have a higher risk of dying from all causes — even those who exercise regularly.

Unemployment: There is a strong association between not working and being in poor health. Unemployed people die earlier, have more physical and mental health issues, and use medical resources more frequently.

Disability: Injured and ill workers need the time and medical interventions provided to them by workers’ compensation, or other insurance, to recover from their injury or illness. However, they too will suffer the ill effects of being off work for extended periods of time.

Going back to work: For the most part, the negative effects of not working can be reversed by going back to work. Disabled and sick individuals should be encouraged and supported to return to some form of work as soon as possible, when their health condition permits. Again, this helps to promote recovery and rehabilitation; leads to better physical and mental health outcomes; improves their economic position and improves quality of life overall.

At home: Many of the factors that influence health in the workplace also apply at home and in all other settings. Better food, less sitting, more exercise, more relaxation, and active community engagement all improve our health and wellbeing.

We all know these things to be true. Physicians and politicians talk about educating the public. And yet rates of obesity, diabetes, high blood pressure, mental health issues and many other chronic illnesses continue to increase. So, while we must continue to promote healthy choices, it is clear that education and information are not very effective without systemic change.

Over the past century, major health improvements and increased life expectancy came about because of clean water and rapid declines in infectious disease, including immunization policy, as well as broad economic growth, rising living standards, and improved nutritional status. Much of this change has been at a societal level, rather than individual – in other words, ordinary people didn’t really need to make any special effort to benefit from these things. More recent smaller gains have resulted from advances in treatment of cardiovascular disease and control of its risk factors, such as smoking.

Frieden’s “Health Impact Pyramid” clearly shows that if we want to improve health, the most effective and straightforward means is through improving socio-economic factors. However, the next level of action is challenging. “Changing the context to make individuals’ default decisions healthy” may sound to some a little too much like the “nanny state” or “big brother.” But does true independent individual choice exist? We tend to eat similar foods to those around us – think of the difference you notice when you travel to another culture. The milk we drink, the bread we eat – as individuals, we do not control the ingredients. We have similar habits to those around us – think social media, cars we drive, holidays we celebrate. These choices all contain elements that are beyond our control, yet they influence our health every day. Individual choices will move in a healthier direction when government, industry and community leadership come together to establish a healthier environment.

I will sign off with my suggested prescriptions for 2017. These are all achievable, without a major amount of effort, at minimal cost, but with major potential benefit:

Prescription for Workers:

Engage in your job. Remain as physically active as possible at work – stand rather than sit, for periods of time; use the stairs rather than the elevator. Eat well – pack a salad for lunch; don’t bring unhealthy sugary snacks to work. Take regular breaks, each day, each week, and use your vacation to renew body and mind. Safety – always take full safety precautions; never operate dangerous machinery when fatigued, distracted or intoxicated; report any dangers you discover.

Prescription for Employers:

Engage your workers. Provide opportunity for physical activity. Facilitate options for healthy eating. Schedule workers appropriately, allowing adequate rest periods. Provide support for stressed, sick, or injured workers. And of course, always provide a safe work environment, cultivating a safety culture where workers are comfortable discussing dangers and precautions.

Prescription for Decision Makers (Government, Healthcare Providers, Industry, etc.):

Continue to work towards full employment. Promote exercise, and make it easier for all to exercise safely – with walking paths, cycle lanes and paths, safe crosswalks. Encourage a better general diet – create incentives for healthy choices. Encourage and incentivize the healthcare sector to make cost effective choices for treatment and investigation. Prioritize health and prevention of disease when making policy decisions – factor in long term investment and cost savings over short term gains. Help create a healthy, safe culture for all.

Prescription for All of us at Home:

Let’s think about what food we buy – we are likely to eat it! We are what we eat (and drink) – it is not just fuel. Don’t drink sugary beverages – they will damage our livers and increase our chance of diabetes and obesity. Don’t smoke – it kills – and help is available to stop. Stand up, walk around, then walk some more. There are 24 hours in a day – why not spend at least half an hour exercising? Spend some time with friends and family, and spend some time alone, thinking.

Here’s to a healthier 2017, at work, and at home.

