Practice Changing ED Research
Dr Dane Horsfall FACEMCabrini Hospital
Literature extensive Listen to this talk! Journal watch-http://emergency-medicine.jwatch.org/
EM:RAP-http://www.emrap.org/
Landmark Trials -Trials that affect our practice
How to approach Literature
NINDS 1995/ECASS III 2008 Rivers 2001/Surviving Sepsis 2008 + Case USA vs Canada: NEXUS 2001/Canadian
Cervical Spine 2001 SAFE 2004 Sullivan 2007 Perry/Steill SAH 2011
The Good Stuff…
National Institute of Neurological Disorders and Stroke-Washington DC
“t-PA for acute ischemic stroke” Randomized, Double Blinded, recomb t-PA
(Alteplase) tPA 0.9mg/kg(max 90mg) 10% bolus then
inf 1/24 Recommended tPA < 3/24
NINDS 1995
NIHSS-National Institutes of Health Stroke Scale◦ neuro deficit, 42-point scale, neurologic deficits in 11 categories.
Eg mild facial paralysis = 1, complete right hemiplegia/aphasia =25.
Barthel Index◦ perform activities of daily living (eating, bathing, walking, toilet)
out of 100 Modified Rankin Scale-overall assessment of function
◦ 0= asymptomatic up to 5 =severe disability Glasgow Outcome Scale-global assessment of function
◦ 1=good recovery, ◦ 2=moderate disability ◦ 3=severe disability◦ 4=vegetative state◦ 5=death
NINDS 1995 Scales
Part 1 291pts NIHSS score at 24hrs= no difference
Part 2 333pts Combination score at 3/12 Results combined for analysis t-PA minimal/no disability scores- 12% absolute
increase, 32% relative, in, NNT=8 t-PA Increase ICH by 6% NNH=17
◦ Assoc with more severe isch strokes/more oedema on CT Mortality t-PA 17%, Placebo 21% (Not stat.
significant)
NINDS 1995
European Cooperative Acute Stroke Study “Thrombolysis with Alteplase 3 to 4.5 Hrs after
Acute Ischemic Stroke” 821pts tPA 3-4.5 hrs 90 day disability –modified Rankin Scale
◦ 0-1 no disability t-PA 52% vs Plac 45% - NNT 14◦ 2-6 disability
ICH(symp) t-PA 2.4% vs Plac 0.2% - NNH 45 Mortality t-PA 7.7% vs Plac 8.4% no difference BUT studies showing no Difference:
◦ ECASS I 1995 620pts tPA < 6/24◦ ECASS II 1998 300pts 0-6hrs
ECASS III 2008
Contraindications:◦ Bleeding risk
Anticoagulants, Platelets <100 Massive CVA > 1/3 cerebral hemisphere-obtund/complete
hemiplegia Uncontrolled HT >185/110 CVA/Head Injury in last 3/12 or ICH at an time Bleed in last 3/52, bleeding diathesis, arterial puncture last 7/7 Pregnancy Trauma/Surgery in last 14/7
◦ Not Stroke: Seizures Hypoglycaemia
◦ No significant improvement possible Resolving stroke Previous disability
Alfred/Cabrini Protocol- t-PA for Ischaemic Strokes < 4.5 hrs
263 pts Rx in ED for 6/24 prior to ICU: ◦ 130 EGDT◦ 133 standard Rx◦ In hospital Mortality EGDT 30%, Standard 46%◦ NNT 6
EGDT: ◦ CVP 8-12mmHg if < Fill 500ml bolus N/S every
30 mins◦ MAP >65mmHg if < vasopressors Noradrenaline◦ ScvO2 (central mixed venous O2 sat) >70%
if < Tx RBC to Hct > 30% if ScvO2 still < inotropes(dobutamine) Central venous Sats >70% surrogate marker of adequate
tissue perfusion-ie adequate resus from septic shock
Rivers 2001 - Early Goal Directed Therapy in Sepsis
Funded by manufacturer of CVC High control mortality Dr Rivers managing pts in ED Continuous Scv O2sats not practical to
measure Cant argue against concept
Rivers – Criticisms:
EGDT Antibiotic within 1 hr Source Control crystalloid or colloid fluid resuscitation Vasopressor = Noradrenaline Dobutamine if CO low post
filling/vasopressors Stress-dose steroid only if BP poorly
responsive to vasopressors
Surviving Sepsis 2008
BIBA at 0430 - fever and severe R leg pain since 0100
PHxCLL/Neutropenia - treated with gCSF
0435-Temp 400CBP 87/62 mmHgHR 160/min irregular (AF)RR 17/minO2 sat 95% (air)
Right leg red / swollen to thigh “Cellulitis”
ED Case 85 yo M
Two peripheral IVs, IV Tazocin 4.5g (early broad spectrum antis )✔IV fluid N/saline 1000mls (filling )✔IV analgesia Morphine incrementsIV Digoxin 500 mcg
0510 Initial empiric treatment
Persistent hypotension, SBP 70-90/DBP 50-60 Remained in AF Pain very difficult to control Temp 38.4
0720-Hypotension persists 80/50Rx-Gelofusine 500 and further 1000 ml N/Saline (Filling✔)
0620 Course
0845 IDC 0900 IV Metaraminol increments 0930 IV Gelofusine then IV Albumin 1000 CVC (1000, IJV) CVP 28-30-well filled ✔ 1035 Noradrenaline inf -Vasopressor ✔ 1200 IV Vancomycin 1g 1220 Transfer ICU
Non EGDT-central venous sats, Survivng sepsis-Source control
Outcome ◦ Clinical Dx Necrotizing Fasciitis by ID, pt palliated
deceased later that day in ICU
0830 – 1220 in ED ICU Reg Mx
National Emergency X-ray Utilization Study (Jerry Hoffman UCLA)
34,000pts, 21 sites, prospective observation of decision tool: Sens >99% Spec 12%
If none of 5 clinical signs=clear Cx spine◦ Midline tenderness◦ Distracting injury◦ Altered GCS◦ Neurology◦ Intoxication
