1. Two studies examined the prevalence of pulmonary embolism (PE) in patients hospitalized for syncope and found a prevalence of 3.75% in one study but less than 1% in a larger retrospective study, suggesting the first study had a high rate of false positives. 2. A randomized controlled trial found that administering IV antibiotics in ambulances to patients with suspected infection did not reduce mortality compared to usual care with IV fluids and oxygen alone. 3. The evidence supporting components of the MONA (Morphine, Oxygen, Nitrates, Aspirin) approach for suspected cardiac chest pain is limited, with no clear evidence that routine oxygen or morphine administration improves outcomes.

1. What’s Hot in EM?
Dr F Morris
Education Registrar

2. SyncoPE

3. PE causing syncope
• PESIT (PE in Syncope Italian Trial) 2016:
– Cross sectional multi-centre study; n=2584
– All patients with 1st episode of syncope admitted
from ED (717 -> 560 included)
• All had D-dimer and Wells score +/- CTPA or VQ scan
• 17.3% (97) diagnosed PE
– 45% RR >20, 33% HR >100, 36% SBP <110, 40% signs of DVT,
20% active cancer.
– 97/2584 = 3.75% of all syncope presentations.
Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. Prandoni et al. N Engl J Med.
20/10/2016

4. PE causing syncope
• New retrospective multi-national study
– Canada, US, Denmark and Italy
– n = 1,671,944 from Jan 2000 to Sept 2016
Prevalence of Pulmonary Embolism in Patients with Syncope. Costantino et al. JAMA Intern Med.
29/01/2018

5. Prevalence of Pulmonary Embolism in Patients with Syncope. Costantino et al. JAMA Intern Med.
29/01/2018

6. PE causing syncope
• PE identified in <1% of all patients with
syncope
– Even within 90 days <1%
– Suggesting PESIT algorithm has high false positive
and subsegmental PE rates.
• And only enrolled hospitalised patients.
• Possible over-representation of indeterminate
syncope in studies.
Prevalence of Pulmonary Embolism in Patients with Syncope. Costantino et al. JAMA Intern Med.
29/01/2018

7. Sepsis update

8. Sepsis debates
• SIRS criteria vs qSOFA
• IV fluids vs early pressors
• Reduced survival associated with Abx delay
• Is there benefit from pre-hospital Abx?

9. Pre-Hospital Antibiotics
• Multi-centre, prospective, open label, RCT.
– >18y/o, suspected infection + temp >38/<36 + >1
other SIRS criteria.
• IV Ceftriaxone 2g + IV fluid/O2 vs fluid/O2 only
1. All cause 28 day mortality
2. Misdiagnoses, hospital & 90-day mortality, length of
stay, ICU admission, length of ICU stay, TTA, adverse
events, quality of life 1 month after discharge.
Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. Alam N et
al. The Lancet. Nov 2017.

10. Pre-Hospital Antibiotics
• N=2698
• Mean age 73
• Sepsis, severe sepsis (95%) or septic shock
• ~20% already on Abx prior to ambulance.
– EMS also given training in recognising sepsis

11. Pre-Hospital Antibiotics
• Intervention group n = 1535 (from 2698)
• No difference in mortality at 28 days (8%)
– Including subgroups
– TTA ~26mins prior to arrival at ED (intervention)
– TTA ~70mins after arrival at ED (usual care)
• No anaphylaxis; 7 mild allergic reactions

12. Pre-Hospital Antibiotics
• Why is intervention group larger?
• Statistical vs clinical significance
– Onset of illness
• Confounded by sepsis training
– Pre-EMS Abx
• Urban environment and response times

13. The Death of MONA?

15. Morphine
• Clopidogrel, prasugrel & ticagrelor
• Small studies in healthy volunteers
• Absorption, plasma levels +/- anti platelet
effects.
• Platelet reactivity at 2hrs
• Mortality effect?
• Fentanyl?

16. Oxygen
• Cochrane review 2016
• No evidence to support routine use
• Paucity of RCTs to support use.

17. Nitrates
• Sublingual GTN data appears extrapolated
from IV dosing.
• IV GTN initiated within 24hrs of symptoms
reduced mortality

18. References
1. Prevalence of Pulmonary Embolism among Patients Hospitalized for
Syncope. Prandoni et al. N Engl J Med. 20/10/2016
2. Prevalence of Pulmonary Embolism in Patients with Syncope.
Costantino et al. JAMA Intern Med. 29/01/2018
3. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open
label, randomised trial. Alam N et al. The Lancet. Nov 2017.
4. SGEM#207: Ahh (Don’t) Push It – Pre-Hospital IV Antibiotics for Sepsis.
Loosley & Doyle. SGEM. 14/02/2018