Dr. Paul Atkinson MB MA FRCPC
Professor and Research Program Director
Emergency Medicine
Dalhousie University
Saint John Regional Hospital
Saint John, NB E2L 4L2Chair, Department of Emergency Medicine Research Committee,
Dalhousie University in New Brunswick

Chief Medical Officer, WorkSafeNB

Senior Editor, Canadian Journal of Emergency Medicine

[email protected]

@Eccucourse

Dr. Paul Atkinson

 

For original article in OPUS MD and French version see below.

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“Double double” yellow lines for improved road safety!

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When it comes to reducing road deaths and injuries in New Brunswick, perhaps we should be inspired by Voltaire to avoid letting “the perfect be the enemy of the good.” Most serious collisions on our roads result from a combination of problems with road conditions, human factors, technology, and chance. While public safety campaigns and legislation try to affect many of the human factors by highlighting the dangers of distracted driving, intoxication (a subject for another day), and speed; and car manufacturers continue to improve vehicle safety; there is strong evidence that as a society, through improved regulations, we can also save lives by simple changes to road conditions and layout.

According to the world report on road traffic injury prevention, the Dutch policy of sustainable safety divides roads into one of three types according to their function, and then sets speed limits and driving conditions accordingly. These categories are Flow Roads; Distributor Roads; and Residential Roads. For Residential Roads, the needs of non-motorized users take priority, with the use of sidewalks, cycle lanes, crosswalks and slow speed limits. Distributor Roads carry traffic to and from large urban districts, and give equal importance to motorized and non-motorized local traffic, but separate users wherever possible, with variable speed limits. Flow Roads, or arterial roads and highways, are designed to allow through-traffic to go from the place of departure to the destination without interruption. Speed limits are higher, and there should be complete separation of traffic streams. It is on this last point that we in New Brunswick often fail.

While we are fortunate to have many kilometres of twinned highways, we also have several medium volume undivided Arterial Highways such as routes 7 and 11, to name two. And this is where we should consider Voltaire’s observation. We cannot afford to twin all our arterial roads, however we can afford to modify high-risk areas to minimize the chances of major collisions occurring.

If roads did not exist, and we were to ask an engineer to design a safe road for two-way traffic, how likely is it that they would deliberately place oncoming traffic,a mixture of family vehicles and large commercial trucks, heading towards each other at combined speeds of over 200kph separated only by a thin yellow line, encouraging, in places, faster traffic to move into the apposing lane, directly facing oncoming traffic, to pass slower vehicles? Unlikely! So now that we know better, with strong evidence to back up what is essentially good common sense, can we not introduce some simple low cost measures to improve safety?

 

We saw how the government acted quickly to enact “Ellen’s Law” legislating a minimum passing distance of one metre for cars passing cyclists. Should we not consider similar principles for oncoming traffic – perhaps widening the central yellow line to a one metre wide “painted barrier” on fast arterial roads? Kind of like a “double double” yellow line! The addition of central rumble strips to such a widened median, and the erection of central median barriers in high risk areas, with safe passing zones, are all much lower cost interventions than twinning every kilometer of our road network – the perfect solution that will never happen, yet the idea of which stops us implementing other solutions that could save lives. Let’s stop the perfect becoming the enemy of the good when it comes to road safety.

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Is CT-defined obstruction a predictor of urological intervention in emergency department patients presenting with renal colic?

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Larger proximal ureteral stones with severe pain, rather than ureteral obstruction, are associated with urological intervention [excerpt]

…According to the latest Canadian Urological Association guidelines for management of ureteral stones, patients presenting with ureteral stones <5 mm could be managed conservatively, provided that they don’t have infectious symptoms, intolerable pain, or a threat to renal function.1 When urological intervention is contemplated, the decision-making process takes into account patient- related factors (intolerable pain, infectious complications, impending renal failure, coagulopathies and renal anomalies including solitary kidney); and stone-related factors (stone size, location, density, and skin-to-stone distance). However, signs of ureteral obstruction on computed tomography (CT) are not part of the guidelines.

In their study, Massaro et al performed a retrospective review of 195 patients presenting with ureteral stones at a tertiary Canadian centre [@SJRHEM] between 2011 and 2013.2 Forty-two per- cent of the patients presenting with ureteral stones underwent urological intervention, including cystoscopy with retrograde pyelography, placement of ureteric stent, shockwave lithotrip- sy, and/or ureteroscopic laser lithotripsy. A radiologist and a urologist independently reviewed all CT scans for prede ned criteria of ureteral obstruction (no obstruction, partial, or com- plete obstruction) based on degree of hydronephrosis, hydro- ureter, nephromegaly, and perinephric stranding. In addition, the authors examined other potential predictors for interven- tion, including patient demographics, stone size and location, amount of analgesics used, signs and symptoms of infection, serum creatinine, cumulative intravenous uid administered, and the prescription of medical expulsive therapy.

