tPA for stroke debate at IAEM 2014

The 2014 meeting of IAEM was a great experience. For a country of 4.5 million with just over 70 emergency physicians we put on a pretty good show I think. I like to use “we” even though I had no part to play in organising the damn thing. Credit to David Menzies for leading the work.

There was almost a mini SMACC reunion with Rick Body, Mark Wilson, Weingart and John Hinds all in attendance and speaking. Through the premiere of Code Black I also managed to have dinner with Billy Mallon which was everything you would expect it to be.

I also got the chance to do my first stroke thrombolysis debate. I got into all this about 3 or 4 years ago when I first started listening to the abstracts and heard Jerry Hoffman on it. It was the first real topic to get me really excited about critical appraisal and reading the medical literature. If it turns out us skeptics are all wrong on tPA then at least I’ve gained a few skills along the way.

Below is my half of the debate. The pro side was delivered by a local stroke physician and I have to confess that I lost the debate. I must be doing something wrong if the emergency doc can lose a debate on stroke thrombolysis to a room of other emergency docs…

As with most short debates like this, it isn’t a deep and considered view of all the evidence, it’s as much about making the argument as anything else. Any feedback is of course welcomed. I’ve tried to include a reasonably comprehensive list of references at the bottom.

It’s probably worth noting that I work in a hospital that has a very enthusiastic stroke thrombolysis team (which as part of my job I have a small role in activating) and to give credit where it’s due they provide a great service with the quickest and best assessment in the ED you can imagine. It’s very rare in Ireland to get a consultant to the patient’s bedside within minutes of arrival but our stroke team does this well. We would do well to provide close to such a service for our trauma patients but that’s another story altogether…

 

References:

The BMJ Pro Con Debate

The Ioannidis Paper

  • Ioannidis JPA. Why Most Published Research Findings Are False. PLoS Med. Public Library of Science; 2005;2(8):e124. [full text]

A decade of reversal

  • Prasad V, Vandross A, Toomey C, Cheung M, Rho J, Quinn S, et al. A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices. Mayo Clinic Proceedings. Elsevier; 2013 Aug;88(8):790–8. [Full Text]

The Lenzer paper on the problems with guidelines

Roger Shinton’s letter to the Lancet

Simon Thompson’s paper on heterogeneity in meta-analysis [H/T Dave Newman for this one]

  • Thompson SG. Why sources of heterogeneity in meta-analysis should be investigated. BMJ (Clinical research ed). 1994 Nov 19;309(6965):1351–5. [Full Text]

The systematic review mentioned

  • Wardlaw JM, Murray V, Berge E, del Zoppo G, Sandercock P, Lindley RL, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis. Lancet. 2012 Jun 23;379(9834):2364–72. [Full Text]

Jeff Mann’s break down of the NINDS patients revealing the baseline imbalance

  • Mann J. Efficacy of Tissue Plasminogen Activator (Tpa) for Stroke: Truths about the NINDS study: setting the record straight. Western Journal of Medicine. 2002;176(3):192. [Full Text]

The RCTs

  • Intravenous desmoteplase in patients with acute ischaemic stroke selected by MRI perfusion-diffusion weighted imaging or perfusion CT (DIAS-2): a prospective, randomised, double-blind, placebo-controlled study. Lancet Neurology 2009 Feb.;8(2):141–150. PMCID 2730486
  • Effects of alteplase beyond 3 h after stroke in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET): a placebo-controlled randomised trial. Lancet Neurology 2008 Apr.;7(4):299–309.PMID 18296121
  • Randomised controlled trial of streptokinase, aspirin, and combination of both in treatment of acute ischaemic stroke. Multicentre Acute Stroke Trial–Italy (MAST-I) Group. The Lancet 1995 Dec.;346(8989):1509 -1514. PMID: 7491044 
  • Thrombolytic therapy with streptokinase in acute ischemic stroke. The Multicenter Acute Stroke Trial–Europe Study Group (MAST-E). N Engl J Med 1996 Jul.;335(3):145–150. PMID: 8657211
  • Streptokinase for acute ischemic stroke with relationship to time of administration: Australian Streptokinase (ASK) Trial Study Group. JAMA 1996 Sep.;276(12):961–966. PMID: 8805730
  • Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS (B) Study: a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. JAMA 1999 Dec.;282(21):2019–2026. PMID: 10591384 
  • The rtPA (alteplase) 0- to 6-hour acute stroke trial, part A (A0276g) : results of a double-blind, placebo-controlled, multicenter study. Thromblytic therapy in acute ischemic stroke study investigators.(ATLANTIS A) Stroke 2000 Apr.;31(4):811–816.  PMID 10753980
  • Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (NINDS). N Engl J Med 1995 Dec.;333(24):1581–1587. PMID: 7477192
  • Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA 1995 Oct.;274(13):1017–1025.1. PMID: 7563451 
  • Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. The Lancet 1998 Oct.;352(9136):1245–1251. PMID: 9788453 
  • Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke (ECASS III). N Engl J Med 2008 Sep.;359(13):1317–1329. PMID: 18815396 
  • The IST-3 collaborative group. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet. 2012 May 23.PMID: 22632908

