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.

Improving Outcomes, Mythbusting, Pulmonary

Sono-guided ACLS

This study demonstrates what many of us have probably suspected – the absence of cardiac activity on ultrasound portends a grave diagnosis; but this study really is so much more.

Utilizing 20 sites across the US and Canada from May 2011-Nov 2014 looked at all nontraumatic in-ED and out of hospital cardiac arrests that arrived to the ED in either PEA or asystole, and whether or not POCUS demonstrated a potential role in resuscitation.

953 patients, 793 used for final analysis (106 not included due to resuscitation under 5 minutes, 8 patients DNR, 1 uninterpretable sono, 3 with incomplete timing data, 42 for no ACLS meds given) – had a cardiac sono at the “beginning and end of ACLS.” The primary outcome was percentage of patients that survived to hospital admission, with secondary outcomes of survival to discharge and ROSC. Unfortunately, neurologic intact survival was not evaluated. The treating EP’s were credentialed in POCUS at their local institutions and unblinded. Digital clips were reviewed by a single reviewer in a blinded fashion for agreement (which was deemed to be “substantial agreement”).

The data (numbers are percentage, such that “28.9” = the percentage of patients with cardiac activity on POCUS during the resuscitation who survived to admission):



Cutting to the chase, this study brings up a number of key points:

-PEA on the monitor may not necessarily be PEA, with a whopping 54% of patients having cardiac activity on POCUS

-asystole on the monitor may not be cardiac standstill, as 10% had cardiac activity on POCUS

– survival to admission with cardiac activity on POCUS is MUCH higher – 28.9% vs 7.2%, but….

– cardiac activity on POCUS for PEA/asystole portends only a 3.8% survival to discharge

-no cardiac activity = poor prognosis, 0.6% of patients survived (3 out of 530). With two of the three patients were Vfib at some point during EMS working on them.

-pericardial effusion was seen in 34 patients (4.3% of those in the final analysis). 15.3% of patients whom had a pericardiocentesis performed survived to discharge.

– only 15 patients received lytics for suspected PE, with only one (6.7%) surviving to discharge. (which was almost the MORTALITY rate of PEAPETT)


Whew. This is a lot to digest. Let’s just say that ultrasound helps you tease out a spectrum of disease and further characterizes what you are dealing with. I’m looking at POCUS in codes as a risk stratification tool. Is there a prolonged time without cardiac activity without a potentially reversible causes? Might want to consider calling it earlier since survival to discharge is abysmally low. And sheesh… 1 out of 25 cardiac arrests had a pericardial effusion??? Wow. Time to brush up on those pericardiocentesis skills.

Caveats- this was done by EP’s credentialed for POCUS, so they’re likely more talented than the rest of us.  Dont let that scare you though, rather, this.  Perhaps seeing cardiac movement on ultrasound lends a “bridge to hope” and the team puts in a more-heroic-than-usual effort.

And of course, this also leads to more questions- of those 28.9% with cardiac activity that survive to admission, what if they are brought straight to the cath lab? Or started on ECMO? Would this potentially alter survival rates and neurologically intact survival in meaningful ways? Time shall tell.  Until then, cut that KT window, pick up the probe, and have your TPA & long pericardiocentesis needle ready.

Critical Care, Improving Outcomes, Improving Throughput, Mythbusting, Pediatrics, Pediatrics, Pediatrics, Pulmonary

Do we need to give (alot) more Magnesium to asthmatics?

Some of us have quirky things we like to do that not everyone else does– dexamethasone for sore throats, ketamine for the agitated patient (or anything really), et cetera… This paper looks at one of those things – Magnesium in asthmatics. 

This was a prospective, randomized open-label study of patients between 6 and 18 years of age over a two year period who presented to an ED in Asuncion, Paraguay and were admitted for a severe asthma exacerbation.  Patients were excluded if given antibiotics before or during the ED visit, febrile, or if there was suspicion for infectious etiology.  All patients enrolled had no relief despite 2 hours of treatment which included dexamethasone 0.2mg/kg IV, nebulized salbutamol every 20 minutes up to 5mg and nebulized albuterol every 2 hours.  There were two treatment arms, each with 19 patients: one received a 50mg/kg bolus of MgSO4, while the other group received 50mg/kg/hr/4 hrs (ie, up to 2g / hr for 4 hours – up to 8g total).  Physicians in charge of patient disposition, after the initial 8 hours, were not part of the study group and blinded to the treatment received.  Primary outcome was discharge at 24 hours, with secondary outcomes total LOS and cost implications.  The two groups were similar in terms of age, sex, initial Wood-Downes asthma score, and peak flows.

