Journal Club – Diagnostic Accuracy of ECG for Acute Coronary Occlusion resulting in MI

Presenter: Dr. Nick Byers (iFMEM R2)

Host: Dr. Colin Rouse

Article:

Research question/PICOD

  • Question:
    • Does shifting from a STEMI/NSTEMI paradigm to a new approach (ACO-MI/ non-ACO-MI) result in better identification of the patients who need acute reperfusion therapy?
  • Population:
    • Adult ED patients with ACS Symptoms
  • Intervention/Comparison:
    • STEMI/NSTEMI vs ACOMI/NACOMI
  • Outcome:
    • Composite ACO defined as one of:
      • A) Total occlusion or presence of culprit lesion on angiography with a peak troponin I level equal to or greater than 1.0 ng/mL plus an at least 20% rise within 24 h
      • B) A highly elevated peak troponin (greater than 5.0 ng/mL), which was shown to be correlated with ACO
      • C) Cardiac arrest before any troponin rise has been documented with supporting clinical evidence of possible ACO
    • All cause in hospital mortality
    • All cause long term mortality
  • Secondary Outcomes: 
    • Time from ECG to coronary angioplasty or CABG
    • The sensitivity and specificity of current criteria in diagnosing ACO
    • The sensitivity and specificity of ECG without ST-segment elevation to diagnose ACO (accuracy of ECG interpretation of acute coronary occlusion without STEMI criteria)
    • The specificity of ECG with STEMI criteria (correct ECG interpretation of false positive STEMI criteria)
    • The sensitivity of ECG with STEMI criteria (correct ECG interpretation of false negative STEMI criteria)
    • The outcome according to ECG subclassifications (outcomes of the patients who are labeled as STEMI and the patients who are labeled as having NSTEMI but have acute coronary occlusion)
  • Design:
    • Single center, retrospective case-control study in Turkey

Results

Authors conclusions

“We believe that it is time for a new paradigm shift from the STEMI/non-STEMI to the ACOMI/non-ACOMI in the acute management of MI”

 

Discussion at Journal Club

Strengths

  • 3000 patients included, 1000 per arm
  • Reviewers were blinded, disagreements were resolved by a 3rd independent reviewer
  • EKGs were reviewed again 3 months later to decrease inter-observer variability
  • Consecutive patients with an initial diagnosis of MI (i.e. not a convenience sample)
  • All patients received guideline-recommended medical treatment
  • There were documented criteria of ECG findings to classify the ECGs

Weakness

  • This was a retrospective study and at a single centre.
  • When troponins were taken was not controlled for/accounted for in any way
  • Control group age, medical comorbidities, and cardiac risk factors were much less
  • Their results suggest 17% of patients in N-ACOMI (N-STEMI Subgroup B) with angiographic ACO were missed (slide 16 results)
  • Study wasn’t powered enough to indicate modest benefit of early intervention over late
  • Extrapolating results to the real world may be difficult because ecg interpretation

 

Bottom line/suggested change to practice/actions

  • This single center retrospective chart review suggests that considering coronary occlusion vs. just ST elevation on ekg decreases long-term mortality, and has a better sensitivity, specificity, PPV, and NPV.
  • This could be a great way of getting patients better access to PCI for occlusive lesions, though inter-operator variability and time constraints are likely to be difficult to implement

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EMSJ CPD Recommendations – March 2023

 Dr Mackenzie Howatt MD FRCPC, Director of CPD

 

I’ve listed below a few external CPD activities for your perusal. I’m hoping to be able to update you monthly on upcoming activities both internal and external to our department to make sure everyone is aware of at least some of the myriad activities out there. I have no involvement/personal stake in any of the listed activities.

 

External CPD Activities 


Clinical Courses:

 

