1. Best Articles:
2012-2013
Tyson Pillow, M.D., M.Ed. !
Associate Program Director!
Section of Emergency Medicine!
Assistant Professor!
Baylor College of Medicine

2. I have no
financial
disclosures

3. Objectives
A few good articles!
“A La Casa”!
Resuscitation!
Post-resuscitation Care

4. A Few Good Men
Articles

5. VS.
When to do head CTs?
314 patients with GCS 15!
22 with any intracranial findings!
11 with “significant” injuries!
3 with neurosurgical emergency

6. Sensitivity
Specificity
Any lesion!
“Significant”!
Neurosurgery
100% 100%
36%
35%
81%
10%
10%
10%
Papa, et. al. Acad Emerg Med. Jan 2012.

7. Low Risk Chest pain
Prospective, observational*!
TIMI score of 0, negative troponin
at 0 and 2 hours, and no “new”
EKG changes!
Used their own standard troponins
Than, et. al. J Am Coll Cardiol. Jun 2012.

8. Low Risk Chest pain
392 of 1957 patients were low risk!
One patient with cardiac event
(0.25%)!
Sensitivity 99.7%
Kelly, et. al. Emerg Med. Jan 2013.

9. History!
EKG!
Age!
Risk Factors!
Troponin
Age > 65!
> 3 CAD risk factors!
Known CAD!
ASA use in past 7 days!
Recent severe angina!
Elevated cardiac markers!
ST deviation > 0.5 mm
TIMI + HEART

10. TIMI + HEART
No patient with TIMI < or =
to 2 and HEART score 0 had
an event
Retrospectively applied to
9000 patients
Marcoon, et. al. Crit Pathw Cardiol. Mar 2013.

11. Text
Distinguishing Causes of
Troponin Elevations

12. Text
Cardiac disease
associated with:
Higher median value!
0.113 mcg/L vs 0.012 mcg/L
Higher change in values!
0.019 mcg/L vs 0.001 mcg/L
Haaf, et. al. Circulation. July 2012.

13. Troponins DO
NOT “LEAK!”

14. “A la casa”

15. Abdomen

16. Appendicitis
Modified Alvarado was
only 76% sensitive
Decision rule:
Meltzer, et. al. Ann Emerg Med. Apr 2013.

17. Appendicitis
25% of the radiation dose with
similar diagnostic accuracy
Low dose CT scan vs standard:
Kim, et. al. NEJM. Apr 2012.

18. Neurology

19. Is it safe to send TIA
patients home?
60 patients in France!
If met criteria*, then discharged on
antiplatelet therapy!
F/u in 8 to 15 days!
One (1.7%) with stroke!
3 (5.0%) with recurrent TIA
Q1
Montassier, et. al. J Emerg
Med. May 2013.

20. Are head CTs useful
for vertigo?
448 patients!
2.2% of CT scans abnormal!
104 patients received f/u imaging
[78.7% MRI/A; 22.3% CT]!
17 patients with findings on f/u!
Most commonly missed
ischemic stroke
Q2
Lawhn-Heath, et. al. Emerg
Radiol. Sept 2012.

21. Can we stop doing LPs
after negative CT scans?
Retrospectively applied to 55
patients with SAH !
CT within 6 hours missed 11 (20%)!
Q3
Mark, et. al. Ann Emerg Med. Oct 2012.

22. Cardiovascular

23. 246
patients
Electrical
Pharmacologic
89% conversion!
1.5 shocks
74% conversion!
220 min longer
33 more patients
cardioverted with
electricity
Bellone, et. al. Emerg
Med. Mar 2012.

24. Pulmonary

25. Case 1
34 y/o M presents with wheezing
Moderate-severe
How do you order your
nebulizer treatments?

26. Continuous vs. intermittent nebulization of
beta-agonists in asthma
NNT = 7
Gregory.Acad Emerg Med. Nov 2012

27. Case 2
56 y/o M presents with mild
COPD exacerbation
“Antibiotics always clear it up for me”
Are antibiotics indicated in this
patient?