Despite the numerous downfalls to this study (single center, open-label, prospective, small sample size…), the results are intriguing- bolus magnesium had an average LOS of 48 hours vs 34 hours for high dose prolonged infusions, had a higher cost ($834 vs $603), and fewer patients with a LOS <24 hrs (10.5% vs 47.4%).  It took almost two years to get under 40 patients in this single-center study,  but still, there were no adverse events and no bounceback visits within a week from discharge.  Interestingly, there were no obese patients in the study – so how applicable this study is to the US patient population, I do not know (plus, salbutamol is not widely used for acute asthma in the US).   That, and even for this mag-o-phile 8g per hour for 4 hours seems like alot!

Should this change your practice?  Not quite yet – unless you’re not giving magnesium.  In the meantime, I’ll add another one to the list of trials I’d love to see.

Improving Outcomes, Mythbusting, Pulmonary, Twelve Trials of Christmas!

Day six of Christmas – curing the bronchitis!

Welcome to the Twelve Trials of Christmas series on EMinFocus! This is the sixth of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done. I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM. Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

Essentially, there are about 4 things to do for a cough.  Dextromethorphan (robitussin), anything with Benadryl/codeine/phenergan/hydrocodone, tessalon, and honey.  For pediatrics at least, honey seems to be the preferred method for parents and seems work better than Dextromethorphan and Benadryl in head to head trials.  I’ve yet to find data on Tessalon, Phenergan, or codeine suggesting it is useful for a cough when compared to placebo.  I’d like to add another medication to the toolkit for an intractable cough: nebulized lidocaine.

The studies are not of the best quality, but here is what I can find:

– 21 patients with obstructive, restrictive, or infective disease who received 10-20mg of nebulized lidocaine Q4-6hrs seemed to improve and/or resolve the cough when compared to standard of care (hycodan, Robitussin).

– A case series of 3 pts treated with a single dose 10mg lidocaine and 5mg bupivacaine (both nebulized) and had no recurrence of cough.

– A case series of 3 patients with a chronic cough secondary to lung cancer treated with higher doses of nebulized lidocaine  (up to 400mg!) along  with 2-5mg albuterol.  Resolution of cough persisted for >1week in all patients.

– A case report of a pediatric patient treated with 30mg nebulized lidocaine for a cough refractory to cough suppressants, beta agonists, steroids, and antibiotics.  The cough completely resolved.


There are multiple studies looking at nebulized lidocaine for endoscopy and laryngoscopy, but no reports of systemic toxicity from nebulized lidocaine as there appears to be less systemic uptake when administered via nebulizer.  So, it appears safe in that regard.   The asthma literature is a mixed bag, as some say it cause harm during asthma exacerbations as it may decrease FEV, but others show benefit.  However, for COPD flares, it appears beneficial.

For those hacking coughs that truly feel bad for, I’d love to see an ED trial of nebulized lidocaine as a one time dose – or even perhaps in an observation unit for your COPD’ers / pneumonia/bronchitis patients.  Easy trial to perform, and one that would significantly improve patient satisfaction – and perhaps then something other than a z-pack would get credit for improving the cough!  

Cardiology, Cardiology, Improving Outcomes, Improving Throughput, Mythbusting, Pulmonary, Pulmonary, Twelve Trials of Christmas!

Day Five of Christmas- where’s the Obs EBM?

Welcome to the Twelve Trials of Christmas series on EMinFocus!  This is the fifth of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done.  I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM.  Some may pan out, some may not.  All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

I believe that the longer a patient stays in the hospital, the more likely they are to develop new and exciting pathology (pulmonary emboli, VRE, general deconditioning, an unhealthy affinity for tuna sandwiches, etc).  t’s not that I want to throw people out so to so to speak, it’s that their risk of developing hospital acquired badness is higher than their risk of adverse outcome from their diagnosis (like, say, low / no risk chest pain).  As such, I’ve recently taken an affinity towards our observation unit to see which, if any, of the classically admitted COPD’ers / CHF’ers, etc, can be placed in observation for <24 hours (actually need to be there), and do well.

We need to see some studies for who is a candidate for observation – and perhaps some data on why ED providers put no risk chest pain and other similar low yield findings in observation. There is little to no data on observation units, despite over a third of hospitals in the US having them.  Despite guidelines for observation, there are few evidence based guidelines.  We know that increasing age is associated with an increased rate of admission from observation status (about 26% vs 18 %); and there are also cellulitis guidelines for observation units, but that is about it.  While there are Ottawa guidelines for admission for CHF and COPD, and the famous PORT scores, these rules were designed to identify low risk patients, not necessarily those that needed a day or two in the hospital.

 So, perhaps, much like we have recently begun to risk stratify PE’s into going home and being lysed, so we will have to do the same for utilization of observation & inpatient resources.  What delineates which patients in the grey area between obvious discharge home and ICU admission can go to observation – not just the ED provider saying “yeah, they look ok for observation” – some actual evidence that suggests the patient can be turned around in under 24-36 hours.  I suspect for CHF, we’ll see that most of these patients, once properly cared for in the ED (cough, nitro nitro nitro, cough), can go to observation, which will likely surprise most ED & inpatient providers – thus, hopefully decreasing the risk of hospital acquired badness for these patients.

