Practical Evidence Podcast

Image Taken from the FOAMCast Episode We've discussed SEPSIS a ton on EMCrit. * Podcast 154 - Preemptive Sepsis Panel SmaccBack * Wee - Cliff Deutschman with Additional Thoughts on Sepsis 3.0 * Renoresuscitation: Sepsis resuscitation designed to avoid long-term complications * Podcast 112 - A Response to the Marik Sepsis Fluids Lecture * Podcast 169 - Sepsis 3.0 with Merv Singer * Podcast 89 - Lessons from the STOP Sepsis Collaborative Recently, the Surviving Sepsis Campaign released their 2016 guideline update. Overall, I think this iteration moves the guidelines closer to the best evidence out there. Of course, when you travel that path it forces a divergence from the distinctly non-evidence-based CMS guidelines. In this Practical Evidence Podcast, we will discuss the SSC guidelines, the aforementioned divergence, and various alcohol recommendations. I brought on my buddy, Jeremy Faust, to discuss the changes. Jeremy is 1/2 of the FOAMcast podcast which just discussed the new guidelines in a recent episode. Guideline Stuff * The SSC 2016 Guidelines * PDF Version of the SSC 2016 * Users' Guide to the Guidelines * Our Emergency Medicine Clinics Article The Guideline Recommendations The Definition of Sepsis They basically ratified SEPSIS 3.0 (Jeremy found where he saw the remnants of the old definition; it was in the Users' guide figure 2--super contradictory) Fluids 30 ml/kg in the first 3 hours Crystalloid first, then maybe albumin Use dynamic markers and/or fluid challenges Goal MAP>65 EGDT is no longer recommended Lactate attempt to normalize lactate Blood Cultures get them before antibiotics, if obtaining them will not delay the provision of antibiotics Antibiotics Within 1 hour of sepsis or septic shock Vasopressors Norepi is the first choice, add in epi or vaso Do not use dopamine Steroids 200 mg Hydrocortisone for patients who are still unstable after fluids and vasopressors Blood In most circumstances, use a trigger of <7.0 g/dL Glucose goal is < 180 mg/dL Bicarb Not recommended if pH is >7.

Here is the policy: Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department They addressed 4 questions: 1. In patients undergoing procedural sedation and analgesia in the emergency department, does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration? Level B recommendations. Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia. 2. In patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events? Level B recommendations. Capnography* may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone in patients undergoing procedural sedation and analgesia in the ED. 3. In patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications? Level C recommendations. During procedural sedation and analgesia, a nurse or other qualified individual should be present for continuous monitoring of the patient, in addition to the provider performing the procedure. Physicians who are working or consulting in the ED should coordinate procedures requiring procedural sedation and analgesia with the ED staff. 4. In patients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil, and remifentanil be safely administered? Level A recommendations. Ketamine can be safely administered to children for procedural sedation and analgesia in the ED. Propofol can be safely administered to children and adults for procedural sedation and analgesia in the ED. Level B recommendations. Etomidate can be safely administered to adults for procedural sedation and analgesia in the ED. A combination of propofol and ketamine can be safely administered to children and adults for procedural sedation and analgesia. Level C recommendations. Ketamine can be safely administered to adults for procedural sedation and analgesia in the ED. Alfentanil can be safely administered to adults for procedural sedation and analgesia in the ED. Etomidate can be safely administered to children for procedural sedation and analgesia in the ED. Tell me what you think in the comments Now on to the Podcast...

We discuss the management of asymptomatic markedly elevated blood pressure as evaluated by the ACEP Clinical Policies Committee in Sept 2013. The Policy ACEP Management of Asymptomatic HTN 2013 The Questions and the Recs In ED patients with asymptomatic elevated blood pressure, does screening for target organ injury reduce rates of adverse outcomes? Patient Management Recommendations Level A recommendations. None specified. Level B recommendations. None specified. Level C recommendations. * In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required. * In select patient populations (eg, poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (eg, hospital admission).   In patients with asymptomatic markedly elevated blood pressure, does ED medical intervention reduce rates of adverse outcomes? Patient Management Recommendations Level A recommendations. None specified. Level B recommendations. None specified. Level C recommendations. * In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required. * In select patient populations (eg, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control. [Consensus recommendation] * Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up. [Consensus recommendation] What is EMCrit Drinking? Now on to the Podcast...  