  1. CAEP –AIME – Airway Interventions & Management in Emergencies. Hands on course to enhance your airway skills. Advanced and Awake courses take place in Halifax and use high quality cadavers for training. Requires registration on CAEP website. https://caep.ca/cpd-courses/. AIME April 18, 19 (Niagara Falls), 24, 25 (Toronto) May 26, 27 (Toronto).  AIME advanced April 20 (full but can be put on waitlist), September 10 (Halifax). AIME awake April 19 (full but can be put on waitlist), Sept 9th (Halifax). Different rates for CAEP and non CAEP members
  2. https://imagesim.com/ – An online repository of pediatric images (xray, US, etc) and cases used for resident or faculty education. Different “packages” can be purchased and you have access for 2 years to the particular images/cases. Based out of SickKids in Toronto.
  3. CAEP – Geriatric EM – mix of video modules and then live virtual course on May 27th. Registerhttps://caep.ca/cpd-courses-2/geri_em/.
  4. CAEP “National Grand Rounds” –https://caep.ca/cpd-courses-2/caep-national-grand-rounds/  
  5. The Resus Course – 2 day course. April 27/28, July 27/28, Oct 5/6 organized by Dr. James Gould in Halifax, NS. Contact at [email protected]
  6. Simulation Educator Training – Hosted by the Royal College on March 28/29 in Moncton. Course teaches debriefing, providing feedback, and building psychological safety. Hybrid of online self teaching courses followed by 2 day in person session. Cost is 1700. https://cpd.royalcollege.ca/product?catalog=Simulation_Educators_Trainingq2qP7vmq4nL3k5Q
  7. Trauma Resuscitation in Kids (TRIK) – In person simulation courses held over two days with focus on pediatric trauma management. April 3-4 (Calgary), April 28-29 (Manitoba), and June 16-17 (Montreal).https://cpd.royalcollege.ca/product?catalog=TRIK
  8. Resuscitative TEE – 1 or 2 day simulation course on using TEE in the emergency setting. Held across the world, mostly as pre course offerings for various conferences. Please see website for details.https://www.resuscitativetee.com/workshop

 


Conferences:

  1. CAEP National conference – May 28-31. Toronto. Requires registration
  2. EMU – Emergency Medicine Update – April 26-28 Toronto. https://emupdate.ca/. 3 day in person conference with updates to clinical medicine.
  3. ICEM (International Conference on Emergency Medicine) – June 13-16, 2023. https://icem2023.com/Taking place in Amsterdam. 
  4.  SRPC Rural and Remote Conference. in Niagara, April 20-22 2023. https://srpc.ca/rr2023
  5. Dalhousie – 48th Annual Dalhousie Spring Refresher – Emergency Medicine – can be in person (Halifax) or virtual. 2 day event. April 21 and 22. Registration not yet open.https://medicine.dal.ca/departments/core-units/cpd/conferences.html
  6. EUSEM – European Emergency Medicine Congress – September 17-20 in Barcelona, Spain. An international conference on Emergency Medicine. Early bird registration until June 7th.https://eusemcongress.org/
  7. ACEP – American College of Emergency Physicians – Oct 9-12 in Philadelphia. International conference on Emergency Medicine. https://www.acep.org/sa. “super”early bird registration until March 31.

 


Administrative/Leadership/Faculty Development/Education:

  1. Dalhousie CPD – “Saint John Family Medicine Education Rounds: Teacher as Coach “ – Online course by Dr. Lisa Turner from the Saint John Area. https://medicine.dal.ca/departments/core-units/cpd/conferences.html
  2. Dalhousie Faculty Development – Emerging Leaders in Academic Medicine (ELAM) – An online course comprised of 8 units that will takes approximately 20 hours to complete. “The program provides an opportunity for faculty with limited leadership experience to become more familiar with the functioning of the medical school and acquire knowledge and skills to take on expanded roles in their academic settings.”  Online introduction webinar April 4th from 7-8 pm, and concluding webinar June 6th 7-8 pm. Limited to 30 participants. https://medicine.dal.ca/departments/core-units/cpd/faculty-development/programs/emerging-leaders-in-academic-medicine–elam-.html
  3. Physician Leadership Institute (PLI) – Through Joule (affiliated with CMA). Currently being redesigned to “better align with advocacy priorities and support physicians in driving system level change”. Current offerings include a variety of online leadership courses/modules including “Leadership for medical women” (March 30-31), “Building and leading teams” (April 20-21), “Leading change” (June 8-9).https://joulecma.ca/learning/physician-leadership-institute?_gl=1*d7fypw*_ga*MTcxNjY1Njc0Mi4xNjcwOTQ1MDIz*_ga_91NZ7HZZ51*MTY3ODM3MjMzNS45LjAuMTY3ODM3MjMzNS42MC4wLjA.
  4. CAEP – “Better Together: moving towards Gender Equity in Emergency Medicine.”https://caep.ca/cpd-courses-2/women-in-em-gender-equity/. April 4th, 18th, and 25th at 8pm Atlantic. Online course designed to give physicians foundational knowledge in how female and non-binary trainees and physicians experience discrimination throughout medical training and in practice.


