Cardiology, Improving Outcomes, Mythbusting

SVT: treat, wait, re-evaluate

What do you *really* need to do with your SVT patients? Well, this is a retrospective observational study of 633 consecutive SVT patients over 10 years seen in a single ED. This was more hypothesis generating than anything – they basically provide patient characteristics and try to tease out if labs / imaging were necessary.

Their mean age was 55, 62% of patients were female, 55% had prior SVT history, 31% had at least one cardiovascular risk factors (dyslipidemia, hypertension, diabetes, CHF, or vascular disease), and 9% had ischemic heart disease.

Some interesting lab nuggets:

-0.4% had a hemoglobin < 8g/L

-1.5% had a sodium >150 mmol/L, none <126

-no patient with severe hyperthyroidism

Chest Xray was obtained 30% of the time, and while it was abnormal 21.6% of the time (41 of 190), none of the time did it alter ED treatment – despite showing 14 cases of pulmonary edema, 4 cases of pneumonia, and 3 pleural effusions.

The authors conclude that patients with uncomplicated SVT are over-investigated, and that most have normal or near-normal results. While I tend to agree – for the 25 year old in SVT without a concerning story – the 55 year old diaphoretic (14% were diaphoretic) female with ischemic heart disease I’m going to work up. Chest films were only ordered on 30% of these patients – frankly in a US hospital, I’m thankful its not higher.

I know Billy Mallon loves his TSH, but why not get a better history to see if there are other concerning symptoms before sending off TSH… Speaking of which, maybe we could decrease those Chest films if we fixed the patient a bit, then reassessed to see if imaging is wanted. (ie, are you still short of breath?).

Finally, I think this study is plagued by premature closure, as they only searched for cases with a discharge diagnosis of paroxysmal supraventricular tachycardia. They’re likely missing at least a few patients who came in with SVT and were found to have actually have another diagnosis.

Ultimately, while this study should not change practice by any means, it should give us pause before shotgunning labs & chest films until after we treat the patient, re-evaluate, and get a better history. This could probably be said for many other diagnoses besides SVT.

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Cardiology, Cardiology, Critical Care, Improving Outcomes, Improving Throughput, Mythbusting, Pulmonary, Radiology, Radiology

Probing the dyspneic patient.

For undifferentiated dyspnea, how would you like to have an accurate diagnosis in 24 minutes?

I love this study.

Basically, for all dyspneic patients (not trauma related, and over age 18), 10 EP’s were given an H&P, vital signs, and an EKG, as well as access to a Chest X-Ray, Chest CT, cardiologist performed echo, and labs including an ABG.

These same 2,683 patients, in tandem, had point of care ultrasound testing (lung, IVC, echo). Here’s the catch – the ultrasonographers were only provided the H&P, vital signs, and EKG then asked to make a diagnosis. The treating provider was blinded to POCUS diagnosis.

These numbers for diagnostic accuracy of POCUS are astounding.

+LR for acute HF? 22 (-LR 0.12)

+LR for ACS? 105 !!!

+LR for pneumonia? 10.5 (-LR 0.13)

+LR for pleural effusion? 95 (-LR 0.23)

+LR for pericardial effusion? 325!!! (-LR 0.14)

+LR for COPD/asthma? 22 (-LR 0.14)

+LR for PE? 345!!!

+LR for pneumothorax? 4635!!! (-LR 0.12)

+LR for ARDS? 90

Yes, for certain things like pneumonia, the difference in p-values between tradition means and POCUS diagnosis was not significantly different, but what about volume status? I cant imagine blindly giving 30 cc/kg would benefit the patient with a plethoric IVC and pleural effusion. There is some elegance a play here.

Additionally, sure, ED diagnosis for ACS had a higher LR, but they also had a cardiologist performing and interpreting echos in the ED (a rather rare siting in a US ED I would imagine) – without much improvement in their -LR (0.53 vs 0.48). For PE, the -LR of POCUS was predictably mediocre if not outright bad (0.6), while the -LR for ED diagnosis of PE, with the benefit of chest CT, was -0.10.

Now look, I get that these EP’s were quite sono-savvy. They all had 2+ years of experience, over 80 hours of ultrasound lessons & training, with at least 150 lung and 150 ED echo’s under their belt. The diagnosis was made in 24 minutes with POCUS in comparison to 186 minutes for traditional means. And while most of us can not do a year+ ultrasound fellowship, and neither can we all be as savvy with the probe as these authors (or Matt, Mike, Jacob, Resa, Laleh, etc) – it does not mean we shouldnt try. You can still greatly increase your yield just by practicing. To boot, the cognitive offload you experience by saving yourself a few hours by (correctly!) knowing which direction you are heading with a patient is an immense boon to both your mental heath & your patients well being.

