Most life-saving articles of 2014?

Of all the articles of importance in emergency medicine in 2014 Medscape has selected the five that could have the greatest impact in helping you save lives. Make sure you read them!

2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines 

Medscape says that the section to be highlighted is the recommendation for urgent catheterization. Patients with NSTE-ACS needing “urgent/immediate invasive strategy” include patients with:

  • refractory angina despite aggressive use of standard antianginal medications
  • evidence of evolving heart failure or worsening mitral regurgitation
  • hemodynamic instability
  • sustained ventricular tachycardia or ventricular fibrillation (excepting patients with serious comorbidities or contraindications to such procedures).

Such patients have been given a Class I indication, level of evidence A, for invasive therapy within 2 hours. Note that immediate catheterization is now indicated for patients who are post-ventricular fibrillation cardiac arrest even in the absence of ST-segment elevation on the ECG.

Full-text available here

A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity

Cardiac arrest victims who present with pulseless electrical activity (PEA) usually have a grave prognosis. Several conditions, however, have cause-specific treatments which, if applied immediately, can lead to quick and sustained recovery. Current teaching focuses on recollection of numerous conditions that start with the letters H or T as potential causes of PEA. This teaching method is too complex, difficult to recall during resuscitation, and does not provide guidance to the most effective initial interventions. This review proposes a structured algorithm that is based on the differentiation of the PEA rhythm into narrow- or wide-complex subcategories, which simplifies the working differential and initial treatment approach. This, in conjunction with bedside ultrasound, can quickly point towards the most likely cause of PEA and thus guide resuscitation.

Full-text available here

Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the Emergency Department

This article finds that early post-intubation CA occurred with an approximate 2% frequency in the ED. Systolic hypotension before intubation is associated with this complication, which has potentially significant implications for clinicians at the time of intubation. Medscape says that it is easy to forget that intubation can produce significant haemodynamic compromise which may not be a problem in most patients, but which can cause decompensation in critically ill patients with limited haeomodynamic reserve. The conclusion is that it “seems logical” that  critically ill patients should receive aggressive pre-intubation fluid resus and/or vasopressors to prevent heamodynamic collapse on intubation, although further randomized trials are needed

Full-text available here

And finally two articles from the New England Journal of Medicine which both deal with the management of sepsis

A randomized trial of protocol-based care for early septic shock (Full-text available here) and  Early goal-directed resuscitation for patients with early septic shock (Abstract available here. Full text available from the library on request. Use the request form here).

The primary lesson to take from these articles is that a formal early goal-directed protocol does not improve mortality over non-protocol-based aggressive therapy. Specific interventions are the key to improving mortality:

  • Early recognition is key. Blood cultures should be obtained and broad-spectrum antibiotics initiated without delay. Crystalloids should be provided early and vasopressors added for fluid-resistant shock. When initiating mechanical ventilation it is important to use lung-protective strategies with low tidal volumes
  • Central venous catheters and monitoring ScvO2 do not appear to improve outcomes when used routinely. Rather monitoring serial lactate levels as a measure of perfusion appears to be adequate in general. Blood transfusions should be used less often and are best saved for patients with active cardiac or cerebral ischaemia in the presence of a haemoglobin level < 7 g/dl.




Article for critical appraisal session Worthing 20th August – RATPAC trial

Article PDF (full-text of article) available here

RATPAC study website

CASP critical appraisal tools and checklists available here

Submitted by Alice Byram.

The RATPAC (Randomised Assessment of Treatment using Panel Assay of Cardiac markers) trial: a randomised controlled trial of point-of-care cardiac markers in the emergency department.

Citation: Health Technology Assessment (Winchester, England), 05 2011, vol./is. 15/23(iii-xi, 1-102), 1366-5278;2046-4924 (2011 May)
Author(s): Goodacre S,Bradburn M,Fitzgerald P,Cross E,Collinson P,Gray A,Hall AS
Abstract: OBJECTIVES: To evaluate the clinical effectiveness and cost-effectiveness of using a point-of-care cardiac marker panel in patients presenting to the emergency department (ED) with suspected but not proven acute myocardial infarction (AMI).DESIGN: Multicentre pragmatic open randomised controlled trial and economic evaluation.SETTING: Six acute hospital EDs in the UK.PARTICIPANTS: Adults presenting to hospital with chest pain due to suspected but not proven myocardial infarction, and no other potentially serious alternative pathology or comorbidity.INTERVENTIONS: Participants were allocated using an online randomisation system to receive either (1) diagnostic assessment using the point-of-care biochemical marker panel or (2) conventional diagnostic assessment without the panel. All tests and treatments other than the panel were provided at the discretion of the clinician.MAIN OUTCOME MEASURES: The primary outcome was the proportion of patients successfully discharged home after ED assessment, defined as patients who had (1) either left the hospital or were awaiting transport home with a discharge decision having been made at 4 hours after initial presentation and (2) suffered no major adverse event (as defined below) during the following 3 months. Secondary outcomes included length of initial hospital stay and total inpatient days over 3 months, and major adverse events (death, non-fatal AMI, life-threatening arrhythmia, emergency revascularisation or hospitalisation for myocardial ischaemia). Economic analysis estimated mean costs and quality-adjusted life-years (QALYs), and then estimated the probability of cost-effectiveness assuming willingness to pay of 20,000 per QALY gained.RESULTS: We randomised 1132 participants to point of care and 1131 to standard care, and analysed 1125 and 1118, respectively [mean age 54.5 years, 1307/2243 (58%) male and 269/2243 (12%) with known coronary heart disease (CHD)]. In the point-of-care group 358/1125 (32%) were successfully discharged compared with 146/1118 (13%) in the standard-care group [odds ratio (OR) adjusted for age, gender and history of CHD 3.81; 95% confidence interval (CI) 3.01 to 4.82, p < 0.001]. Mean length of the initial hospital stay was 29.6 hours versus 31.8 hours (mean difference = 2.1 hours; 95% CI -3.7 to 8.0 hours, p = 0.462), while median length of initial hospital stay was 8.8 hours versus 14.2 hours (p < 0.001). More patients in the point-of-care group had no inpatient days recorded during follow-up (54% vs 40%, p < 0.001), but mean inpatient days did not differ between the two groups (1.8 vs 1.7, p = 0.815). More patients in the point-of-care group were managed on coronary care [50/1125 (4%) vs 31/1118 (3%), p = 0.041]. There were 36 (3%) patients with major adverse events in the point-of-care group and 26 (2%) in the standard-care group (adjusted OR 1.31; 95% CI 0.78 to 2.20, p = 0.313). Mean costs per patient were 1217 with point-of-care versus 1006 with standard care (p = 0.056), while mean QALYs were 0.158 versus 0.161 (p = 0.250). The probability of standard care being dominant (i.e. cheaper and more effective) was 0.888.CONCLUSIONS: Point-of-care testing increases the proportion of patients successfully discharged home and reduces the median (but not mean) length of hospital stay. It is more expensive than standard care and unlikely to be considered cost-effective.TRIAL REGISTRATION: Current Controlled Trials ISRCTN37823923.FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 15, No. 23. See the HTA programme website for further project information.