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Showing posts from January, 2014

A 2-Hour Diagnostic Protocol for Possible Cardiac Chest Pain in the Emergency Department

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Methodology Score: 3.5/5                          Usefulness Score: 3/5
Than M, Aldous S, Lord SJ, Goodacre S, Frampton CM, Troughton R, George P, Florkowski CM, Ardagh M, Smyth D, Jardine DL, Peacock WF, Young J, Hamilton G, Deely JM, Cullen L, Richards AM. JAMA Intern Med. 2013 Oct 7. doi: 10.1001/jamainternmed.2013.11362. [Epub ahead of print]
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This single centre pragmatic RCT found that an accelerated (2 hour) diagnostic protocol is an effective and practical strategy to improve early discharge (within 6 hours) rates for patients with low risk chest pain (OR 1.89, NNT 13). The group agreed that this study was generally well designed, but unfortunately underpowered for safety and the study population lacked clear definition, limiting generalizability. Larger studies with clearly defined parameters of who ‘low risk possible ACS’ patients are will be needed before such a protocol can be adopted into clinical practice in our centre.  By: Dr. Andrew Willmore (Presented November 2…
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Clinical Decision Rules to Rule Out Subarachnoid Hemorrhage for Acute Headache

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Methodology Score: 4.5/5                          Usefulness Score: 4/5 Perry JJ, Stiell IG, Sivilotti ML, Bullard MJ, Hohl CM, Sutherland J, Émond M, Worster A, Lee JS, Mackey D, Pauls M, Lesiuk H, Symington C, Wells GA. JAMA. 2013;310(12):1248-1255.
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This multicentre prospective validation cohort study found that the 3 previously created SAH decision rules had very good sensitivity (>90%) and by refinement of these rules, the Ottawa SAH rule was derived which was shown to rule out SAH with a sensitivity of 100% (95%CI 97.2-100%). The group agreed that this rule is easy to apply, this study had sound methodology, and although the rule would not change imaging rates, it could decrease the SAH miss rate.  We are eagerly awaiting the prospective validation and implementation study results so we can use it in practice.  By: Dr. Kate McCubbin (Presented November 2013)

Epi lesson: Phases of Clinical Decision Rule Development
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Vasopressin, Steroids, and Epinephrine and Neurologically Favorable Survival After In-Hospital Cardiac Arrest A Randomized Clinical Trial

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Methodology Score: 4/5                 Usefulness Score: 2.5/5
Mentzelopoulos SD, et al. JAMA. 2013;310(3):270-279.
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This randomized, multi-centered, double blind, placebo controlled trial compared vasopressin, steroids and epinephrine (VSE) vs. epinephrine for in-hospital cardiac arrest and found a 18% ARR in favour of the VSE group for ROSC > 20 mins and a 8.8% ARR in favour of the VSE group for survival with a neurologically favourable outcome. JC attendees were intrigued by the results, however, important baseline characteristics were different between both groups and a multivariate analysis would have added strength to the results. Applicability to ED patients was also questioned as these were admitted patients mostly presenting with asystole or PEA. For now, this trial is best considered to be hypothesis generating rather than practice changing.  By: Dr. Lisa Fischer (Presented Nov 2013)

Epi lesson: Adjustment analyses for unbalanced baseline characteristics
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Comparison of dopamine and norepinephrine in the treatment of shock.

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Landmark Series Methodology Score: 4/5                 Usefulness Score: 4/5 De Backer D, Biston P, Devriendt J, Madl C, Chochrad D, Aldecoa C, Brasseur A, Defrance P, Gottignies P, Vincent JL; SOAP II Investigators. N Engl J Med. 2010 Mar 4;362(9):779-89
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This pragmatic, blinded, randomized, multicenter ICU trial comparing dopamine and norepinephrine in the treatment of shock found that there was no difference in the primary outcome of death at 28 days between study groups (P=0.10), but more arrhythmic events in patients treated with dopamine (24.1% vs 12.4%; P<0.001) and an increased rate of death in patients with cardiogenic shock treated with dopamine (P=0.03). This study was considered to be a landmark trial, resulting in a change of practice towards the utilization of norepinephrine as the first line agent in the treatment of shock in a tertiary care center.  By: Dr. Timothy Dalseg (Presented November 2013)

Epi lesson: Pragmatic vs. explanatory trials
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