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Improving Outcomes, Improving Throughput, Radiology

Ultrasound MiniFellowship, eh?

Are you looking for a bridge after taking an ultrasound course at a conference?  Do you feel like you need a bit more oversight until you get comfortable with probe in hand?  Are you having trouble conceptualizing what it means to have ultrasound guide your practice in the critically ill?… Read on.

I recently had the pleasure of attending a CCUS POCUS mini-fellowship –  it was everything I was hoping for & more- and has pushed me to be a better clinician.

First, a blurb about ultrasound fellowships.  As a PA, there isn’t really any hands on US training during our programs.  There likely is some POCUS for PA EM residents – but most practicing EM PA’s are not residency trained.  Therefore, we’re at the mercy of our co-workers who may (or may not) have any US training.  It’s hard to learn POCUS when you don’t have someone over your shoulder to guide you!

I had done a few ultrasound courses, but was struggling to really implement it into my practice regularly.  Ultimately, this was my own fault.  I was repeatedly told to pick up the probe and practice.  Literally, every sono-savvy person has told me this.  A large part of my problem was that I did not pick up the probe immediately after courses to drill down on fundamentals – and scan every person regardless of their complaint.  This is not meant to disrespect those that I took courses with before – they were *extremely* helpful and I’m incredibly thankful for their expertise! – the fact that I continued to seek out ultrasound training is a testament to prior courses showing me the importance of developing this tool set.  Now, onto Canada.

I ended up taking a 2 day course with Philippe Rola in Montreal.  Philippe is extremely responsive via email, we had spoken on the phone a few times prior to my arrival as well.  He’s friendly, approachable, and has been doing mini-fellowships since 2009 (!).

I was looking to optimizing views, particularly on patients with challenging anatomy (I mean, have you seen the average American BMI recently?), and what started with, “where the hell is the IVC” turned into, “This is a plethoric IVC.”  While it might be that the 3rd (or is it 4th?) time is the charm for courses for me, and that I would get it eventually via spaced repetition, but there is something about practicing on patients with acute illness and watching Rola make decisions based on POCUS in real time that helps put the pieces together a bit faster.

I believe the main advantage of this US course is the real time feedback on real patients… and if you are there for more than one day, you get to watch the ICU story unfold.  You see about 10-12 patients in their ICU, and a handful of ICU consults on the floors or in the ED.  You may or may not go to a rapid response, and see how it really makes a difference in the heat of the moment.  Fortunately, this is not reminiscent of your student days when the mentor says, “You’ll have to sit this out, this one’s mine, sorry.”  Philippe was extremely patient with me in the hypotensive altered patient while I scanned.  He’s excellent at questioning at just the right time to help tie it together- “ok, what are you seeing? A plump IVC and some pleural effusions in this hypotensive patient?  So whats your next step?”

To maximize your experience, I would strongly encourage you to have 1-2 specific goals in mind like, “I want be able to consistently visualize the IVC and have a few back up views just in case.” Expecting more than 1-2 things is probably spreading yourself thin.  You’re not going to become a pro overnight.  Be upfront & honest with Rola – he can tailor to your skill level- whether it be an assessment of valvular function or just wanting to visualize the heart.  Philippe had recommended 2-3 days at a time, which I agree with – I think after 2-3 days you reach the point of diminishing returns and “get full.”  You need some time to process what you’ve learned, and to practice on your own (before going back!).

Upon my return home, I made it a point to utilize the probe on my next shift.  If at all possible, I would recommend arranging shifts to be “main ED” shifts when you get back home such that you see the belly pain, shortness of breath, and chest pain patients so that you can apply what you learned immediately.  I did this on my first shift back with the hope of scanning 5 patients or more – I literally brought the machine with me when I walked into the room.  Surprisingly, I thought it would slow me down.  This was not the case at all.  I also realized a major benefit that I was not expecting.  The cognitive offloading of using the probe and eliminating some of the guess work kept me fresher longer. I saw more patients than average, with sicker than average patients, and it did not feel like taxing shift at all.  I didnt have to task switch to check on that xray or CT nearly as much as I usually do (though I was still ordering what I usually would to confirm suspicions since I’m still early in POCUS training)…. I would be interested to see the throughput of docs using POCUS vs those not, and I’d also like to see the level of “decision fatigue” at the end of a shift – I’m convinced that POCUS provides a significant cognitive offload to the EM provider, and the POCUS’ers are less fatigued at the end of their shift.

