In Case You Missed It – Spring 2015

A non-random selection of papers you may or may not have seen:


1. ACS – do you know the rules by heart?

2014 AHA Guideline For The Management Of Patients With Non-ST-Elevation Acute Coronary Syndromes: Executive Summary

Amsterdam, E.A., et al, J Am Coll Card 64(24):2649, December 23, 2014

2014 update of the guideline for the management of patients with non-ST-elevation myocardial infarction (NSTEMI) and unstable angina.

Initial evaluation should include risk stratification, and a 12-lead ECG within ten minutes of ED arrival. When the initial ECG is non-diagnostic, serial ECGs every 15-30 minutes are advised when the clinical suspicion of ACS is high (ongoing pain, etc);

It is reasonable to include leads V7-V9 and/or to perform continuous 12-lead ECG monitoring.

The HEART score may be useful for risk stratification.

Troponin levels should be measured at presentation and three to six hours after symptom onset; if levels are normal additional measurements should be performed beyond six hours after symptom onset (or after presentation if the timing of onset is uncertain) if the risk for ACS is intermediate or high.

When troponin assays are available, measurement of CK-MB and/or myoglobin is not useful.

Additional troponin measurements should be performed beyond six hours if prior levels are normal but the suspicion for ACS is intermediate to high.

When objective variables are negative, it is reasonable to observe in a chest pain or telemetry unit, to perform stress testing before or within 72 hours after discharge, and to discharge low-risk patients on aspirin, short-acting nitroglycerin and other appropriate medications with instructions for follow-up.



2. Not So Normal Saline…

Crystalloid Fluid Therapy: Is The Balance Tipping Towards Balanced Solutions?

Young, P.J., et al, Intens Care Med 40(12):1966, December 2014

Each day, more than one million liters of IV 0.9% saline are administered to patients world wide. Although this solution has been termed “normal saline” its composition is not physiologic as it contains a chloride concentration that is about 1.5 times that of normal plasma. These authors from New Zealand briefly reviewed the growing controversy over possible harm due to 0.9% saline infusion.

Rapid infusion of 0.9% saline can cause acidosis, decreased renal perfusion, decline in glomerular filtration rate and, ultimately, death.

The effects of chloride overload must be separated out from the effects of concomitant volume overload using the “volume-adjusted chloride load,” and this measure has shown an association between rising chloride load during resuscitation and an increase in hospital mortality. Comparisons of high-chloride versus balanced solutions in various populations also suggest greater adverse effects with high-chloride solutions, with a possible dose-dependent association. However, limitations of such studies include the confounding effect of concomitantly high sodium content, differences in patient populations given high- versus low-chloride solutions, and differences in other practice patterns among physicians who choose one solution over another. Studies are under way in Australia and New Zealand to compare 0.9% saline versus balanced solutions.  Chloride load in resuscitation fluid may be a modifiable risk factor for poor outcomes. The authors suggest, however, that until definitive results are published physicians can confidently use 0.9% saline (for now!!)



3. Hang on – run it by me first…

Emergency Department resource use by supervised residents vs attending physicians alone

Pitts, S.R., et al, JAMA 312(22):2394, December 10, 2014

The authors, coordinated at Emory University, examined data from the 2010 National Hospital Ambulatory Medical Care Survey to compare resource use in a representative sample of patient visits to 336 EDs treated by attending physicians alone (25,808) or by residents supervised by attending physicians (3,374). Study outcomes included hospital admission, length of the ED stay, and the use of advanced imaging and blood tests.

Supervised visits were associated with significantly more frequent hospital admission (OR 1.42), use of advanced imaging (OR 1.27) and longer ED stays (OR 1.32), but no significant difference in the frequency of blood testing.

Graduate medical education appears to be associated with greater ED resource use, although these findings were less clear when results were stratified by hospital ED teaching type.



4. Old PEople

Accuracy Of The Wells Clinical Prediction Rule For Pulmonary Embolism In Older Ambulatory Adults

Schouten, H.J., et al, J Am Ger Soc 62(11):2136, November 2014

The Wells clinical prediction rule and a negative D-dimer test have largely involved younger patient populations.

