EMOttawa - Emergency Medicine Ottawa

by Ian Stiell MD @EMO_Daddy













We continue to discuss the latest recommendations for ED management of atrial fibrillation (AF) as presented in the newly published 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. The Guidelines PDF can be downloaded from the CCS website at 2014 Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation
Beware of Unstable Patients who are in Permanent AF! For patients whose recent-onset AF/AFL is the direct cause of instability with hypotension, acute coronary syndrome, or florid pulmonary edema, CCS recommends that immediate electrical cardioversion be considered if rate control is not effective or safe. Unless AF-onset was clearly within 48 hours or the patient has received therapeutic OAC for >3 weeks, CCS recommends immediate initiation of intravenous or low molecular weight heparin prior to cardioversion (if feasible) followed by therapeutic OAC for 4 weeks after…

Methodology Score: 3/5 Usefulness Score:  3.5/5 Jabre P, et al. N Engl J Med.2013 Mar 14;368(11):1008-18
Article Link
This out of hospital, French randomized controlled trial found that when family members were given the option of viewing ongoing resuscitation they had less PTSD at 90 days with an adjusted OR of 1.7 (95%CI 1.2 to 2.5) than those with usual care.JC attendees appreciated the overall design and execution of this challenging study and felt that this supported current standard of care to have family members present during ongoing resuscitative efforts.  By: Qamar Amin (Presented June 2014)

Epi lesson: Validation of Measurement Tools

Methodology Score: 3.5/5              
Usefulness Score: 2.5/5
Scheuermeyer FX, Innes G, Grafstein E, Kiess M, Boychuk B, Yu E, Kalla D, Christenson J. Ann Emerg Med. 2012 Apr;59(4):256-264.e3.
Abstract Link
This prospective single-centre Canadian cohort study of an ED chest pain algorithm (observation, serial troponins, EKGs, and provocative testing within 48 hours) had 82.5% (99/120) ACS cases diagnosed on the index ED visit, and 21/120 (17.5%) diagnosed on outpatient stress testing with none being defined as missed ACS. Our JC group agreed that obtaining provocative testing within 48 hours was better for patient care but would prove difficult in many settings; additionally we felt that the small number of outpatient diagnosed ACS and older generation troponin use limits its utility and generalizability.  By: Dr. Michael Thomson (Presented May 2014)

Landmark Series  Methodology Score: 3.5/5               Usefulness Score: 3.5/5
Sprung CL, et al. CORTICUS Study Group. N Engl J Med. 2008 Jan 10;358(2):111-24
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This Multicenter, double-blind, parallel-group, placebo-controlled RCT of 499 septic shock patients found that hydrocortisone did not improve survival  or reversal of shock,either overall or in patients who did not have a response to corticotrophin (RR1.09;0.77 to 1.52). The group recognized the trial was under-powered, had questionable external validity and an extended enrolment time of 72hrs; an unplanned post hoc analysis showed a mortality benefit in those with a high SAPSII score indicating a potential benefit in this patient population. By: Dr. Robert Ohle

Epi lesson: Pre-specified and Post-hoc Subgroup Analyses Subgroup analyses involve splitting all the participant data into smaller subsets of subjects (e.g. males and females), so as to make comparisons between them. A pre-specified subgroup analysis is one that is …