Bottom line, I think I needed other courses to whet my appetite and open the door, and I needed Montreal to push me through the door and get me to start practicing more.  If you work in an environment where you don’t have much POCUS backup and want to learn with one of the best and don’t want to break the bank, come to Montreal!

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Critical Care

Who ya gonna call? #VancZosyn!

If there’s some strange cough in your resus room,

Who you gonna call? Vanc-ZoSyn!
If something’s fevered… and it don’t look good,
Who you gonna call? Vanc-ZoSyn!

I ain’t afraid of no Staph.
I ain’t afraid of no Strep.

If high lactates are running through your EMR,
Who you gonna call? Vanc-ZoSyn!

 

There’s been some FOAM rumblings about Vanc/ZoSyn causing AKI, but this was the first time it has been compared directly head to head with Vancomycin-Cefepime. This was a retrospective matched cohort study with 279 patients in each arm – one received combination therapy with vancomycin-cefepime (VC), the other received vancomycin-piptazobactam (VPT) for > 48 hours. Patients were excluded if their baseline serum creatinine was >1.2mg/dl or they were receiving RRT. Patients receiving VC were matched to patients receiving VPT based on severity of illness, ICU status, duration of combination therapy, vancomycin dose and number of concomitant nephrotoxins. The primary outcome was the incidence of RIFLE criteria-defined AKI, with a slew of secondary outcomes performed as well.

So, wait, what’s so special about RIFLE anyway? Glad you asked: In general, the worse the acute kidney injury, the higher the mortality.

Since this study shows an 11% AKI rate with VC and 29% AKI rate with VPT, maybe we can improve our mortality if we simply switch from zosyn to cefepime?

Except that this group reports mortality was actually worse in the VC group (though not statistically significant – 8.6% vs 5.7%). That’s right – the group with more AKI had less mortality. In other news, ICU stay was decreased (6 vs 8 days), which was statistically significant., and only ~1% of patients in both arms required long term hemodialysis.

While I was getting ready to click submit on this blog post, I found a second paper (published Nov 28, 2016) that looked at a matched cohort of 1633 VPT vs 578 VC patients, with essentially similar results – 21.4% AKI in VPT vs 12.5% VC.  This second paper found similar LoS, but also a similar trend in mortality-  6.9% for the VPT arm and 9.2 for VC.

So… I’m not certain what to make of this – but it seems more than fair to question whether drug induced AKI is a meaningful surrogate marker for sepsis mortality.  We need a long term look at mortality between VC vs VPT to see if VPT induced AKI follows the same trends. Maybe we’re trading a slight bump short term mortality for improved long term mortality with VC (or maybe not).  In the meantime, I think we need to pump the brakes on shouting about Vanc/Zosyn AKI until we sort this out a bit more.

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Improving Outcomes, Pediatrics

Baby LPs, ultrasounds, and fragility

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How fitting that the SMACCdub talk, What Scares You, has recently been released, and, to some extent, discusses pediatric bleeding. Well, this paper discusses high risk peds (febrile infant <60 days) and (post LP) bleeding, and whether or not ultrasound assisted guidance helps.

SPOILER ALERT: (it probably does).

From February 2007-December 2007 (wow, talk about a knowledge translation delay), the authors attempted to enroll 46 total patients to either standard LP without ultrasound vs ultrasound assisted LP. Here’s one key point – while ultrasound guidance means direct visualization of the needle into the desired space (like for central lines or paracentesis), ultrasound assisted means that landmarks were sonographically visualized, and then they marked the skin and estimated how deep was too deep for the needle, then performed the LP (without direct visualization.-Basically they performed an ultrasound to determine a “maximum safe depth” to limit needle advancement to avoid traumatic taps, since this is a common element of LP failure in this age group.

Patients with known spinal abnormality or VP shunt were excluded, and the procedures were done by either a house officer or pediatric NP with MD oversight (so, I’m not certain how applicable this is to those of us with significant experience in this age group). Unfortunately, the study was terminated prior to reaching their goal of enrolling 23 patients into each group due to academic calendar demands of the lead author (21 vs 22 patients in either arm – meh.) Success was defined as <10k RBC and whether or not CSF was obtained. Their 5 month historical failure rate was 44%.

