April 30, 2015

There are approximately 8 to 10 million patients complaining of chest pain coming to Emergency Departments (EDs) in the United States annually. In the US, we use a very liberal testing strategy in order to avoid acute coronary syndrome (ACS) in patients presenting with chest pain. This results in over 50% of ED patients with acute chest pain receiving serial cardiac biomarkers, stress testing, and cardiac angiography at an estimated cost of $10 to $13 billion annually and yet fewer than 10% of these patients are diagnosed with ACS. Despite these numbers the American College of Cardiology/American Heart Association (ACC/AHA) recommends that low-risk chest pain patients receive serial cardiac markers followed by some sort of provocative/objective cardiac testing. Using this strategy amongst low-risk chest pain patients unnecessarily uses resources on those least likely to benefit. Low-risk chest pain patients have ACS rates of <2% and provocative/objective cardiac testing is associated with a significant amount of “downstream” testing (i.e. cardiac catheterization) due to false positive tests. To date, the HEART score has been examined in >6000 patients and demonstrated a high NPV for MACE at 6 weeks exceeding 98%, but until now there has been no randomized trial.

April 20, 2015

Welcome back to a special edition, or should I say "skeptical edition" of REBELCast. We have started to do something new by inviting guests onto the show to discuss papers in the literature they find interesting.  This month I had the pleasure of working with Ken Milne, an emergency room physician in Canada. Today, Ken and I are going to specifically discuss a new device that recently got FDA approval for CPR in Out of Hospital Cardiac Arrest (OHCA), and the question we are trying to answer is: Is active Compression Decompression CPR with Augmentation of Negative Intrathoracic Pressure for Treatment of Out-of-Hospital Cardiac Arrest superior to standard CPR?

April 16, 2015

There are approximately 8 to 10 million patients coming to Emergency Departments (EDs) in the United States annually. In the US, we use a very liberal testing strategy in order to avoid acute coronary syndrome (ACS) in patients presenting with chest pain. This results in over 50% of ED patients with acute chest pain receiving serial cardiac biomarkers, stress testing, and cardiac angiography at an estimated cost of $10 to $13 billion annually and yet fewer than 10% of these patients are diagnosed with ACS. The 2-hour accelerated diagnostic protocol (ADAPT) combines  0 and 2 hour cardiac troponin (cTn), electrocardiograms (ECGs), and an adapted Thrombolysis in Myocardial Infarction (TIMI) score to help identify ED patients safe for early discharge. Previous studies show that this strategy can identify as many as 20% of patients for early discharge with a high sensitivity of 97.9% to 99.7% for major adverse cardiac events (MACE) at 30 days. This ADP has yet to be tested in a US population until now.

April 6, 2015

Welcome to the REBEL Cast Episode 7, where Swami, Matt, and I are going to tackle a couple of articles just published this year. Today we are going to specifically tackle:
  • Topic #1: Basic Life Support (BLS) vs Advanced Cardiac Life Support (ACLS) in Out of Hospital Cardiac Arrest (OHCA)
  • Topic #2: PROMISE Trial - Anatomic vs Functional Testing for Coronary Artery Disease (CAD)

March 17, 2015

Since 2002, the surviving sepsis campaign (SSC) has stated that best practice in sepsis care includes: early recognition, source control, appropriate/timely antibiotic therapy, resuscitation with intravenous fluids (IVF) and vasoactive medications. Resuscitation of the septic patient in the emergency department has been largely based off the 2001 Rivers trial [1]. This single center study's focus was to optimize tissue oxygen delivery following several parameters including, central venous pressure (CVP), mean arterial pressure (MAP), and central venous oxygen saturation (SCVO2) to guide IVF, vasoactive medications, and packed red blood cell (PRBC) transfusions. Well today, part 3 of the sepsis trilogy was published in the saga of Early Goal Directed Therapy (EGDT) versus "usual" care. The 3 parts to this saga consist of:
  1. Protocolized Care for Early Septic Shock (ProCESS) [2] - 31 Emergency Departments in the United States
  2. Australasian Resuscitation in Sepsis Evaluation (ARISE) [3] - 51 Emergency Departments in Australia, New Zealand, Finland, Hong Kong, and Ireland
  3. The Protocolised Management in Sepsis (ProMISe) Trial [4] - 56 Emergency Departments in the United Kingdom
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