Journal Feed Weekly Wrap-Up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 
Originally published at JournalFeed, a site that provides daily or weekly literature updates. 
Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.

#1: Canadian TIA Score Beats ABCD2

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The Canadian TIA Score has now been validated and is ready for clinical use. Patients with a clinically-defined TIA (no MRI) may be accurately stratified as low, medium, or high risk for subsequent stroke (+/- carotid revascularization) within 7 days.

Why does this matter?
ABCD2 has some issues for determining disposition in TIA patients. ABCD2i considered ABCD2 + presence of infarction on CT or DWI, which improved prediction of short-term stroke. Not unexpectedly, our northern neighbors are at it again and have now validated the Canadian TIA score, which was better than the made-in-California ABCD2 score.

This score looks good but note the TIA definition
This was a prospective cohort of 7,607 ED patients with TIA. For the primary outcome of stroke or carotid endarterectomy (CEA)/ carotid stenting within 7 days, the Canadian TIA Score performed well. For patients deemed low risk (score -3 to 3), the primary outcome occurred in 0.5%; medium risk (score 4 to 8), 2.3%; high risk (score ≥9), 5.9%. If they just considered stroke within 7 days and eliminated CEA/stenting, results were very similar but looked even better for subsequent stroke risk: low 0.2%; medium 1.5%; high 2.7%. The Canadian TIA score outperformed ABCD2 or ABCD2i when considering overall diagnostic accuracy (AUC). These days, the TIA definition includes resolved symptoms and negative MRI. That was not how it was defined in this study, and just 4.2% had MRI. Rather, it was an ED working diagnosis of TIA that warranted inclusion in the study. They used the old school definition of TIA. The majority of patients, 72%, fell into the medium risk group. These are tough to deal with, in my opinion. Lows can probably go home. Highs are probably admitted. But what should we do with medium risk? With a <2% 7-day stroke risk, one could argue that they could be sent home on aspirin with close follow up, ongoing workup, and modification of stroke risk factors. It sounds like there is room for shared clinical decision making here. But we will need to figure out how to manage this in our own practice settings.

Another Spoonful
QxMD has a Canadian TIA Score calculator.

Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study. BMJ. 2021 Feb 4;372:n49. doi: 10.1136/bmj.n49.

#2: VA ECMO for Massive PE + Cardiac Arrest

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Patients with massive PE and cardiac arrest who received venoarterial (VA) ECMO had 61% survival to discharge.

Why does this matter?
Bo did an epic post on current management and controversies in treating PE. Use of VA ECMO is one of the areas where we need all the evidence we can get. Here is a bit more.

PE + VA ECMO for the win
This was a systematic review of 77 articles totaling 301 patients with PE and arrest who were placed on VA ECMO. Of these, 183 of 301 – 61% survived to discharge. Patients >65 years and those cannulated during cardiac arrest fared worse and had lower odds of survival. There was no difference in survival among those who received thrombolysis prior to cannulation; six had major bleeding but survived (n=51). Only 60 patients had neurological status documented, and 53 (88%) had a good outcome (CPC 1 – alert, able to work, none to mild deficits). But this rosy statistic should be viewed with caution, as most patients in the entire cohort did not record neurological outcome, just survival or not. Take home – in patients with massive PE, think VA ECMO early. If hemodynamically trending in the wrong direction, ECMO is a good option, preferably prior to arrest. Also, this study suggests that prior thrombolysis is not a contraindication to starting VA ECMO, although bleeding is still a very real risk.

Venoarterial Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism-Related Cardiac Arrest: A Systematic Review. Crit Care Med. 2021 Feb 15. doi: 10.1097/CCM.0000000000004828. Online ahead of print.

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The original Ten Commandments of Emergency Medicine were published 30 years ago by Wrenn and Slovis. Medicine, especially emergency medicine, has changed in the interim. Here is a modern update on the original classic article

Why does this matter?
While this classic publication still carries weight 30 years later, the specialty of emergency medicine has grown and matured in its role in the modern medical system. What additions to the original commandments have been needed as times have changed?