NEXUS - 2000
9000pts normal conscious state** Sens 100%, spec 45% 1. High risk factors
◦ age>65 ◦ Mechanism (fall>1m,axial,MCA >100km/hr, motorbike,
bicycle)◦ Neuro*
2. Low Risk factors◦ low speed MCA◦ sitting/ walking◦ no midline tenderness*/delayed pain
3. Able to Laterally neck rotation 45 degrees?
Canadian Cervical Spine Rules - 2001
Advantages◦ Mechanism◦ Age >65
Disadvantages◦ Complicated◦ No distracting injury*
Canadian Cervical Spine
A comparison of Albumin and Saline for fluid resus in ICU (Saline vs Albumin Fluid Evaluation)
Multicentre, randomised, double blinded, 7000pts 4% Alb vs N/Saline 28/7- no difference in mortality
Conclusion- Use N/Saline
SAFE 2004
“Early treatment with prednisolone or acyclovir in Bell's palsy”
Double-blind, placebo-control, randomized trial 500 Pts with Bells (no Herpes vesicles) < 72 hrs
onset 10/7 Rx with:
◦ Pred 25mg bd◦ Acyclovir◦ Both◦ Placebo
Rating facial paralysis at 3 and 9/12 with “House-Brackmann scale” (1 normal to 6 total paralysis)
Sullivan 2007
Recovery at 3/12◦ Pred 83% vs no Pred 64%◦ Acyclovir 71% vs no Acyclovir 75%◦ Both 80%
Recovery at 9/12◦ Pred 94% vs no Pred 82%◦ Acyclovir 85% vs no Acyclovir 91%◦ Both 93%
Conclusion-Give Prednisolone!!! Supported by results from: T Berg et al “The Effect of
Prednisolone on Sequelae in Bell's Palsy” Arch Otolaryngololgy - Head Neck Surg. 2012;138(5):445-449 May 2012
Sullivan 2007
“Sensitivity of CT < 6/24 H/A onset for Dx SAH: prospective cohort study”
3100 pts, 11 Hospitals, 2000-2009 Adults, New acute h/a, no abN Neuro-?SAH 240 SAH (8%) Overall CT(3rd Gen) 93% sensitive,
100%specific Subgroup 950pts CT < 6/24 100%
sens/specific (Dx all 121 SAH) ie Normal CT <6/24 rules oot SAH
Perry/Stiell 2011
Urgent CT (Cabrini CT ?3rd Gen) ?to LP or not to LP – depends on case and
discussion with patient Perry study not validated in Australia-
unlikely to be repeated Some ED’s have changed protocols
What to do?
NINDS - “t-PA for acute ischemic stroke”, N Engl J Med 1995;333:1581-7
ECASS III – “Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke” N Eng J Med 2008;359:1317
Rivers et al – “Early goal-directed therapy in the treatment of severe sepsis and septic shock”, N Engl J Med, 345(19):1368-77, 2001 Nov 8.
Surviving Sepsis–Dellinger RP et al. January 2008 "Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008". Intensive Care Med 34 (1): 17–60.
NEXUS – J Hoffman and The National Emergency X-Ray Utilization Study Group – “Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma”, N Engl J Med 2000;343:94-9
References 1
Stiell IG et al, “The Canadian C-spine rule for radiography in alert and stable trauma Patients”, JAMA. 2001 Oct 17;286(15):1841-8
SAFE – “A Comparison of Albumin and Saline for Fluid Resuscitation in the ICU”, N Engl J Med 2004;350: 2247-56.
Sullivan et al – “Early treatment with prednisolone or acyclovir in Bell's palsy”, N Engl J Med. 2007 Oct 18;357(16):1598-607
“The Effect of Prednisolone on Sequelae in Bell's Palsy” Arch Otolaryngology Head Neck Surg. 2012;138(5):445-449 May 2012
Perry/Steill et al – “Sensitivity of CT performed within six hours of onset of headache for diagnosis of SAH: prospective cohort study” , BMJ 2011 July18;343:d4277
References 2