These Dutch authors examined the utility of a low-risk Wells score (4 points or lower) plus a negative qualitative D-dimer result (Clearview Simplify D-dimer assay) for the exclusion of PE in 294 nursing home or community-dwelling persons aged 60 and older (mean, 76) with suspected PE. Nearly half of the patients (44%) were nursing home residents. PE was diagnosed on the basis of imaging or follow-up in 28% of the study participants.

85 patients (28.9%) had a low-risk score in combination with a negative D-dimer result. PE was diagnosed in five of these individuals (failure rate, 5.9%).

Lowering of the Wells cut-off to 2 points would have identified two additional patients with PE at the expense of referring 37 additional subjects for further evaluation. The failure rate with this strategy was 2.9%. Use of a quantitative rather than a qualitative D-dimer assay, which has a higher sensitivity for PE, would have identified four of the five cases of missed PE in this series.

Use of the Wells score plus D-dimer testing might be an unreliable strategy for risk stratifying older ambulatory patients with possible PE.



5. Grey-Dimer Scale…

Assessing 2 D-Dimer Age-Adjustment Strategies To Optimize Computed Tomographic Use In ED Evaluation Of Pulmonary Embolism

Gupta, A., et al, Am J Emerg Med 32(12):1499, December 2014

Recent studies have suggested that the use of age-adjusted D-dimer cutoffs in older patients being evaluated for venous thromboembolism increases the specificity of this test.

The authors, from Brigham and Women’s Hospital, applied two age-adjusted D-dimer calculations to a retrospective cohort of 1055 patients aged 18-96 who underwent CT angiography and quantitative latex-based D-dimer testing for possible pulmonary embolism (PE).

A yearly-based cutoff was calculated for those over 50 (age in years x 10ng/ml).

With the exception of two patients using the yearly-based cutoff, sensitivity remained at 100% for the two age-based methods. Use of the decade-based cutoff would have avoided CT angiography in 37 patients, and use of the yearly-based cutoff would have avoided 52 CT angiograms. Use of age-adjusted D-dimer cutoffs improve specificity in older patients with possible PE and may reduce unnecessary use of CT angiography.



6. Hold that Flo(max)? Medical expulsive therapy in adults with ureteric colic: a multi-centre, randomized, placebo-controlled trial.

Pickard R, Starr K, MacLennan G, et al. Lancet. 2015 May 18. pii: S0140-6736(15)60933-3.

This multicentre, randomized, placebo-controlled trial, recruited adults (aged 18-65 years) undergoing expectant management for a single ureteric stone identified by CT at 24 UK hospitals. Participants were randomly assigned to tamsulosin 400 mug, nifedipine 30 mg, or placebo taken daily for up to 4 weeks, using an algorithm with centre, stone size (</=5 mm or >5 mm), and stone location (upper, mid, or lower ureter) as minimization covariates. Participants, clinicians, and trial personnel were masked to treatment assignment. The primary outcome was the proportion of participants who did not need further intervention for stone clearance within 4 weeks.

1136 patients were included in the primary analysis (17 were excluded because of ineligibility and 14 participants were lost to follow-up). 303 (80%) of 379 participants in the placebo group did not need further intervention by 4 weeks, compared with 307 (81%) of 378 in the tamsulosin group (adjusted risk difference 1.3% [95% CI -5.7 to 8.3]; p=0.73) and 304 (80%) of 379 in the nifedipine group (0.5% [-5.6 to 6.5]; p=0.88). No difference was noted between active treatment and placebo (p=0.78), or between tamsulosin and nifedipine (p=0.77).

Serious adverse events were reported in three participants in the nifedipine group and in one participant in the placebo group.

Tamsulosin 0.4 mg and nifedipine 30 mg are not effective at decreasing the need for further treatment to achieve stone clearance in 4 weeks for patients with expectantly managed ureteric colic.



6. “5” is long enough after all…

Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Walters JA, Tan DJ, White CJ, et al. Cochrane Database Syst Rev. 2014 Dec 10;12:CD006897.

Standard methodological procedures as expected by The Cochrane Collaboration were used to review eight studies with 582 participants met the inclusion criteria, of which five studies conducted in hospitals with 519 participants (range 28 to 296) contributed to the meta-analysis.

