Modified Sgarbossa Criteria: Part Deux

11 Jan
January 11, 2016

Modified Sgarbossa CriteriaBackground: Left Bundle Branch Block (LBBB) on the ECG makes accurate recognition of ST-Elevation Myocardial Infarction (STEMI) rather difficult. The 1996 and 2004 American College of Cardiology/American Heart Association (ACC/AHA) STEMI guidelines recommended immediate reperfusion therapy for patients with potentially ischemic symptoms and new, or presumed new, LBBB. In 2013, this recommendation was removed from the guidelines. Historically, reperfusion decisions in LBBB have been determined by the original Sgarbossa criteria published in 1996, but there are three key limitations to the original study by Sgarbossa et al:

  1. The original Sgarbossa criteria (i.e. the “weighted” Sgarbossa criteria) depends on a point system that rely on 3 findings, only 2 of which would provide enough points (i.e. 3) to make the diagnosis of AMI. Using the Sgarbossa criteria without the point system (i.e. the “unweighted” Sgarbossa criteria) increases sensitivity but decreases specificity.
  2. Sgarbossa et al diagnosed AMI by creatine kinase MB (CK-MB) elevations instead of angiographic evidence of acute coronary occlusion (ACO), which limits the sensitivity of the rule because it combines NSTEMI and STEMI patients in the outcome definition
  3. Finally, Sgarbossa et al used an absolute criterion (5mm) rather than a proportional criterion for excessively discordant ST elevation lowering the sensitivity of the criteria.

The modified Sgarbossa criteria replaces the absolute 5mm discordant ST elevation with a proportion (ST elevation/S-wave amplitude ≤ -0.25). In other words, the modified Sgarbossa criteria only changes the last of the original Sgarbossa criteria with the first two criteria staying intact. Now, if any of these criteria are met, the cardiac catheterization lab should be activated. We have written on REBEL EM before about the modified Sgarbossa criteria and one of our conclusions was this rule looked very promising, but needed an external validation study. Well that study is now here and for full disclosure I am one of the authors on the paper. Read more →

Does a Normal Head CT Within 6 Hours of Onset of Headache Rule Out SAH?

07 Jan
January 7, 2016

SAHBackground: The traditional standard workup for ruling out subarachnoid hemorrhage (SAH) has been a non-contrast head CT and, if negative, a lumbar puncture. The thought behind this is that the sensitivity of head CT to rule out SAH is not 100% and declines over time and missing a SAH is potentially devastating. There has been a series of studies published in the past few years looking at the value of a negative head CT scan performed within 6 hours of headache onset in ruling out SAH. I have heard many say that if they have a negative Head CT at 6 hours or less in a neurologically intact patient they would not perform a lumbar puncture. Read more →

The Role of TEE in Cardiac Arrest

04 Jan
January 4, 2016

TEEBackground: Sudden cardiac arrest has very poor outcomes; less than 11% of patients in cardiac arrest in the Emergency Department survive to discharge from the hospital. The management of cardiac arrest is algorithmic because providers have limited tools at their disposal and limited knowledge of the patient’s past medical history. EKG is limited in its evaluation of cardiac function. Pulses are often difficult to palpate. The blood pressure cuff is often unreliable. As a result, there is a sense of futility when running resuscitations.

Transthoracic echocardiography (TTE) in the Emergency Department gave providers another tool to help guide management through direct visualization of cardiac activity, tamponade physiology, right heart strain, etc . It also offers prognostic value if there is no cardiac activity upon arrival to the Emergency Department on TTE, there is a near 0% chance of survival. However, TTE has its limitations: obesity, emphysema, poor windows, interrupts compressions, gel gets everywhere.

Transesophageal echocardiography (TEE) provides significant benefits when compared to TTE in the management of cardiac arrest in the emergency department. Read more →

Reflections on the Closing of a Hospital

17 Dec
December 17, 2015

ReflectionsI know, I know. We here at REBEL EM are normally very clinically oriented. We take recent articles or hot topics and give you the breakdown and clinical take home points. But a recent event happened that made me look at my own practice, and now on the other side, I feel that I am a better doctor. The hospital I was working at as medical director of the Emergency Department (ED) closed its doors. This was a hospital that had been in the community for more than 60 years. I won’t go into the reasons for closure, but rather, I would like to tell the story from the side of the ED provider and what I had to change until the lights were turned out. Read more →

Should We Give Fingertip Amputations with Exposed Bone Prophylactic Antibiotics?

14 Dec
December 14, 2015

FingertipBackground: Fingertip amputations are not an uncommon injury seen in the emergency department. Treatment options range from healing by secondary intention to flap coverage or replantation. Selection of the appropriate treatment modality depends on the nature of the injury, the physical demands of the patient, and the patient’s co-morbidities. Prophylactic antibiotic use in patients with fingertip amputations is controversial. The routine use of prophylactic antibiotics is universally recommended on grossly contaminated wounds, in immunocompromised patients, and in injuries with extensively destroyed/devitalized tissue as it is thought the infection risk is high in these circumstances. However, many reflexively prescribe antibiotics prophylactically in all distal tip amputations. Moreover, there is often an underlying tuft fracture and we reflexively give these patients antibiotics because we were all taught that any open fractures require antibiotics in addition to usual fracture care. Prior studies on distal fingertip amputations and the use of prophylactic antibiotics suggest no change in infection risk with the routine use of antibiotics but these studies were small and have done little to inspire an antibiotic-restrictive approach universally. Read more →

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