Not surprisingly, the authors found that stone size and location, in addition to cumulative opioid dose, were independent predictors for urological intervention. In fact, every mm increase in stone size increased the likelihood of intervention 2.2 times (odds ratio [OR] 2.17; 95%  [CI] 1.67‒2.85). The OR exceeded unity for stones larger than 4.5 mm, indicating higher likelihood of urological intervention for stones larger than 4.5 mm. Similarly, proximal stones were 4.7 times more likely to require intervention than distal stones (OR 0.21; 95% CI 0.09‒0.49). Finally, every 10 mg increase in morphine administered was associated with a 30% increase in the odds of intervention (OR 1.30; 95% CI 1.07‒1.58). However, degree of obstruction was not an independent predictor of intervention for ureteral stones (OR 1.757; 95% CI 0.899‒3.436). Finally, none of the variables predicted 30-day return to the emergency department (ED). This could be explained by the very low number of returns to the ED in both groups.

Despite its retrospective nature, this study con rms previ- ous studies that ureteral stone size (>4.5 mm), proximal loca- tion, and intractable pain requiring higher doses of opioids are associated with urological intervention. Furthermore, the degree of ureteral obstruction on CT scans did not pre- dict intervention. While CT scan ndings of hydronephrosis, hydroureter, nephromegaly, and perinephric stranding are helpful in diagnosing ureteral stones, they are not helpful in guiding the decision-making process for intervention.

Sero Andonian, MD, MSc, FRCSC, FACS; Associate Professor of Urology, McGill University, Montreal, QC, Canada

Cite as: Can Urol Assoc J 2017;11(3-4):93. http://dx.doi.org/10.5489/cuaj.4511

References

  1. Ordon M, Andonian S, Blew B, et al. CUA guideline: Management of ureteral calculi. Can Urol Assoc J 2015;9(11-12):E837-51. https://doi.org/10.5489/cuaj.3483
  2. Massaro PA, Kanji A, Atkinson P, et al. Is computed tomography-de ned obstruction a predictor of urological intervention in emergency department patients presenting with renal colic? Can Urol Assoc J 2017;11(3-4):88-92. http://dx.doi.org/10.5489/cuaj.4143

Read the @SJRHEM paper here…

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“Bypass in a box” – Team ECMO takes first prize at Dragons’ Den Event

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April 2017 – Team ECMO, lead by Drs. Paul Atkinson, Michael Howlett, Mark Tutschka, Jay Mekwan, and Mr. Bill O’Reilly, and representing Emergency Medicine, ICU and the NB Heart Centre, has been awarded the first prize of $75,000 to fund the initial phases of their proposed ECPR project. The team hopes to research the feasibility of introducing Extracorporeal CPR (“bypass in a box”) at the Saint John Regional Hospital.

https://www.telegraphjournal.com/greater-saint-john/story/100172219/dragons-den-saint-john-hopsital

 

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SHoC blog from @CanadiEM

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Social media site @CanadiEM recently featured the @CJEMonline @IFEM2 #SHoC Consensus Protocol, featuring authors from @SJRHEM among others.

So why do we need another ultrasound protocol in emergency medicine? RUSHing from the original FAST scan, playing the ACES, FOCUSing on the CAUSE and meeting our FATE, it may seem SHoCking that many of these scanning protocols are not based on disease incidence or data on their impact, but rather on expert opinion. The Sonography in Hypotension (SHoC) protocols were developed by an international group of critical care and emergency physicians, using a Delphi consensus process, based upon the actual incidence of sonographic pathology detected in previously published international prospective studies [Milne; Gaspari]. The protocols are formulated to help the clinician utilize ultrasound to confirm or exclude common causes, and guides them to consider core, supplementary and additional views, depending upon the likely cause specific to the case.