The authors conclude that five days of oral corticosteroids is likely to be sufficient for treatment of adults with acute exacerbations of COPD, and this review suggests that the likelihood is low that shorter courses of systemic corticosteroids (of around five days) lead to worse outcomes than are seen with longer (10 to 14 days) courses. They graded most available evidence as moderate in quality because of imprecision; further research may have an important impact on our confidence in the estimates of effect or may change the estimates. The studies in this review did not include people with mild or moderate COPD; further studies comparing short-duration systemic corticosteroid versus conventional longer-duration systemic corticosteroid for treatment of adults with acute exacerbations of COPD are required.



7. TNK or PCI…?

ST-segment-elevation myocardial infarction patients randomized to a pharmaco-invasive strategy or primary percutaneous coronary intervention: strategic reperfusion early after myocardial infarction (stream) 1-year mortality follow-up

Sinnaeve P.R., et al, Circulation 130(14):1139, September 2014

Delays in performing primary PCI, which is unavailable in many healthcare facilities, have been shown to have negative effects on the morbidity and mortality of patients with ST-segment-elevation myocardial infarction (STEMI).

This multinational follow-up study to assess one-year mortality in 1,877 STEMI patients included in the open label randomized STREAM trial that compared a pharmaco-invasive strategy (936) (tenecteplase with antiplatelet and anticoagulant therapy and coronary angiography within 6-24 hours) with primary PCI (941). All of the patients presented within three hours after symptom onset but did not undergo primary PCI within one hour after first medical contact.

The STREAM trial reported a nominal nonsignificant advantage of initial pharmaco-invasive (TNK then delayed PCI) management for the composite 30-day endpoint (death, shock, congestive heart failure [CHF] and reinfarction). At one year, the all-cause mortality rate was 6.7% in the group receiving initial pharmacologic management and 5.9% in the primary PCI group (p=NS), and the corresponding cardiac mortality rates were 4.0% vs. 4.1% (p=NS).

These findings suggest that the dose-adjusted early pharmacologic regimen utilized in the STREAM trial can be a safe and effective alternative to primary PCI in STEMI patients who are unable to undergo primary PCI within one hour after presentation.



8. Make a B-line for CHF diagnosis…

Point-Of-Care Ultrasonography For The Diagnosis Of Acute Cardiogenic Pulmonary Edema In Patients Presenting With Acute Dyspnea: A Systematic Review And Meta-Analysis

Al Deeb, M., et al, Acad Emerg Med 21(8):844, August 2014

This review of seven prospective cohort or case-control studies (1,075 patients) of B-lines on point-of-care ultrasonography (POCUS) by non-radiologist physicians to establish a diagnosis of acute cardiogenic pulmonary edema in patients with undifferentiated dyspnea.

PoCUS was performed in the ED in two of the studies, in the prehospital setting in one, and in the ICU or hospital ward in the remaining four. POCUS had an overall sensitivity and specificity for cardiogenic pulmonary edema of 94.1% and 92.4%, respectively, and positive and negative likelihood ratios of 12.4 and 0.06, respectively. Findings were not significantly affected by study type, patient population, or the type of ultrasound protocol that was used.

B line-based POCUS might facilitate the identification of cardiogenic pulmonary edema in patients with acute dyspnea, although further study in the ED setting is advised. The authors suggest that a positive study is highly suggestive of this diagnosis in patients with a moderate to high pretest probability, and that the diagnosis can “almost” be excluded by a negative study in a patient with a low pretest probability.


9. Lazarus to the lab…stat…

Cardiac Catheterization Is Associated With Superior Outcomes For Survivors Of Out Of Hospital Cardiac Arrest: Review And Meta-Analysis

Camuglia, A.C., et al, Resuscitation 85(11):1533, November 2014

It has been suggested that survivors of pre-hospital cardiac arrest may benefit from invasive cardiac assessment and coronary angiography to achieve revascularization. These Australian authors performed a systematic review and meta-analysis of studies reporting on early coronary angiography in patients resuscitated after pre-hospital cardiac arrest.

