Sedation

Just curious if you have a preference for moderate / conscious sedation medications, and if you would share some experiences (good and bad) in the comments section about what has worked and what has not worked for you in the past.

The impression I get is that everyone loves ketamine for pediatric patients, and most people administer propofol for adult patients. Is this your practice? Do you use a one drug fits all approach for every patient, or does it depend on the procedure?

Have any of you had experience with alfentanil, remifentanil or Dexmedetomidine ? Was it good? bad?

Do you always give opiate medications prior to the actual sedation?

What are some of the reactions your patients have had to different sedation agents?

This is pure opinion, I think it will be nice to see what the rest of our colleagues are preferentially using in the ED for conscious sedation.  The greatest benefit would be from comments, but if you are too lazy, at least vote in the poll!

HEART Score – yes, AGAIN! going to keep mentioning it until everyone uses it!

The HEART score is a risk stratification score for identifying the risk of a Major Adverse Coronary Event (MACE) within 6 weeks of presentation that has been validated for the ED population.  (MACE defined as: All Cause Mortality, Myocardial Infarction, or Coronary revascularization).  All those framingham risk factors that we are forced to memorize and that cardiologists always ask about?  They mean almost nothing for ED patients.  Wonderful for the patients who go to their PCP’s on a regular basis, but in terms of people who present to the ED, using risk factors as the sole predictor of badness is probably worse than just flipping a coin.

Well, about about TIMI score?  Isn’t that validated?  YES, it is validated, but doesn’t perform nearly as well for ED patients as the HEART score.  Also, TIMI was derived for  “patients admitted and anticoagulated for concerning chest pain in the setting of ECG changes, known coronary artery disease, or positive biomarkers. The original predictive value of the TIMI Score was intended to prognosticate 14-day mortality or new cardiac ischemia for cardiac inpatients.” (ACEP Now).  I’m pretty sure all of us can stratify patients as moderate to high risk if they are already admitted and on anticoagulation.

Backus et. al compared the c-statistic of the HEART Score, GRACE Score, and TIMI for ED patients.  A c-statistic is used to predict the probability that an outcome is greater than chance.  Values are from 0.5 – 1.0, with a value of 0.5 meaning it is no better than chance. 0.7 is considered a reasonable score and 0.8 is considered strong.

GRACE: 0.70

TIMI: 0.75

HEART: 0.83

So basically GRACE is okay, but so complex to use and so many variables that it’s nearly impractical to use.  TIMI was derived initially for patients with known ACS, but has been found to be acceptable to use for ED patients.

But the HEART score was created specifically to be used for ED patients, AND it outperforms the other scores.

There is also the EDACS (Emergency Department Assessment of Chest Pain Score) that may outperform the HEART score, but I personally find it to have too many variables.  Not nearly as many as GRACE, but still a lot.  Click Here if you want to play around with it.

If you have not memorized the HEART score, This link can help you out.

I have also added a smart phrase in epic (.HEARTSCORE) for everyones convenience.  Please let me know if it does not work for you.

Please vote in the poll and please share your thoughts in the comment section.

Thank you!

Some links:

http://www.emlitofnote.com/2013/12/time-to-move-to-heart-score.html

http://rebelem.com/heart-score-new-ed-chest-pain-risk-stratification-score/

Backus, B E, A J Six, J C Kelder, M A R Bosschaert, E G Mast, A Mosterd, R F Veldkamp, et al. 2013. A prospective validation of the HEART score for chest pain patients at the emergency department. International journal of cardiology, no. 3 (March 7). doi:10.1016/j.ijcard.2013.01.255.http://www.ncbi.nlm.nih.gov/pubmed/23465250.

http://mchp-appserv.cpe.umanitoba.ca/viewDefinition.php?definitionID=104234 (if for some reason you want to learn more about what a c-statistic is)

 

