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The topic for Journal Club on August 4, 2010 was STEMI. We started by reviewing the history behind the current treatment of MI patients. Then we talked briefly about the FDNY Protocols, which include notifying the receiving hospital of an inbound STEMI pt & faxing a copy of the EKG to that hospital. 

Then we discussed the background article entitled “Emergency Department Activation of an Interventional Cardiology Team Reduces Door-to Balloon Times in ST-Segment-Elevation Myocardial Infarction”. This was a study led by Dr Singer out of Stony Brook University.  It was a before-and-after trial in a suburban academic medical center with 500 beds and 75,000 annual ED visits to compare DTB times in pts w/STEMI before and after implementation of a “code H” protocol.  They used a consecutive sample of pts presenting to the ED with EKG and clinical evidence of STEMI within 30 minutes of arrival during 2 similar 24-month periods, before and after implementation of the code H protocol.  This protocol included:  1) EPs activating the cath lab via a single call to a central page operator, 2) ED activating the cath lab while the pt is en route to the hospital, 3) Expecting the cath lab staff to arrive within 20 minutes, & 4) Having ED and cath lab staff use real-time data feedback.  The primary outcome was door-to-balloon (DTB) time. They had 97 total pts, 43 before and 54 after the implementation of the code H protocol.  Implementation of the code H protocol reduced the median DTB time by 68 min (p<.001) and increased the proportion of pts undergoing PCI within 90 minutes from 2.8% to 29%.  If you look at it in terms of risk of missing the 90-min D2B mark, the absolute risk reduction (ARR) was 26% and you’d need to treat (NNT) 3.85 pts under “Code H” to expect one more makes it in under 90 min.  They concluded that “the greatest opportunity for improvement is in reducing the time from cardiology arrival to the bedside and initiation of the percutaneous coronary intervention. Equally important is the need to engage all health care providers involved in the treatment of patients with ST-segment-elevation myocardial infarction.”

The 2^nd paper, entitled “Impact of the Prehospital ECG on Door-to-Balloon Time in ST Elevation Myocardial Infarction”by Rao, et al. out of SE Michigan was a prospective, observational study conducted in 3 hospitals from Oct 2003-April 2008.  (They had no conflicts of interest.) During the trial, EMS 12L EKGs were transmitted to the ED & the cath lab was activated “as soon as the ED physician diagnosed STEMI”.  The control group included all patients who came to the ED during the same time period via EMS w/o prehospital EKGs or as walk-ins.  The primary endpoint was DTB time and secondary endpoints included time of admission, cardiac risk factors, LOS (length of stay), and infarct-related arteries.  They found that pts who had a prehospital ECG had a mean DTB time of 60.2 minutes, compared to 90.5 minutes in pts with in-hospital ECGs.(ARR=30%, NNT=3.33pts).  No pts in the prehospital ECG group died but there was a 2% mortality rate in the control group. 

Some questions we asked about this study included:

• 3 centers with different time periods (Hospital A had 386 pts between 10/03 & 4/08 but only 18 prehospital ECGs. Hospitals B&C had 89 & 134 pts, respectively, between 3/07 & 4/08, with 40 & 50 prehospital ECGs, respectively.)
• Why did hospital A have 386 pts but only 18 w/ prehospital ECGs?
• W hy were hospitals B&C only involved at the end of the study?
• They did not reveal enough data about their control pts. Were they STEMI pts?  Did they have chest pain or CP equivalent symptoms? Etc.
• ~50% of pts had a R-sided MI, which seems like a high number.  However, they had no deaths in the prehospital group but the majority of pts had non-LAD lesions, which speaks well of their data.
• They concluded there were no differences in LOS between the groups, yet the in-hospital deaths had LOS of 3.5 days +/- 3.2 (i.e. ~0-7 days), which seems like a wide range.
• There was a significant difference in the data of African American pts, which they attributed to these mostly being seen at an inner-city hospital which didn’t get a machine to receive EMS ECGs until late in the study. However, they did not show age- & race-matched data sets to account for these differences.

The final paper by Steg et al. out of France (cardiologists who are affiliated with Sanofi-Aventis) was entitled “Bypassing the Emergency Room Reduces Delays and Mortality in ST Elevation Myocardial Infarction: the USIC 2000 Registry”.  This registry was a prospective registry of all pts admitted to ICUs in France for AMI by the end of 2000.  The study included all consecutive pts admitted from November 1-30, 2000 with a confirmed diagnosis of STEMI who were admitted within 12 hours of the onset of symptoms. 1204 of 1922 pts met criteria for inclusion in the study. Of these, 66.9% were admitted directly to the CCU or cath lab, as mobile ICUs in France are staffed by physicians who decide where the pt goes.  33.1% were admitted via the ED & these pts were sicker based on TIMI score & Killip Class. 787 pts (65.4%) received reperfusion, including primary PCI and thrombolysis (both prehospital & in hospital).  All-cause mortality at day 5 was 4.9% in pts admitted directly to CCU and 8.6% in those admitted via the ED.  (ARR=3.7%, NNT=27pts) More ED pts (35%) received lytics and they received them later than the 30% of CCU pts who received them. However, the authors did not account for this in their results.