28. 310 patients in initial study
152 in the placebo arm analyzed!
(80.1% did well without abx)
Increased purulence
CRP > 40 mg/L
Miravitlles. Chest. Nov 2013

29. Case 3

30. Case 3

31. 122/78, 104, 22, 100.6 F
Healthcare worker
What is your management for
this patient?

32. New strategy for healthcare-associated
pneumonia
Marayuma. Clin Infect Dis. Sept 2013
HCAP CAP p-value
n 321 124 -
MDR
pathogens
15.3% 0.8% < 0.001
Mortality 13.7% 5.6% 0.017

33. Mortality for 0-1 MDR risk
factor without severe PNA still
4.4%!

34. www.ann-clinmicrob.com
Don’t forget MRSA
Of 595 patients with
CAP, 2.4% overall and
4.8% of ICU admits
with MRSA as source
2 of 14 (14.3%) died
Moran, et. al. Clin Infect Dis.Apr 2012.

35. Can PE patients be sent
home?
Meta-analysis of 7 studies including 741 patients!
Included “symptomatic” patients*!
13 with recurrent PE (all undergoing active
cancer treatment) and 3 with bleeding
complications!
None of the patients died within 90 days
Vinson, et. al. Ann Emerg Med. Nov 2012.

36. Resuscitation

37. Lactate predicts mortality...
In medical disease
In trauma
Lactate > or = 4 mg/dL had a
18.8% mortality
Linear relationship of lactate to
mortality ranging from 6% (< 1
mmol/L) to 39% (19-20 mmol/L)
Puskarich, et. al. Acad Emerg Med.Aug 2012.
Odom, et. al. JTrauma Acute Care Surg. Apr 2013.

38. ...but not useful in trauma
after negative CT scan
0 of 104 patients with
negative w/u has post-
traumatic sequelae
Vohra, et. al. WJEM. May 2013.

39. “Fast” = 75-120 bmp!
!
Machine is better!
!
Blacks don’t do CPR???
Idris, et. al. Circulation. Jun 2012.
Sasson, et. al. NEJM. Oct 2012.
Westfall, et. al. Crit Care Med. May 2013.

40. Should we be giving epi?!

41. Epinephrine
417,188 patients analyzed from 2005 to 2008!
!
Epi associated with 2.36 adjusted odds ratio for
ROSC!
!
...but after one month, survival (AOR 0.46) and
cerebral performance (AOR 0.31) suffered
Hagihara, et. al. JAMA. Mar 2012.

42. Should we be giving epi?!
!
Role of ECMO?

43. Extracorporeal Membrane
oxygenation
29% vs 8% with good neurologic outcomes!
NNT in study was 4.8
...but
ECMO group younger,
healthier, more likely to
receive PCI and therapeutic
hypothermia, etc...
Maekawa, et. al. Crit Care
Med. Feb 2013.

44. Extracorporeal Membrane
oxygenation
...however
61 patients received ECMO !
(45 min + down time prior to arrival)
then PCI with a 100% rate of ROSC
and 33% rate of survival to discharge
with good neurologic function
Kagawa, et. al. Circulation.Aug 2012.

45. Resuscitation

46. Post-resuscitation
Care

47. HypothermiaParalysis?!
(Salciccioli.
Resus. Jun 2013.)
ROSC
Prevent secondary injury
PCI + CT protocol!
(Chelly. Resus. Dec
2012)
Prevent
hyperoxygenation!
(Janz. Crit Care Med.
Dec 2012)
Prophylactic lidocaine?!
(Kudenchuk. Resus. Jun 2013.)

48. Summary

49. Best Articles:
2012-2013
Tyson Pillow, M.D., M.Ed. !
Associate Program Director!
Section of Emergency Medicine!
Assistant Professor!
Baylor College of Medicine