Why would I take the time to scan the aorta of a 22 year old female with hypotension, when looking for pelvic free fluid might be more appropriate? Why would I not look for lung sliding, or B lines in a breathless shocked patient? Consideration of the shock category by addressing the “4 Fs” (fluid, form, function, and filling) will provide a sense of the best initial therapy and should help guide other investigations. Differentiating cardiogenic shock (a poorly contracting, enlarged heart, widespread lung B lines, and an engorged IVC) in an elderly hypotensive breathless patient, from sepsis (a vigorously contracting, normally sized or small heart, focal or no B lines, and an empty IVC) will change the initial resuscitation plan dramatically. Differentiating cardiac tamponade from tension pneumothorax in apparent obstructive shock or cardiac arrest will lead to dramatically differing interventions.

SHoC guides the clinician towards the more likely positive findings found in hypotensive patients and during cardiac arrest, while providing flexibility to tailor other windows to the questions the clinician needs to answer. One side does not fit all. That is hardly SHoCing news. Prospective validation of ultrasound protocols is necessary, and I look forward to future analysis of the effectiveness of these protocols.

References

Scalea TM, Rodriguez A, Chiu WC, et al. Focused Assessment with Sonography for Trauma (FAST): results from an inter- national consensus conference. J Trauma 1999;46:466-72.

Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, Porter TR, Spencer KT, Tayal VS, Wei K. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. Journal of the American Society of Echocardiography. 2010 Dec 31;23(12):1225-30.

Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J. C.A.U.S.E.: cardiac arrest ultra-sound exam – a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation 2008;76:198–206

Atkinson PR, McAuley DJ, Kendall RJ, et al. Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension. Emerg Med J 2009;26:87–91

Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in Shock in the evaluation of the critically lll. Emerg Med Clin North Am 2010;28:29 – 56

Jensen MB, Sloth E, Larsen KM, Schmidt MB: Transthoracic echocardiography for cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol. 2004, 21: 700-707.

Gaspari R, Weekes A, Adhikari S, Noble VE, Nomura JT, Theodoro D, Woo M, Atkinson P, Blehar D, Brown SM, Caffery T. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016 Dec 31;109:33-9.

Milne J, Atkinson P, Lewis D, et al. (April 08, 2016) Sonography in Hypotension and Cardiac Arrest (SHoC): Rates of Abnormal Findings in Undifferentiated Hypotension and During Cardiac Arrest as a Basis for Consensus on a Hierarchical Point of Care Ultrasound Protocol. Cureus 8(4): e564. doi:10.7759/cureus.564

Sonography in Hypotension and Cardiac Arrest: The SHoC Consensus Statement

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CAEP Definition of an Emergency Physician and the Importance of Emergency Medicine Certification

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CAEP Definition of an Emergency Physician

An emergency physician is a physician who is engaged in the practice of emergency medicine and demonstrates the specific set of required competencies that define this field of medical practice. The accepted route to demonstration of competence in medicine in Canada is through certification by a recognized certifying body.*

CAEP recognizes that historically many of its members are physicians who have practiced emergency medicine without formal training and certification. Many have been, and continue to be key contributors to developing emergency medicine and staffing emergency departments in Canada. CAEP acknowledges the contributions of these valued physicians and recognizes them as emergency physicians. It is CAEP’s vision going forward that physicians entering emergency practise will demonstrate their competencies by obtaining certification.

* Recognized certifying bodies in Canada are:
The Royal College of Physicians & Surgeons of Canada
The College of Family Physicians of Canada
(Emergency Physicians with equivalent non-Canadian training and certification are also recognized in Canada eg The American Board of Emergency Medicine)

CAEP Statement on the Importance of Emergency Medicine Certification in Canada

It is CAEP’s vision, that by 2020 all emergency physicians in Canada will be certified in emergency medicine by a recognized certifying body.*

Toward that vision, provincial governments and Faculties of Medicine must urgently allocate resources to increase the numbers of emergency medicine postgraduate positions in recognized training programs so the Colleges are able to address the gap in human resources and training. Furthermore, physicians who have historically practiced emergency medicine without certification must be supported in their efforts to become certified. CAEP is committed to facilitate this process by cataloguing and nationally coordinating practice- and practitioner-friendly educational continuing professional development programs designed to assist non-certified physicians to be successful in their efforts.