Today, we discuss two new Trauma Guidelines ATLS 9th Ed. The 9th edition of ATLS has been published. In this episode, I review the changes from the 8th edition. Management of C-Spine Injuries We also go over the new management of spinal cord injuries from the Neurosurgeons Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries from the American Association of Neurological Surgeons (Neurosurgery 2013;72(supplement 2):1-259 Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries) What's EMCrit Drinking?

Ischemic Stroke Guidelines from the ASA Hot off the presses; the 2013 Ischemic Stroke Guidelines from AHA/ASA (Stroke 2013;44:870) Want the full recommendations as written by the AHA/ASA? Stroke Centers * Comprehensive Stroke Centers are god * Should have neurocritical care unit * EMS should bypass hospitals that can’t care for stroke * Should have tele-rads if no in-house radiologists Initial Eval * Door to Drug within 60 minutes (80% compliance) * Use a Stroke Scale, preferably NIHSS * Get labs, but glucose is the only one that needs to be done before tPa * Get EKG and troponin, don’t delay tPA for this   ED-Based Care Imaging * Get either a NCCT or MRI to exclude hemorrhage prior to tPA * tPA indicated even if ischemic signs, unless a frank hypodensity is noted * A non-invasive intracranial vascular study is strongly recommended during initial imaging if IA tPA or mechanical thrombectomy is contemplated. This should not delay tPA administration * In tPA candidates, the CT or MRI should be read within 45 minutes of arrival by a physician with expertise in reading CTs or MRIs of the brain * Consider CT Perfusion or MRI perfusion in patients outside of the window for IV tPA * If frank hypodensity involves more than 1/3 of the MCA territory, IV tPA should be withheld TIAs * They should get imaging of their cervical vasculature * Noninvasive imaging by CTA or MRA of the intracranial vasculature is rec. to exclude proximal intracranial stenosis or occlusion. Intracranial lesions may need confirmatory angio if occlusion seen on CTA * Pts with transient sx should receive imaging within 24 hours, preferably by MRI Acute Treatment * Cardiac Monitoring * New BP meds allowed to get the pt <180/110. Shoot for 180/105 for first 24 hours * Intubate airway compromise or bulbar dysfunction * Shoot for pulse ox > 94%. Don’t give supplemental O2 in patients with normal RA pulse ox * Lower temps >38 C * Until further evidence, use the same BP goals for IA/mech treatments * In Non-tPA, only treat if SBP>220 or DBP>120 * Treat hypovolemia with NS and treat CO-reducing dysrhythmias * Treat hypoglycemia * May restart home anti-hypertensives after 24 hours * Treat hyperglycemia to achieve a Blood Sugar of 140–180 mg/dl IV Fibrinolysis * Give IV tPA in patients who meet 3 hour criteria (IA) * Getting it within window is not enough, shoot for the <60 minutes timeframe * Give IV tPA to pts who meet criteria within 4.5 hours (IB) * Be prepared to treat complications including bleeding and angioedema * tPA is reasonable if pt had a seziure if treating team feels deficit is from stroke and not post-ictal state (IIaC) * Benefits of sono-thrombolysis are unknown at this time * Other agents besides tPA should only be used in clinical trials * Benefit of tPA unknown in patients in the 3–4.5 hr range with one of the additional contra-indications * Use of tPA in pts with mild deficits, rapidly improving deficits, major surgery in prior 3 months, and recent MI may be considered and should be based on risk benefit assessment * Don’t use streptokinase * The use of intravenous rtPA in patients taking direct thrombin inhibitors or direct factor Xa inhibitors may be harmful and is not recommended unless sensitive laboratory tests such as aPTT, INR, platelet count, and ECT, TT, or appropriate direct factor Xa activity assays are normal, or the patient has not received a dose of these agents for >2 days (assuming normal renal metabolizing function). Similar consideration should be given to patients being considered ...