Some issues that came up in discussing this study:

•  The French EMS system is different from the US system (ED MDs on Mobile ICUs)
• Conflicts of interest (Sanofi)
• Only ran study for 1 month. Why that one?
•  Data from 2000, before we knew lytics prior to PCI was bad.
• Didn’t explain why pts went to ED vs CCU
• Some pts went directly to the cath lab but had no PCI, which wasn’t explained.
• They also didn’t explain why the mortality was so much higher than we would expect.

They concluded that “bypassing the ER was associated with an apparent substantial survival benefit at both five days and one year compared with patients admitted via the ER. These findings of shorter delays and improved survival suggest that pathways should be established for patients with STEMI to bypass the ER.”  However, was it really the ER that was the problem, or was it a delay in treatment?

In conclusion, as stated in the Singer article, “to be successful at reducing door-to-balloon times, we must develop strategies that reduce all the intervals that make up the process of treating patients with ST-segment-elevation myocardial infarction. Thus, the best-performing hospitals have improved each of the key components that make up the overall process of care, including door-to-ECG, ECG-to-laboratory, and laboratory-to-balloon times.”

Thanks to Dr. Patrick for her expertly-presented M&M today.Key points from today’s discussion:* Diagnostic inertia, or the persistence of a diagnosis and treatment plan based on that diagnosis despite discordant evidence, is a powerful driver for bad outcomes in the emergency department. We are particularly susceptible to this type of cognitive error, which is closely related to early diagnostic closure or diagnostic anchoring, because we hand off patients to incoming providers and cede control over patients to consultants and admitting services while we manage the front door. When a patient’s course is not as expected, retreat from the plan and reconsider the presumptive diagnosis.* Pericardial tamponade is an immediately life-threatening diagnosis. When point of care ultrasound demonstrates a pericardial effusion in a crashing patient, immediate pericardiocentesis performed by the emergency physician is warranted.* When point of care ultrasound demonstrates a pericardial effusion in patient who is not crashing but shows any clinical signs of tamponade (most importantly hypotension or tachycardia but also JVD and evidence of end-organ hypoperfusion such as elevated lactate, renal failure, chest pain or mental status changes) an immediate cardiology consultation is warranted to perform formal echocardiography and assess for tamponade physiology.* Patients with chronic effusions can develop rapidly evolving tamponade.* Dialysis is not usually an appropriate therapy for an unstable patient. Most patients who require dialysis to address conditions that have made them clinically unstable require medical optimization prior to dialysis.* When overwhelmed in the resuscitation area, consider recruiting help from the zone (MDs, RNs, technicians).* Consultants often do not appreciate the environment in which we work. Bringing them to the ED for an in-person assessment may optimize their perspective and may occasionally be helpful as a patient management resource.

Please join us for conference this Wednesday in the 8th floor conference room at Elmhurst.

9a - Journal Club - Dr. Fasina, articles below
10a - Interesting Cases in Pediatrics - Dr. Caglar
1045a - Perspectives on Community Practice - Dr. Kwun
11a - Trauma Conference - Dr. Weingart
12p - M&M - Dr. Galjour
1p - US Case of the Month - Dr. Mok
130p - The Organizational World of Emergency Clinicians - Dr. Nugus

Abiola has chosen three articles and requests that everyone comes prepared.
Residents as usual the journal articles are behind the normal logon and password.
Everyone should read: McCormack et al. Can CTA of the brain replace LP in the evaluation of acute onset Headache after a negative noncontrast CT scan?Paper.

PGY1 and 2: Perry et al. Is the combination of negative CT result and negative LP sufficient to rule out SAH? Annals of Emergency Medicine2008; 51: 707-713. Paper.
PGY3 and 4: Baraff et al. Prevalence of herniation and intracranial shift on CT in patients with SAH and a normal neuro exam? Academic emergency Medicine 2010; 17:423-428. Paper.

As usual, lunch will be served.

Thanks to Dr. Hill for these important summary points from today’s M&M.
For those who missed, these were some of the take-home points:

- You, the emergency physicians, are the trauma experts. Do not rely on hospital protocols and consultants to manage the case.

- Do a complete primary survey and intervene as needed.

- If you intubate, see an x-ray post intubation

- Do a complete secondary survey- this includes a full body exam, includes the back, abdomen and chest, includes palpation for fractures. Rectal (for gross blood), tubes

- Don’t get stuck focusing on the most obvious injury and fall victim to “early closure” error

- If you have the resources, FAST, Hct or GEM

- Document- DOCUMENT- your full exam- FULL EXAM- and ultrasound findings.

- Traumatic arrest is rarely a survivable disease regardless of cause. Arrest from abdominal trauma is essentially non-survivable.

Thanks-

And try to make the next M and M.