* Recognized certifying bodies in Canada are:
The Royal College of Physicians & Surgeons of Canada
The College of Family Physicians of Canada
(Emergency physicians with equivalent non-Canadian training and certification are also recognized in Canada eg The American Board of Emergency Medicine)

We have also published on this topic, highlighting the need for more resident positions in New Brunswick and PEI. Read our paper here.

 

Read more from CAEP here.

 

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IFEM Consensus Statement – SHoC – PoCUS use in Undifferentiated Hypotension and Cardiac Arrest

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International Federation for Emergency Medicine Consensus Statement: Sonography in hypotension and cardiac arrest (SHoC): An international consensus on the use of point of care ultrasound for undifferentiated hypotension and during cardiac arrest.

Paul Atkinson, MB, MA*†; Justin Bowra, MB‡§; James Milne, MD¶; David Lewis, MB*†; Mike Lambert, MD**; Bob Jarman, MB, MSc†††‡‡; Vicki E. Noble, MD§§¶¶; Hein Lamprecht, MB***; Tim Harris, BM†††‡‡‡; Jim Connolly, MB†† on behalf of the International Federation of Emergency Medicine Sonography in Hypotension and Cardiac Arrest working group: Romolo Gaspari, MD, PhD; Ross Kessler, MD; Christopher Raio, MD; Paul Sierzenski, MD; Beatrice Hoffmann, MD; Chau Pham, MD; Michael Woo, MD; Paul Olszynski, MD; Ryan Henneberry, MD; Oron Frenkel, MD; Jordan Chenkin, MD; Greg Hall, MD; Louise Rang, MD; Maxime Valois, MD; Chuck Wurster, MD; Mark Tutschka, MD; Rob Arntfield, MD; Jason Fischer, MD; Mark Tessaro, MD; J. Scott Bomann, DO; Adrian Goudie, MB; Gaby Blecher, MB; Andrée Salter, MB; Michael Rose, MB; Adam Bystrzycki, MB; Shailesh Dass, MB; Owen Doran, MB; Ruth Large, MB; Hugo Poncia, MB; Alistair Murray, MB; Jan Sadewasser, MD

Canadian Journal of Emergency Medicine (CJEM) 

The International Federation for Emergency Medicine (IFEM) Ultrasound Special Interest Group (USIG) was tasked with development of a hierarchical consensus approach to the use of point of care ultrasound (PoCUS) in patients with hypotension and cardiac arrest.

The IFEM USIG invited 24 recognized international leaders in PoCUS from emergency medicine and critical care to form an expert panel to develop the sonography in hypotension and cardiac arrest (SHoC) protocol. The panel was provided with reported disease incidence, along with a list of recommended PoCUS views from previously published protocols and guidelines. Using a modified Delphi methodology the panel was tasked with integrating the disease incidence, their clinical experience and their knowledge of the medical literature to evaluate what role each view should play in the proposed SHoC protocol.

Consensus on the SHoC protocols for hypotension and cardiac arrest was reached after three rounds of the modified Delphi process. The final SHoC protocol and operator checklist received over 80% consensus approval. The IFEM-approved final protocol, recommend Core, Supplementary, and Additional PoCUS views. SHoC-hypotension core views consist of cardiac, lung, and inferior vena vaca (IVC) views, with supplementary cardiac views, and additional views when clinically indicated. Subxiphoid or parasternal cardiac views, minimizing pauses in chest compressions, are recommended as core views for SHoC-cardiac arrest; supplementary views are lung and IVC, with additional views when clinically indicated. Both protocols recommend use of the “4 F” approach: fluid, form, function, filling. An international consensus on sonography in hypotension and cardiac arrest is presented. Future prospective validation is required.

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In case you missed it, 2016…

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Don’t touch – from colon to screen.

Am J Infect Control. 2016 Mar 1;44(3):358-60.

Gerba et al. compared the occurrence of opportunistic bacterial pathogens on the surfaces of computer touch screens used in hospitals and grocery stores. Clostridium difficile and vancomycin-resistant Enterococcus were isolated on touch screens in hospitals and in MRSA in grocery stores. Enteric bacteria were more common on grocery store touch screens than on hospital computer touch screens. So don’t snack while you shop over the holidays. The keywords say everything…

Clostridium difficile; Coliforms; Computer touch screen; Methicillin-resistant Staphylococcus aureus; Vancomycin-resistant enterococcus

 

It hurts, it’s tender, but it’s not appy!