Read these modern commandments from your digital tablet, not your stone one

  1. Secure the ABCs, but carefully
    Original: Secure the ABCs
    Comment: While the ABCs are still paramount, and prioritization of their securement is one of the pillars of our specialty, 30 years of research and experience have shown us there is great nuance to safely securing the ABCs. In particular, there has been an emergence of data helping us focus on identifying and mitigating risk in the physiologically difficult airway.

  2. Remember naloxone, glucose, and thiamine (NGT)
    Original: Consider or give naloxone, glucose and thiamine

    • The number of patients presenting with opioid intoxication is growing, and the gentle reversal of patients without severe respiratory depression with naloxone is in the art of medicine – consider starting with 0.4mg and titrate to effect.

    • In contrast to empiric administration of glucose in the altered or ill patient, rapid assessment of glucose level with point-of-care testing is recommended.

    • Thiamine deficiency may be less prevalent than previously thought in intoxicated patients, but we now know that giving 100mg of IV thiamine can benefit other malnourished patients, including those with calorie-malnourishment from cancer, gastric bypass, hyperemesis gravidarum, and eating disorders. Personally, I use the ‘T’ of ‘NGT’ to remind myself not to miss alcohol withdrawal.

  3. Administer a pregnancy test (and sometimes bedside ultrasonography)
    Original: Administer a pregnancy test
    Everyone still gets a pregnancy test, but as reproductive technology advances and the age spectrum of pregnant patients (and their complications) grows, the role of POC ultrasound in the experienced user can quickly help evaluate and screen for pregnancy related emergencies, particularly in unstable pregnant patient.

  4. Assume the worst
    Original: Assume the worst
    Comment: Emergency physicians have always been good at this – but as medicine becomes more specialized and more, sicker patients present to our departments, ED physician recognition and identification of threats is increasingly important.

  5. Do not send unstable patients to radiology, but if you must, do not let them go alone
    Original: Do not send unstable patients to radiology
    Comment: Increased availability of portable radiography and ultrasound should be prioritized in the ill patient. However, the role of CT has increased in diagnosis and disposition for emergency department patients. If you need a CT scan, do not send the patient to radiology alone, and if possible, you should focus on trying to resuscitate the patient before departing the ED.

  6. Seek out the red flags
    Original: Look out for the common red flags
    Comment: Electronic medical records increase accessibility of trending the 5 vital signs and should be routinely checked. The onus of recognizing red flags has shifted from just noticing when they are present to seeking them out by ‘assuming the worst’ and obtaining pertinent social history and planning an appropriate workup. Specific examples include being aggressive in evaluating the aorta in elderly patients with back pain and being wary of the patient who presents with simple alcohol intoxication as the chief complaint, especially if there are abnormal vital signs or hypoglycemia.

  7. Trust no one, believe nothing (not even the electronic health record)
    Original: Trust no one, believe nothing (not even yourself)
    Comment: While electronic health records have revolutionized the amount of data available to physicians, care must be taken to not rely blindly on their data. False information is easily propagated through the EMR; verify as much as you can with patients and their family.

  8. Learn from your mistakes
    Original: Learn from your mistakes
    Comment: Mistakes will always happen. Electronic data has increased opportunities for recognition of errors, and we should create a culture of constructively working through errors, instead of a purely punitive system.

  9. Do unto others as you would your family (and that includes families different from yours)
    Original: Do unto others as you would your family (and that includes coworkers)
    Comment: Make sure to keep an open mind about a patient or their family’s preferences, as it may be outside of your personal or family preference. Be proud of what you do, and make sure you treat people in a way that would make you and your family proud.

  10. When in doubt, err on the side of the patient
    Original: When in doubt, err on the side of the patient
    Comment: This hasn’t changed, but in an increasingly complex medical world with increased recognition of health disparities, always advocate for your patient. Sometimes as an ED provider you may be the only person doing so.

Editor’s note: Prior to clinical retirement, Dr. Slovis used to pound into our brains, “Err in a way the patient suffers the least,” which is a modification of the tenth commandment. I still think about this on many ED shifts. This simple statement can be remarkably clarifying. ~Clay

Evans CS, Slovis C. Revisiting the Ten Commandments of Emergency Medicine: A Resident’s Perspective. Ann Emerg Med. 2021 Mar;77(3):367-370. doi: 10.1016/j.annemergmed.2020.10.013.

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