Fifteen nonrandomized controlled studies compared outcomes in survivors of pre-hospital arrest who underwent early coronary angiography versus those managed without angiography. Overall survival was significantly improved in the angiography groups (58.8% vs. 30.9% in patients not undergoing angiography, odds ratio [OR] 2.77, 95% CI 2.06-3.72). A similar pattern was observed for the secondary endpoint of survival with a good neurologic outcome (58.0% vs. 35.8%, OR 2.20, 95% CI 1.46-3.32). There have been no randomized trials assessing the role of acute angiography in pre-hospital cardiac arrest patients.

Early coronary angiography appears to be associated with improved outcomes in survivors of pre-hospital cardiac arrest. The authors caution against reliance on the 12-lead ECG to identify patients with acute coronary occlusion.



10. Myth busting for Motrin (and other NSAIDs)

Fracture Healing And NSAIDs

Taylor, I.C., et al, Can Fam Phys 60(9):817, September 2014

Some methodologically limited retrospective cohort and case-control studies have reported that treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) impairs fracture healing. Nevertheless, NSAIDs provide relief of pain that has been found to be at least as good as other analgesics, often with fewer adverse side effects.

These authors, from the University of Alberta and writing for the “Tools for Practice” series of the Canadian Family Physician, provide a brief review of three randomized controlled trials of NSAID treatment in patients with fractures. Two trials performed in 140 adults (predominantly middle-aged women with Colles fractures) reported no difference between NSAIDs (flurbiprofen or piroxicam) or placebo for the outcomes of recovery time, need for physical therapy, malunion or nonunion, functional recovery or healing. One study of 336 children with fractures of the arm who were randomized to ibuprofen or acetaminophen/codeine reported no difference between the groups in fracture nonunion. Pain relief with ibuprofen was comparable to that of the comparison drug but produced less functional impairment and fewer adverse effects. The authors acknowledge that data from randomized controlled trials are limited, but do not support impairment of fracture healing with NSAID therapy. They note that studies have found that pediatric fracture patients, in particular, often receive inadequate analgesia.

They conclude that short-term NSAID therapy should not be withheld from patients presenting with fractures.


11. O Canada – it ain’t so bad…Work stressors affecting emergency physicians and residents; an international survey.

De Haan et al. CAEP 2015

High levels of occupational stress can cause health and performance issues within the specialty of emergency medicine (EM). These issues can lead to increased burnout and attrition from the profession. We examined workplace stress experiences for both trainees and certified EM specialists in settings where the specialty of EM is new (South Africa) and better established (Canada).
An online cross-sectional survey of EM trainees and physicians in both countries was conducted using the validated Management Standards Indicator Tool (MSIT, Health and Safety Executive, UK), a 35-item questionnaire where each item is weighted on a five-point scale. There were 77 South African, and 510 Canadian respondents.

In Canada, specialists (N=396) had significantly higher Demands (2.6 (95%CI 2.6-2.7) vs. 3.0 (2.8-3.1)) and Manager support stressors (3.3 (3.3-3.4) vs. 3.9 (3.6-4.0)) than trainees (N=36). Canadian trainees had higher Role stressors (4.0 (3.9-4.1) vs. 4.2 (4.2-4.3)).

In South Africa, trainees (N=39) had higher stressors than specialists (N=36) on Demands (2.2 (2.1-2.3) vs. 2.7 (2.5-2.8)), Control (2.6 (2.4-2.7) vs. 3.5 (3.3-3.7)), Role (3.6 (3.4-3.7) vs. 4.0 (3.7-4.3)) and Change (2.4 (2.2-2.6) vs. 3.0 (2.7-3.3)). South African trainees had significantly higher stressors on ALL domains than Canadian trainees. While South African specialists had lower Control stressors than Canadian counterparts, they had higher Peer support and Relationship stressors.
Risk factors for work-related stress are higher in all domains among South African EM trainees compared with Canadian trainees, and differ from South African EM specialists. Canadian EM trainees reported a lack of role clarity. Canadian specialists had lower work control, but better peer support and work relationships than SA specialists.


Best regards,


Dr. Paul Atkinson

Emergency Medicine,

Dalhousie & Memorial Universities,

Saint John Regional Hospital, NB

[email protected]



  1. Emergency Medicine Journal 2014/15
  2. Emergency Medicine Abstracts 2014/15
  3. ACEP Now 2014/15
  4. Evidence Updates (BMJ/McMaster) 2014/15
  5. Local Research


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