J Pediatr Gastroenterol Nutr. 2016 Mar;62(3):399-402.

Siawash at al. remind us about anterior cutaneous nerve entrapment syndrome (ACNES), a frequently overlooked condition causing abdominal pain. They carried out a cross-sectional cohort in a population 10 to 18 years of age consulting a pediatric outpatient department with new-onset AP during a 2 years’ time period. History, physical examination, diagnosis, and success of treatment were obtained in patients who were diagnosed as having ACNES. Twelve of 95 adolescents were found to be experiencing ACNES. Carnett sign was positive at the lateral border of the rectus abdominus muscle in all 12. Altered skin sensation was present in 11 of 12 patients with ACNES. Six weeks after treatment (1-3 injections, n = 5; neurectomy, n = 7), pain was absent in 11 patients.

BUT WHAT IS CARNETT’S SIGN? Have them tense the abdominal wall (by pulling their legs or head off the bed) and if the pain gets worse or stays the same- it is not intra abdominal.

 

Is there a good REASON to stop CPR?

Gaspari R, Weekes A, Adhikari S, Noble VE, Nomura JT, Theodoro D, Woo M, Atkinson P, Blehar D, Brown SM, Caffery T, et al. Resuscitation. 2016;109:33-9.

Some clinicians use a lack of cardiac activity on ultrasound as a reason to terminate resuscitation efforts. We at the Saint John Regional Hospital Emergency Department (ED) participated in this prospective observational study at 20 EDs across North America. We assessed the association between cardiac activity on point of care ultrasound (PoCUS) during advanced cardiac life support (ACLS) and survival to hospital discharge in patients with pulseless electrical activity (PEA) or asystole. Of 793 patients with out-of-hospital cardiac arrest enrolled, 26% had ROSC, 14% survived to hospital admission, and 1.6% survived to discharge. Among 530 patients without cardiac activity on PoCUS, only 0.6% survived to discharge (compared with 3.8% of those with cardiac activity).

There is always an argument that the association between dismal survival and lack of cardiac activity is just a self-fulfilling prophecy, if absence of cardiac activity led to early termination of salvageable resuscitations. In this study, resuscitation had to continue until at least 2 scans were completed. So, unless there are very special circumstances, such as significant hypothermia, or post defibrillation, it seems safe to terminate resuscitation for most patients with asystole on ECG and without cardiac activity on ultrasound.

 

 

SIRS, I’m not sure what you mean? The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

JAMA. 2016;315(8):801-810.

Singer et al. lay out the new definitions for sepsis and septic shock. SIRS is out. Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Quantify as a SOFA score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L  in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. In emergency department, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following: quickSOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less. These updated definitions and clinical criteria should replace previous definitions, and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing sepsis.

 

NSAIDs and Lasix – best of friends.

Eur J Intern Med. 2015 Nov;26(9):685-90.

Ungprasert and co. look at the association between exacerbation of heart failure (HF) and use of non-steroidal anti-inflammatory drugs (NSAIDs). Their systematic review and meta-analysis looked at six studies where the use of conventional NSAIDs was associated with a significantly higher risk of development of exacerbation of HF. The excess risk was approximately 40% for conventional NSAIDs and celecoxib.

 

Dispelling the nice or naughty myth: retrospective observational study of Santa Claus

BMJ 2016; 355

Park et al. report their attempt to determine which factors influence whether Santa Claus will visit children in hospital on Christmas Day. They carried out an observational study in paediatric wards in the UK. They discovered that Santa Claus visited most of the paediatric wards in all four countries: 89% in England, 100% in Northern Ireland, 93% in Scotland, and 92% in Wales. The odds of him not visiting, however, were significantly higher for paediatric wards in areas of higher socioeconomic deprivation in England (odds ratio 1.31 (95% confidence interval 1.04 to 1.71) in England, 1.23 (1.00 to 1.54) in the UK). In contrast, there was no correlation with school absenteeism, conviction rates, or distance to the North Pole. The results of this study dispel the traditional belief that Santa Claus rewards children based on how nice or naughty they have been in the previous year. Santa Claus is less likely to visit children in hospitals in the most deprived areas. Potential solutions include a review of Santa’s contract or employment of local Santas in poorly represented regions. Clearly Santa likes everyone in Northern Ireland too! Merry Christmas and happy holidays!

 

PA Dec 2016

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