SCOT-HEART: CCTA Decreases Long-Term Risk of MI and Death?

22 Oct
October 22, 2018

Background: CT coronary angiography (CTCA) is a relatively new technology that has gained popularity over the past few years in evaluating patients presenting with chest pain. CTCA is an anatomic test that has been shown to increase downstream testing and increase healthcare costs but its impact on patient-oriented benefit has been questioned. Early concerns of CTCA including poor image quality in the obese and high levels of radiation exposure have been mitigated by improved technology.

Another trial, called PROMISE, also evaluated anatomic CCTA vs functional stress testing in greater than 10,000 patients with symptomatic chest pain with suspected CAD.  In this study an initial strategy of CCTA was not associated with better clinical outcomes compared to functional testing over a median follow-up period of two years, and it was also associated with higher radiation exposure and downstream testing.

In this post we will cover the original SCOT-HEART trial published in 2015 [1] and the 5 year follow up of the original SCOT-HEART trial [2]. Read more →

Clinical Pearls from ACEP 2018 – San Diego, CA

18 Oct
October 18, 2018

This year ACEP 2018 took place in San Diego, CA from Oct 1st– 4th, 2018.  There were lots of amazing speakers and topics as was evidenced by the eruption of everyone’s twitter feeds with the #ACEP18 hashtag.  I was fortunate enough to not only attend, but also speak at this amazing conference.  I was approached by several attendees requesting that I put together a list of my favorite pearls from this conference, as I have done in years past on REBEL EM.  Below is my top 10 list, in no particular order. Read more →

Approach to the Critically Ill Child: Shock

15 Oct
October 15, 2018

If you mainly treat adults or both adults and children like me, then you have probably heard the (very annoying) quote, “kids are not just small adults”, and so I won’t say it again. Well, I guess I just did, but at least I wont stop at this quote, but attempt to explain how kids are not small adults, and how this may impact their care in the emergency department and the intensive care unit.

Nearly all organ systems of young children are immature and developing throughout childhood and on into adulthood, including the cardiovascular system. Without a basic understanding of the key physiologic differences, the emergency and intensive care physicians will be ill equipped to care for the critical ill child.

To understand how kids with shock present differently than adults, it’s important to discuss a few basic differences regarding intravascular volume and cardiovascular system in children especially neonates and infants (1-24 months of age). Also remember shock is defined the exact same way as it would be in adults even though the presentation and underlying physiology may differ. Shock is simply a state where tissue/organ blood flow is inadequate to meet tissue/organ metabolic demands. Read more →

Coronary Computed Tomography Angiography (CCTA): The Holy Grail of “Low Risk” Chest Pain Evaluation?

11 Oct
October 11, 2018

Background: CCTA has become a popular modality in the ED setting to assess anatomic atherosclerotic disease in patients presenting with chest pain.  Advocates of CCTA feel that CCTA has a greater accuracy in identifying obstructive coronary artery disease and identification of high-risk disease compared to standard physiologic testing.  However, many published trials on CCTA were not adequately powered to evaluate patient oriented end points.  The aim of the current published study was to perform a systematic review and meta-analysis comparing CCTA with other standard of care (SOC) approaches in evaluation of patients with acute chest pain. Read more →

Accidental Hypothermia

08 Oct
October 8, 2018

Definition:

  • Accidental hypothermia is an unintentional core body temperature of < 35°C when heat loss to surroundings is greater than heat generation
  • Most frequent cause is environmental exposure
  • Patient with impaired thermoregulation can develop hypothermia in relatively warm environments
    • Elderly, underlying illness, trauma, intoxication, or malnutrition (Brown 2012)

Read more →