Please join us for conference this Wednesday at Elmhurst in the 8th floor conference room. We begin the day with Journal Club, so please come prepared!

9a - Journal Club - Dr. Trivedi - articles below
10a - Procedure Lecture - Dr. Fawaz
1030a - US Case of the Month - Dr. Roddy
11a - Trauma Conference - Dr. Weingart
12p - M&M - Dr. Nite
1p - Finance 101 - Dr. Shah

Shefali has chosen 2 articles to review and requests that everyone comes prepared.Residents as usual the journal articles are behind the normal logon and password.
PGY3s and 4s: Sturm et al. Ondansetron use in the Pediatric Emergency Department and effects on hospitalization and return rates. Are we masking alternative diagnoses? Annals Emerg Med 2009. Paper.
PGY1s and 2s: Braude et al. Antiemetics in the ED: a randomized control trial comparing 3 common agents AJEM 2006;24:177-182. Paper.

Please join us for conference this Wednesday in Hatch Auditorium. We have a very diverse, full day that concludes with a 2 hour joint Grand Rounds session with the Department of Infectious Disease focused on HIV testing in the ED setting. See you there!

9a - M&M - Dr. Holland
9:30a - Peer Review - Dr. Strayer
10a - Senior Lecture - Dr. Fasina
11a - LVADs/Heart Transplants in the ED - Dr. Pinney
12p - Joint ID/ED Grand Rounds featuring Drs. Brown and Tsoi and Ms. San Antonio-Gaddy, RN.

As usual, lunch will be served. CME is also available.

Please join us for conference this Wednesday in the 8th floor conference room at Elmhurst. We begin the day with Journal Club - please be prepared!

9a - Journal Club - Dr. Vashi (links below)
10a - Interesting Case Conference - Dr. Sarohia
11a - Trauma Conference - Dr. Weingart
12p - Joint Commission Update - Dr. Halbach
1p - M&M - Dr. Green

Anita has chosen 3 articles to review and requests that everyone comes prepared.
Residents as usual the journal articles are behind the normal logon and password.

PGY1s and 2s: Reed et al. The ROSE (Risk Stratification of Syncope in the Emergency Department) Study J ACC 2010;55(8):713-721. Paper.

PGY3s and 4s: Del Rosso et al. Clinical Predictors of Cardiac Syncope at Initial Evaluation in Patients Referred Urgently to a General Hospital: the EGSYS Score Heart. 2008;94:1620-26. Paper.

All: McGinn et al. User’s Guide to the Medical Literature XXII:How to Use Articles About Clinical Decision Rules JAMA. 2000;284(1):79-84. Paper.

Thanks to Ashish K for his succinct presentation of a scary case and discussion of DIC (for those who braved a little snow to further their craft).

Couple of take homes for those who missed it:
*DIC is always a consideration in sick patients with sepsis, multitrauma, post-op post delivery
*never occurs in isolation; triggered by release of throboplastins or endothelial injury
*hallmark is intravascular activation of coagulation with loss of localization
*may cause abnormal bleeding or clotting
*has a myriad of presentations- organ failures, bleeding , thrombosis
*PT, Platelets, D Dimers, FDPs may be normal early in the course and need monitoring
*Bleeding may require replenishment of components- FFP or platelets
*PPC may have a role but data incomplete and consultation prudent before use
*Clotting may require heparin, preferred for rapid on/off control
*There is little evidence supporting the “fueling the fire” excuse for withholding products if needed to control bleeding-
*Beware the pre-diagnosed patient- an EM is THE expert on diagnosing or ruling-out in the ED.
*Beware of trusting triage to make the final determination of “sick”
*Eyeball everyone in your zone early in their course as per the above 2 points
*A blizzard is never a completely adequate excuse to miss conference and M and M, unless you caught some freshies at your local ski area.

Thanks to Liz Cho for a nicely presented case of a PE sudden death and lit review of thrombolytics in PE and arrest.

For those of you who missed, (and you know who you are):

Heparin lives in the ED, and can be given IV immediately (Order>nurse> patient).

Lovenox takes a while. (Order,>nurse> tube> pharmacy (who sends it back for dosing adjustment)> tube > BA> nurse> patient)

The literature supports thrombolysis in PE/ shock.

10% of hemodynamically stable patients with RV dysfunction will deteriorate into shock with 50% mortality rate
Patients with RV dysfunction have mortality rate of 9.3% compared with 0.4% with normal RV function.

If you think a patient has RV dysfunction and are considering thromboytics, look at the RV.

Signs of RV dysfunction are RV distention or hypokinesis, paradoxical RV septal systolic motion, RV larger than LV in subcostal or apical view

If you are uncomfortable (most of us may be) evaluating for RV dysfunction, call for echo.

Cardiology has committed to 24/7 cardiac echo; call them if the answer will change your treatment (i.e. thrombolytics).

Consider thrombolytics if suspicion is high for PE as opposed to a bleeding pathology, such as dissection. Thrombolytics in undifferentiated cardiac arrest have not been shown to improve outcome.