See the Guidelines at (CCM 2013;41(2):580) Diagnosis of Sepsis Diagnosis of Severe Sepsis The New Bundles A. Initial Resuscitation * Protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration ? 4 mmol/L). Goals during the first 6 hrs of resuscitation: * Central venous pressure 8–12 mm Hg * Mean arterial pressure (MAP) ? 65 mm Hg * Urine output ? 0.5 mL/kg/hr * Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (grade 1C). * In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C). B. Screening for Sepsis and Performance Improvement * Routine screening of potentially infected seriously ill patients for severe sepsis to allow earlier implementation of therapy (grade 1C). * Hospital–based performance improvement efforts in severe sepsis (UG). C. Diagnosis * Cultures as clinically appropriate before antimicrobial therapy if no significant delay (> 45 mins) in the start of antimicrobial(s) (grade 1C). At least 2 sets of blood cultures (both aerobic and anaerobic bottles) be obtained before antimicrobial therapy with at least 1 drawn percutaneously and 1 drawn through each vascular access device, unless the device was recently (<48 hrs) inserted (grade 1C). * Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan antibody assays (2C), if available and invasive candidiasis is in differential diagnosis of cause of infection. * Imaging studies performed promptly to confirm a potential source of infection (UG). D. Antimicrobial Therapy * Administration of effective intravenous antimicrobials within the first hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) as the goal of therapy. * Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis (grade 1B). Antimicrobial regimen should be reassessed daily for potential deescalation (grade 1B). * Use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection (grade 2C). * Combination empirical therapy for neutropenic patients with severe sepsis (grade 2B) and for patients with difficult-to-treat, multidrugresistant bacterial pathogens such as Acinetobacter and Pseudomonas spp. (grade 2B). For patients with severe infections associated with respiratory failure and septic shock, combination therapy with an extended spectrum beta-lactam and either an aminoglycoside or a fluoroquinolone is for P. aeruginosa bacteremia (grade 2B). A combination of beta-lactam and macrolide for patients with septic shock from bacteremic Streptococcus pneumoniae infections (grade 2B). Empiric combination therapy should not be administered for more than 3–5 days. De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known (grade 2B). * Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have a slow clinical response, undrainable foci of infection, bacteremia with S. aureus; some fungal and viral infections or immunologic deficiencies, including neutropenia (grade 2C). * Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin (grade 2C).

Screening for by cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma 73:(5) Supplement 4, S301-S306, 2012. Michael McGonigal has a great summary of the BCI guidelines on his Trauma Professional's Blog Click here to download the blunt cardiac injury algorithm What's EMCrit Drinking?

  Should we be prescribing opioids from the ED? This question is explored in the recent ACEP Clinical Policy on ED Opioid Prescriptions.  

The difference between screening, rule-out, and risk prediction criteria.

From American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis, 9th ed Guidelines Chest 2012;141:7S-47S (Executive Summary) For outpatient treatment, start 10 mg daily for the first 2 days followed by INR measurements Give 1 day of LMWH or UFH before initiation, if treating VTE If the patient is on VKAs, avoid NSAIDs and certain ABX (table 8 from full guidelines) Avoid anti-plt agents unless clinical condition warrants Normal goal is 2-3, including antiphospholipid No need to taper when d/cing Heparin – 80/18 for VTE, 70/15 for cardiac or stroke patients For outpatients with VTE treated with SC UFH, they suggest weight-adjusted dosing (first dose 333 units/kg, then 250 units/kg) without monitoring rather than fixed or weight-adjusted dosing with monitoring High INRs 4.5-10, no bleeding: no vitamin K necessary > 10, no bleeding: Oral Vitamin K If anticoagulant related major bleeding: 4-factor PCC and Vitamin K Slow IV Injection See Michelle Lin’s Paucis Verbis on the same Critically Ill Patients Recommend against routine screening Use LMWH or LDUH in all patients unless contra-indicated For travelers at risk of VTE, use graded compression stockings; do not prescribe aspirin or anticoagulants Diagnosis of DVT Low Risk moderate sens d-dimer, high sens d-dimer, or CUS of proximal veins only. D-dimers are preferred If d-dimer is positive, get Compression Ultrasound (CUS) of proximal veins Moderate Risk Use High sens d-dimer, CUS of prox, or CUS of whole leg Can stop if high-sens D-dimer is negative If no d-dimer or d-dimer postive, need a second CUS 1 week later if only prox CUS done If whole leg CUS is negative, you are done High Risk Prox CUS or Whole Leg CUS If prox CUS and d-dimer negative as well, done If d-dimer positive or only prox CUS, get 1 week f/u CUS If whole leg CUS is negative, you are done Recurrent In patients with past DVT, recommend high-sens d-dimer, if positive get Prox CUS and 1 week Prox CUS If negative, get just one Prox CUS If the old CUS is not available, confirm with venography if positive CUS Upper Ext Go right to Doppler CUS for upper extremity dvt suspicion Treatment of DVT Start with IV or SQ UFH, LMWH, or fondaparinux (Latter two preferred) If high pretest, start heparin immediately; If moderate, start heparin only if diagnostic tests are expected to be > 4 hours delayed Isolated distal DVT-serial CUS rather than treatment unless severe symptoms or risk factors for extension (see full text) Ambulate DVTs, no bed rest In patients with hypotension (SBP) < 90 and PE, give systemic thrombolytics (through peripheral, rather than PA cath) Atrial Fib Chads 0 – nothing Chads 1/2 – VKA/oral anti-coag; Dabi is preferred If a-fib > 48 hours; give 3 weeks of VKA/dabi before cardioversion. Or get TEE with LMWH. Follow with 1 month of Vka/oral anti-coag If a-fib < 48 hours; Start LMWH and then VKA for 4 weeks If hemodynamically unstable, treat with anticoagulation ASAP preferably before cardioversion and then continue for 4 weeks Treat a-flutter like a-fib for all of the above Stroke If hemorrhagic,