Improving Outcomes, Improving Throughput, Mythbusting, Pulmonary, Pulmonary, Radiology, Radiology

Good thing you caught that Chest Cold early.

There has been recent discussion in the #FOAM world in regards to labeling otherwise benign conditions (such as GERD in pediatrics) and the patient & family perception requiring medications for this.
Seth Trueger (@mdaware), at ACEP13, brought to my attention an interesting paper in regards to another common labeling of a benign condition, acute bronchitis.

In 2005, 459 patients were presented with a written scenario describing a typical acute respiratory infection in which they were labeled either to have a “chest cold”, “viral infection” or “acute bronchitis” and also were provided with a treatment plan that excluded antibiotic treatment. There is no changes in satisfaction or dissatisfaction with the diagnostic label however, 26% of patients were dissatisfied with treatment 1 provided with the label “bronchitis”and not provided a prescription for antibiotics compared to 13% for a chest cold and 17% for a viral illness respectively. There was no differences in regards to patient’s satisfaction based on age, sex, or education level.

The authors also note that patient pressure is a significant role in antibiotic overprescribing. They note that 54% pediatricians feel parental pressure to inappropriately prescribe antibiotics. For adults, 77% of the time when providers were questioned about antibiotics, they were prescribed first 29% of the time when providers were not asked.

So, to want to decrease your patient dissatisfaction, might I suggest, in the words of Hoffman & Bukata:

“It seems to be a chest cold. Good thing you caught it early before it turned into bronchitis!”





PMID: 16322409

Improving Outcomes, Pulmonary

Cold Weather is Coming – add CO Poisoning to the DDX.

It’s Fall in the great Northeast, the leaves are changing, the temperatures dropping, and Caramel Apple Spice and Pumpkin Spice are selling out at your local Starbucks.

It’s a routine shift in the ED, a spattering of belly pain and chest pain, and the next patient up is here for a headache.  They have stable vitals, here last week and felt well after treatment of Compazine, Benadryl, and Decadron.  The prior provider even did labs and a CT which were unremarkable.  The patient reports it gradually worsened while they were watching TV.  No vomiting, no fever, no vision changes, not worse with exertion, and an unconcerning neurological exam.  Now you could just reach for a similar treatment as last week, but you could also…

In one particular study of 483 patients presenting with a headache in the winter months- all of whom had SpCO monitoring/screening- 6.4% of patients had a carboxyhemoglobin over 10%.  Of those diagnosed, 77% were suspected CO poisoning.  Basically, we missed a fair amount.  Also, it is important to note that CO poisoning was more frequently seen in patients that presented after midnight and in the morning hours.  A separate study looking at 1006 New York and New Jersey CO poisoned patients showed that, unsurprisingly, CO exposure was significantly increased in October – March.   Somewhat surprising to me was that the median age of these patients was actually 30 years old!

Lastly, in a survey of 1030 patients, only 44.4% had home carbon monoxide detectors installed, and only 17.2% had carbon monoxide detectors installed in or near the correct place (hint- its supposed to be near sleeping quarters.)
I realize its a bit of a red herring diagnosis, but we see headache patients almost on a daily basis, and perhaps one of us will actually catch the patient that lives alone that has CO poisoning and actually make a difference.  Cold weather will be upon us soon.  Next time a patient “woke up with a headache” and there’s a cold spell, consider carbon monoxide poisoning in your differential.  Consider asking about household members with similar symptoms, and if symptoms have been more frequent lately.

#FOAM on.





PMID: 24128732

PMID: 19860138

PMID: 22577866

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

NIV for Pneumonia

It is by and large a foregone conclusion that non-invasive ventilation (NIV) saves intubations (and lives) in COPD and CHF. There has not been too much #FOAM specifically for pneumonia and NIV, so let’s dive in.

Recently, there was a publication stating that NIV treatment failure was significantly higher for pneumonia vs COPD (49% vs 12%). This was a small study (under 80 patients), but does this mean we should not try NIV for pneumonia? More importantly, do pneumonia patients have worse outcomes than they otherwise would if they were intubated sooner? Is it worthwhile to give a NIV trial in pneumonia?

To start, 127 patients with respiratory failure secondary to community-acquired pneumonia (CAP) were examined prospectively. 25% of these patients failed NIV. Those that failed NIV were more likely to have confusion at presentation, were >65 years old, had worsening chest films over time, and lack of improvement at 1 hour on NIV.  A second study of similar ilk (CAP placed on NIV) examined 64 patients in which 43% of patients successfully avoided intubation (ie, 57% failed NIV). Success was associated with a lower APACHE II score, higher pH at the end of NIV trial (7.34 vs 7.44), and lower respiratory rate (28 vs 23 breaths/minute).