Atrial Fibrillation

Atrial fibrillation is one of the most common arrhythmias we encounter.  However, there is no universally accepted approach for ED management of recent onset atrial fibrillation.  There is a protocol called the “Ottawa Aggressive Protocol” for rapid discharge of ED patients with rapid onset atrial flutter or atrial fibrillation.  (http://emed.wustl.edu/Portals/2/Answer%20Key%20PDF/2012/April2012/SecondYear.pdf)

In short the protocol states it is safe to cardiovert patients with recent onset A-fib or a-flutter (<48 hours) with either a 1 gram infusion of procainamide over an hour, and / or synchronized cardioversion.  In the initial study, the protocol was an infusion of procainamide.  For the individuals that failed chemical conversion, a dose of 150-200 J of synchronized cardioversion under procedural sedation was utilized.  The success rate of procainamide alone was 58.3%, and overall with subsequent cardioversion was 91.7%.  

There was an adverse even reported in 7.6% of patients, with the most common event being hypotension.  No strokes or deaths were reported.

Rob Orman, of the ERCast Podcast, has a nice post about the safety of cardioversion in the ED, along with an excerpt from his podcast, with the relevant material starting at about 1:45 in to the audio.  Here is the link http://blog.ercast.org/2012/10/should-we-cardiovert-atrial-fibrillation-in-the-ed/

If you want more links advocating this policy:

Dr. David Vinson, from “Physician’s Weekly,” replicated similar results in a smaller study.  http://www.physiciansweekly.com/recent-onset-atrial-fibrillation-management/

And here is something from ACEP, although it is a bit older, from 2009: http://www.acep.org/Clinical—Practice-Management/Aggressive-Ottawa-Protocol-for-A-Fib-Succeeded-in-ED/

What do you all think?  Have you utilized this approach before?  What is your approach to the recent onset atrial fibrillation patient?  Please discuss.

Migraine treatment with….propofol?

http://academiclifeinem.com/on-the-horizon-propofol-for-migraines/                              Image

The link above shows a summary of a few studies showing some effectiveness for propofol in treatment of migraines..

An interesting idea, with apparently a decent amount of evidence behind it.  I’ve always been curious about trying it with some of our chronic migraine patients, but I have not used it.  Has anyone had any experience with this?

Also, I’m curious whether people have a certain “migraine cocktail” they prefer using.  Please post in the comments section.

Also don’t forget to vote in the poll!

What patients should receive oseltamivir (tamiflu)?

I’m pretty sure there are varying opinions on this topic.  Do you prescribe it for everyone who just has symptoms?  Do you only give it those who present within 48 hours, as the indication states?  Do you only give it to those patients who test positive?  below is a quick read about on ED physician’s opinion.

http://www.epmonthly.com/departments/columns/in-my-opinion/tamiflu-a-drug-looking-for-an-indication/

please click on the “reply” button to share your thoughts!

Don’t forget to vote in the poll below!

Should beta blockade be part of the ED protocol for patients with Acute Coronary Syndrome?

I’m pretty sure everyone agrees beta blockade has significant benefit on patients with heart disease.  However, when is the best time to give the beta blocker?  Within the first hour?  24 hours?  Month?  Should beta blockade be given intravenously?  or orally?

UpToDate’s summary recommends: “For all patients with acute MI, we recommend initiation of oral beta blockers within the first 24 hours, as long as no contraindications are present. (Grade 1B). ”

The 2013 ACCF/AHA STEMI Management Guidelines give a Class 1 recommendation to starting oral beta blockers within 24 hours of presentation, but a class 2a recommendation to give IV beta blockade at time of presentation to those “who are hypertensive and have ongoing ischemia.”  (https://circ.ahajournals.org/content/127/4/e362.full)

Please post your thoughts below by clicking on the “reply” button.

Link

http://media.blubrry.com/emcrit/p/traffic.libsyn.com/emcrit/EMCrit-Podcast-20140127-116-tPA-Cage-Match.mp4

 

Dr. Andy Jagoda and Dr. Swaminathan debate the pros and cons of tPA for acute stroke.  Please vote in the poll below

tpa pro and con debate from EMcrit website