National Institute for Health and Clinical Excellence: Acute upper GI bleeding: NICE guideline http://guidance.nice.org.uk/CG141/NICEGuidance/pdf/English Great Britain’s National Health Service has a group called the National Institute for Health and Clinical Excellence (NICE); this group has recently put out guidelines for the management of Upper GI Bleeds. Thanks to my friend, Cliff Reid, for bringing these guidelines to my attention. The Guidelines Before endoscopy, calculate a Blatchford Score consider discharge if the score is zero. After endoscopy, calculate a Rockall Score, this helps determine disposition Transfuse massively bleeding patients as per local protocols, realizing that both under- and over-transfusion are bad Do not give platelets if the patient is not bleeding. If they are bleeding, give plts for count < 50,000. Offer FFP to pts with fibrinogen < 1 g/L or INR > 1.5 Use PCC for patients taking warfarin and are actively bleeding Do not use Factor VIIa until other methods have failed Offer endoscopy for severe acute bleeding immediately after resuscitation Do not offer PPI to patients with non-variceal upper GI bleeding unless endoscopy reveals an ulcer Offer them if the patient has stigmata of recent hemorrhage on endoscopy If patient still bleeding after intial endocscopy or rebleeds after repeat endoscopy, go to IR, then to surgery In variceal bleed, they recommend terlipressin until definitive haemostasis or for 5 days GIVE PROPH ABX for suspected variceal bleeds Go to TIPS if endoscopic treatment is unsuccessful What is EMCrit drinking? Rodenbach, an amazing Flemish Sour Ale Now on to the Podcast…

The Recs:   * Use Hunt & Hess or WFN Scores * Risk of early rebleeding is high – be quick and decisive in getting the aneurysm secured * Still recommending LP if negative CT * Get CTA if CT or LP is positive * MRI may be useful if negative CT, but if negative you still need a LP * Keep SBP < 160 until clip/coil * If delay until clip/coil, use aminocaproic acid or TXA * Give nimodipine to prevent delayed cerebral ischemia * Need CSF drainage if acute, symptomatic hydrocephalus * Consider anti-convulsants in acute SAH management * Use isotonic fluids, keep fluid balance positive * Keep patient Normothermic * Control Hyperglycemia from: Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage doi: 10.1161/?STR.0b013e3182587839 What is EMCrit drinking? An insanely good aged sour ale: Rodenbach 2009 Vintage  

The original ACEP guidelines can be found here. This table from (Annals of Emergency Medicine  Volume 58, Issue 1, July 2011, Pages 12–20) shows the IUPs eventually discovered on f/u vs. what was seen in the ED at various thresholds of bHCGs.  What is EMCrit drinking? Rare Vos by Omegang Now on to the Podcast:

Welcome to the second episode of Practical Evidence, a podcast about the evidence you NEED to know but may not have time to read. This month we discuss the American College of Emergency Physicians’ Pulmonary Embolism Clinical Policy(2011) What’s EMCrit Drinking? This month, I’m drinking a Dreamweaver by Troeg Brewery Please visit our bandwidth sponsor: Please check out our bandwidth sponsor EB Medicine for great offers exclusively for our listeners.

Welcome to the first episode of Practical Evidence, a podcast about the evidence you NEED to know but may not have time to read. This month we discuss the Eastern Association for the Surgery of Trauma’s (EAST) guidelines on the management of penetrating trauma. What’s EMCrit Drinking? This month, I’m drinking a Mary’s Maple Porter from Brooklyn Brewery Please visit our bandwidth sponsor: Please check out our bandwidth sponsor EB Medicine for great offers exclusively for our listeners.