Now that flu season is upon us, let’s examine the 685 patients with confirmed influenza A that were studied in Barcelona in a prospective observational registry.  489 patients were intubated in the ED and 177 received NIV.  NIV was effective 40.6% of the time, and associated with shorter LOS.  Key details in this study were that not requiring vasopressors, the absence of renal failure, and fewer than one lobe involvement on CXR were all significantly associated with successful NIV. Most importantly, the delay in intubation did not affect mortality (26.5% for ETT, 24.2% for NIV).  Thus, for every 100 NIV patients in whom the decision to intubate was made, there was ~25% mortality – roughly the same rate as those that were intubated without a NIV trial – so the delay does not worsen outcomes.

For the immunocompromised, an evaluation of 120 patients came to similar conclusions: higher APACHE II scores and a need for vasopressors were associated with failure of NIV.  Underlying disease did not affect NIV duration rates or outcomes.  Again, the authors found that the mortality rate of failed NIV patients that required intubation was similar to those that were intubated from the start.

Conclusions?  If you need to start pressors, or have new onset renal insufficiency, you may want to skip NIV and reach for the intubation kit first.  Otherwise, with 40-75% success rate of NIV, and without an adverse outcome for delayed intubation in pneumonia patients, it seems reasonable for the patient to first have a trial of non-invasive ventilation.





PMID: 24814916

PMID: 25043135

PMID: 20435435

PMID: 22404211

PMID: 22944604

Mythbusting, Pulmonary

Being Color Blind to Bronchitis.

An October 2013 BMJ study compared patients aged 18-70 without underlying lung disease or immunosuppression, with an acute cough of less than one weeks duration. Cough with “discolored” sputum was a requirement of all patients, and they required at least one other symptom of lower respiratory tract infection (dyspnea, wheezing, chest pain or chest discomfort). Patients were excluded if they had previously used NSAIDs or antibiotics within the last 2 weeks, greater than 7 days of cough, allergies to NSAIDs or Augmentin, or had pneumonia on chest film. The three arms were as follows for ten days:

Ibuprofen 600mg TID (136 patients)
Augmentin 500-125 TID (137 patients)
Placebo TID (143 patients)

Patients had follow up at 2-4 days, 11-13 days, and again at 30 days if symptoms were not resolved by the second visit. Patients kept a diary of disease severity, daytime cough, night time cough, limitations of ADLs, and fever. There was essentially no difference in the number of days with cough, regardless of treatment, and 12 % of Augmentin patients having an adverse drug reaction, compared to 3% of placebo and 5% of ibuprofen. The authors point out a previous Cochrane review found antibiotics to have a slight advantage over placebo in controlling cough, but that review came from a total of 275 patients – more than a hundred fewer than this trial. The authors are also quick to point out that COPDers have been shown to benefit from antibiotic treatment with a change in sputum color.

The next time a patient states, “but I’m coughing up green stuff,” you’ll have the evidence in hand to either refute the prescription request, or give a risk benefit discussion about the 400% increased rate of side effects from antibiotics over placebo in this setting (12% vs 3%).

PMID: 24097128

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

How do you PE part 2

Last PE post, we discussed PEITHO, TOPCOAT, MOPPETT, and the lysis of massive and submassive PEs.  So what do we do for the un-submassive and unmassive PEs?

     The Outpatient Treatment of Pulmonary Embolism (OTPE) study compared outpatient vs inpatient treatment of low-risk patients with acute PE.  Patients were treated with lovenox bridge to coumadin either as outpatient or inpatient (171 v. 168 patients). Patients were followed for 90 days, with follow up calls at days 1-7, 14, 30, 60, 90.  Only 1 outpatient developed a recurrent VTE, two outpatients developed “major bleeding” within 2 weeks – both IM hematomas.  Neither recurrent VTE or major bleeding between the two groups was statistically significant.  Likewise, one person in each group died from non-VTE and nontreatment-related causes. 99% of participants completed the Press-Ganey, satisifaction survey with 92% of outpatients and 95% of inpatients being satisfied or very satisfied with their care.  As for bounce backs?  Readmissions, ED visits, and PMD visits were similar in the two arms.  The total number of home nursing visits was higher among outpatients (14% vs 6% of patients), but the mean time spent in the hospital was obviously greater for inpatients (3.9 days vs 0.6 days).

     I question whether or not outpatient treatment at most facilities would be >90% satisfied, but certainly intriguing.  Gazing into my crystal ball, I suspect the day will come when we are either admitting & providing lytics, or discharging from the ED on Xarelto / Pradaxa / other.  For PE risk score, you may use Hestia or PESI .



Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. PMID: 21703676