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EMSJ CPD Recommendations – November 2022

Dr Mackenzie Howatt MD FRCPC, Director of CPD

External CPD Activities 

I’ve listed below a few external CPD activities for your perusal. I’m hoping to be able to update you monthly on upcoming activities both internal and external to our department to make sure everyone is aware of at least some of the myriad activities out there. I have no involvement/personal stake in any of the listed activities.

 

Clinical:

  1. CAEP -AIME – registration open for AIME Awake and Advanced in Jan 2023. AIME awake Jan 27th. AIME Advanced Jan 28th. Both in Halifax. Requires registration
  2. CAEP webinar – DOAC related bleeding management. Nov 30th 2 pm Atlantic. Requires online resgistration (free for CAEP members)
  3. CAEP National conference – May 28-31. Toronto. Requires registration
  4. EMU – Emergency Medicine Update – April 26-28 Toronto. https://emupdate.ca/. 3 day in person conference with updates to clinical medicine.
  5. ICEM (International Conference on Emergency Medicine) – June 13-16, 2023. https://icem2023.com/Taking place in Amsterdam.
  6. Annual Update in EM – Feb 25-28th – Whistler, BC. Arranged by UofT DEM.https://www.cpd.utoronto.ca/whistler/ .
  7. EM cases Summit – Feb 2-4, 2023. Virtual, based out of Toronto on the “EM cases” group. Tickets are available starting early November.https://emcasessummit.com/ . Not sure of the cost, and I suspect the videos are available after course for a fixed cost.

Administrative/Leadership/Faculty Development

  1. Dalhousie CPD – “Language Matters: Navigating Stigma and Respect Clinical Education and Patient Care”https://medicine.dal.ca/departments/core-units/cpd/faculty-development.html. Online webinar from 8-9 AM over Zoom. Free.

Education

  1. Dalhousie- Fundamentals of Teaching: Fundamentals of Clinical Teaching and Supervision – Nov 1 – Dec 13.  A hybrid course of offline readings, videos, quizzes, etc that ends with a 1hr live webinar on Dec 13. https://medicine.dal.ca/departments/core-units/cpd/faculty-development/programs/Fundamentals_Teaching.html. 100$ registration fee.
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EMSJ CPD Recommendations – September 2022

Dr Mackenzie Howatt MD FRCPC, Director of CPD

External CPD Activities

I’ve listed below a few external CPD activities for your perusal. I’m hoping to be able to update you monthly on upcoming activities both internal and external to our department to make sure everyone is aware of at least some of the myriad activities out there. I have no involvement/personal stake in any of the listed activities.

 

Clinical:

  1. CAEP CPD – There is an upcoming Geriatric ER course on Oct 27 12-4 (eastern) 400$ for members. Course is mix of pre-recorded videos along with the 4 hour live virtual event. https://caep.ca/cpd-courses/
  2. CAEP CPD – “Pump  it up: updates on POCUS, Risk Stratification, and new meds for ED patients” – FREE online webinar – Oct 19 at 1 pm eastern. Need to Register via CAEP. https://caep.ca/cpd-courses/
  3. Dalhousie CPD – “Community Hospital Programs.” – Is a series of CPD events across NS, most of which has a virtual component. Is free to register. Many topics are primary care, but given current realities are presentations we are being asked to manage in the ED. Some appear relevant, some not. held from 7-8 pm on Tues-Thurs. https://medicine.dal.ca/departments/core-units/cpd/programs/nova-scotia-community-hospital-program.html
  4. Critical Care – Recorded lectures from a conference in the spring held in montreal are available “The Hospitalist and Resuscitationist”. You can “rent” the entire library for 375 for a years worth of access. Have not attended so can’t attest to quality, but have heard positive things. https://thinkingcriticalcare.com/

 

Leadership:

  1. CAEP CPD – Virtual leadership series Nov 3, 10, 17, 24 from 3-430 (eastern). 400/550 (member non member).
  2. NBMS – Foundations of Leadership certificate – multi week commitment for a 4 module leadership course. Free registration. Need to apply by Sept 19. 30 participant max. application can be found on NBMS website.