The groups did not differ in terms of prematurity, patient weight or length, there was a lower median age in ultrasound assisted group (38 days vs 45 days p=0.02), which may give them a bit more of an uphill battle. The results are seen below:

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On first glance, these look good – less frequent traumatic taps, more frequently obtaining CSF with NNTs of 3.7 and 5.6 respectively. However, with such a small sample size, a Fragility index of 1, and having house officers and NP’s do the tap (with an unclear level of experience), I’m not certain this is broadly applicable to all providers, particularly when you add that 19 sono-assisted attempts are not enough to reach 80%  success in this study.  With that said, we commonly perform interventions with much lower NNTs with higher risks to the patient than a few ultrasonic waves. This is a cant hurt, will probably help intervention that we should probably be utilizing more frequently for all of our patients, not just our pediatric population.

For a great review on this topic check out sonomojo for more on ultrasound use for LPs.

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Improving Outcomes, Improving Throughput

How soon to safely discharge the opiate OD?

For those of us wondering how long we need to keep the thrashing, agitated, cursing “narcan’ed” patient in our ED, look no further. This is essentially a review of the literature on whether or not adopting a treat & release policy for opiate overdose in the prehospital realm is safe & feasible.

They review 4 papers, 3 of which contain data points from 1994-2003, of which two were non-US studies. In general, they look at some short time period for bouncebacks, (6-12 hours), and if the patient does not come back to receive chest compressions or repeat narcan dosing, they considered it a win. Ultimately, out of 3875 patients that received narcan in the field and were able to AMA after a 15-20 minute observation period, only 3 had a recurrence that resulted in death.

Digging a bit deeper, part of the problem here is that two of the papers had exclusion criteria that does not necessarily fit what happens in practice. One paper excluded patients brought to the hospital, while another excluded those with polysubstance abuse. I’m not sure about your patient population, but the heroin abusers I’ve like to chase with China White with a stick of xanax. Fortunately, the two US studies were more likely applicable, with almost no exclusion criteria – and of which zero patients out of 1550 prehospital treat & release patients died within 12 hours.

So how does this apply to the ED? It is important to note that there are clinical decision rules to help guide who can go home relatively quickly.  If patients can ambulate, has normal vitals and a GCS of 15, then your miss rate is likely well below 1% for them to return in the next few hours from this particular overdose. So, by the time a patient is reversed with narcan, you write the chart and get discharge papers ready, if they remain alert, oriented, competent and reasonable, they can likely go. However, it should be noted that there were a small number of patients who returned within a few weeks with various other issues – one patient hung themselves within 48 hours. Another overdosed 4 days later. All in all, still <1% dying within 30 days, but this is potentially a teachable moment. Patients do have the right to make bad decisions, but that shouldn’t necessarily allow us to stigmatize them and not at least offer them the help they likely need.

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Cardiology, Improving Outcomes, Improving Throughput

A chicken in every pot, and a cardiologist in every box.

I think the HEART score is useful, and an incredible start to getting everyone on the same page. Getting both an ED and consultant group to universally agree on a protocol, and implement observation / admission protocols off of it are probably a bit more difficult.

And this is only with a few “soft” variables– what exactly differentiates slightly from moderately suspicious anyway? As we all know, stories change (and not just from patients!).

This paper retrospectively looked at 6 months worth of ED chest pain charts which had a cardiology consult and tries to extract a HEART score based off the ED documentation as well as the cardiology consultation.

Unfortunately the retrospective nature and lack of a standardized “flow sheet” for history probably greatly contributes to cardiology/EP disagreement in the HEART score (like, say, documenting tobacco usage in the chart). History between EP and cardiology was in agreement 47% of the time, EKG interpretation agreement at 76%, and risk factor agreement at 85%. Overall HEART score agreement between EP’s and cardiology occurred 70% of the time, primarily with some mixture of cardiology consistently downplaying elements and/or EP’s upselling some.

Of those who had a phone consultation with cardiology, only 5.4% were discharged, vs 45% discharged when physically seen by cardiology. Only 9% were admitted after in-person cardiology evaluation vs 77% for those with phone consultation. Of those who received further testing, 45% of the cardiology phone consultations were discharged, vs 87% discharge rate for those who received additional testing after an in-person cardiology consultation…. Seems like cardiology is scared to discharge without seeing the patient, and that we are probably upselling the patient a bit.

Regardless, this is hypothesis generating at best, particularly with such low numbers to evaluate (33 patients evaluated by cardiology and EP’s over this 3 month period!), and frankly, the retrospective data extraction without a clear checklist for HEART scores makes me question the validity of their conclusions. Nonetheless, I hold hope that cardiology and EM can live in harmony at some point in the future.

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