 

Faculty Development:

  1. Dalhousie CPD office puts on frequent Fac Dev topics that are available to us. They seem to have reasonable registration fees if affiliated with Dalhousie. Topics are on the page linked. https://medicine.dal.ca/departments/core-units/cpd/faculty-development.html

Administration:

  1. EDAC Nov 7 – Fully virtual. Based out of Toronto. Full day course on ED administration (For current or wanna-be admins). 500 dollars for the day
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ED Rounds – February 2015

An enjoyable and informative set of presentations by Dr Ramrattan, Dr Talbot and Dr Greer
The presentations can be downloaded and reviewed from the CPD File Store (Rounds)

Dr Brian Ramrattan – Alphabet Soup

TREKK –  Translating Emergency Knowledge for Kids
To create a national network that is a trusted source for easy access to the latest evidence, best practices, user-friendly resources and discussions in pediatric emergency care. It will be created and used by health professionals and the families they care for and its work will drive the highest quality of health care for children and families seeking emergency care in Canada.
Their mission is to deliver the highest standard of care to every child, whether they choose to seek treatment in a pediatric or general emergency department
More topics on their website
The following were presented:
Bronchiolitis, Croup, Gastroenteritis
Bronchiolitis
  • Routine CXR not supported by evidence however need to take each case on its merits. If suspect pneumonia – CXR
  • NPA or CBC does not alter management
  • High risk groups – Prems, <3/12
  • Most can be discharged
  • Steroids do not reduce LOS
  • Epinephrine may reduce admissions on day 1 but there is no long term benefit
  • Bronchodilators are not effective in bronchiolitis
  • Steroids plus Epinephrine may reduce admission rates for up to 7 days, but not recommended routinely
  • Recommended- Oxygen and Hydration
  • Admission criteria – include unable to maintain sats > 90% without O2, Not feeding, increase WOB, Resp rate > 70
Croup
  • Worse at night
  • Usually improve on way to hospital
  • Clinical diagnosis
  • Febrile, bark, tachypnea
  • Westley Croup Score – may be useful for RT to do while observing child pending discharge
  • Lateral Neck X-ray may be helpful for retropharyngeal abscess, epiglotitis
  • Recommended – Steroids +/- Epinephrine (if need rapid Rx)
Gastroenteritis
  • ORT as good as IV Rehydration
  • Anti emetics lower need for admission and IVRT
  • Not enough evidence for probiotics
  • Consider weight in kg as ORT mL per 5 mins e.g. 10kg = 10mls per 5 mins
  • Ondansetron 8-15kg – 2mg 15-30kg – 4mg
Alberta – Vomiting and Diarrhoea Pathway

 

Dr Jo-Ann Talbot – Do We Choose CPD Wisely?

We are not very good at deciding what to focus on?
Continuum from competence to expertise
Scope of Practice will impact on how we choose our CPD
Why should we have-  Practice Assessment
  • Role in Feedback in identifying areas where our competency can be improved
  • Flaws in self assessment
  • Increasing expectation of the profession
Revalidation is comming…
  • Association of Canadian Regional Colleges have guidelines
  • ACEP – Exam, PAR, Lifelong learning, Patient Feedback etc
  • UK GMC –  system
How can we Improve – Where is the Gap?
  • Perhaps chart reviews
  • Review M&Ms and complaints
  • Are there common things that we do that say if we are a safe doctor?
Needs Assessment Triangulation
  • Synthesis and integration of data from multiple sources
  • Narrow down to the most important problems
  • Assessment
    • Knowledge – e.g self assessment
    • Performance assessments – Sim, Audit, 360, Teaching
  • “How do we know if we are providing excellent care?” – Group discussion – suggested ways below
    • Informal follow up
    • CQI chart audits
    • Bounce backs
    • Procedural audits
    • External chart review
    • M&M’s
    • Trauma Charts
    • Should we get the discharge summary
    • Letters from clinics
    • But what is excellence?
      • Combination of knowledge, skill, implementation, communication
      • We are the experts in Emergency Care – we should set the standards.

 

Download (PDF, 5.91MB)

Dr Matt Greer – Turn it up to 11. LP in the Diagnosis of SAH

  • 1% Headaches = SAH
  • 14% of ED Headaches get CT (US Stats)
  • Unenhanced CT is 100% sensitive < 6hrs
  • Xantho is only useful >12hrs  but < 2weeks (this is now debated – see presentation for details)
  • Type and Location of pain has no predictability for cause
  • Do we still need to LP after CT – ( answered in the presentation)
  • No Gold standard
  • But CT plus LP had been considered standard for early studies
  • LP’s are hard to interpret
  • Unenhanced CT performed < 6hrs – 100% sensitivity
  • Need 3rd generation CT Scanner
  • Need Radiologist – who is routinely reading Head CTs
  • LP – most sensitive >12hrs  and < 2 weeks
  • Xanthochromia determined the positive result
  • But Xanthochromia may not be such a good gold standard?
  • Why  not just do CTA
  • But 2-5% have aneurysm in population
  • So which ones do you treat?
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