 

A few #FOAMed resources

Anatomy for Emergency Medicine 028: Fascia Iliaca Block

Hi Guys, sorry for the big gap in posting.

Life has a way of taking over as you all know.

Direct Download

iTunes subscription

AFEM RSS feed

I’m currently trying to introduce fascia iliaca blocks as part of routine care for patients in our department so i thought a podcast on some of the anatomy wouldn’t go a miss. If you want some light reading on the literature, then I’ve included a big list below.

If you’re more practically orientated then I’d strongly recommend the following:

Ultrasound Podcast: Fem Nv Block

NYSORA: Fascia Iliaca Block.

 

References:

Gray’s Anatomy 41st Edition

1.Godoy Monzón D, Vazquez J, Jauregui JR, Iserson KV. Pain treatment in post-traumatic hip fracture in the elderly: regional block vs. systemic non-steroidal analgesics. Int J Emerg Med. 2010;3(4):321–5.

2.Mouzopoulos G, Vasiliadis G, Lasanianos N, Nikolaras G, Morakis E, Kaminaris M. Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study. J Orthopaed Traumatol. 2009 Aug 19;10(3):127–33.

3.Høgh A, Dremstrup L, Jensen SS, Lindholt J. Fascia iliaca compartment block performed by junior registrars as a supplement to pre-operative analgesia for patients with hip fracture. Strat Traum Limb Recon. 2008 Sep 2;3(2):65–70.

4.Godoy Monzón D, Iserson KV, Vazquez JA. Single fascia iliaca compartment block for post-hip fracture pain relief. JEM. 2007 Apr;32(3):257–62.

5.NZ Guidelines Group. Acute Management and Immediate Rehabilitation After Hip Fracture Amongst People Aged 65 Years and Over. 2003;:1–40.

6.National Clinical Guideline Centre. The management of hip fracture in adults. 2011;:1–664.

7.SIGN SIGN. Management of hip fracture in older people. 2009 Jun;:1–56.

8.(null) INHFDSG. Irish Hip Fracture Database Preliminary Report 2013. 2014 Mar 4;:1–50.

9.(null) TCOEM. Clinical Standards for Emergency Departments. 2013;:1–16.

10.Beaudoin FL, Haran JP, Liebmann O. A Comparison of Ultrasound-guided Three-in-one Femoral Nerve Block Versus Parenteral Opioids Alone for Analgesia in Emergency Department Patients With Hip Fractures: A Randomized Controlled Trial. Academic Emergency Medicine. 2013 Jun 12;20(6):584–91.

11.Elkhodair S, Mortazavi J, Chester A, Pereira M. Single fascia iliaca compartment block for pain relief in patients with fractured neck of femur in the emergency department: a pilot study. Eur J Emerg Med. 2011 Dec;18(6):340–3.

12.Williams R, Saha B. Best evidence topic report. Ultrasound placement of needle in three-in-one nerve block. Emergency Medicine Journal. 2006 May;23(5):401–3.

13.Christos SC, Chiampas G, Offman R, Rifenburg R. Ultrasound-guided three-in-one nerve block for femur fractures. West J Emerg Med. 2010 Sep;11(4):310–3.

14.Fletcher AK, Rigby AS, Heyes FLP. Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: a randomized, controlled trial. Ann Emerg Med. 2003 Feb 1;41(2):227–33.

15.Beaudoin FL, Nagdev A, Merchant RC, Becker BM. Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures. Am J Emerg Med. 2010 Jan;28(1):76–81.

16.Haines L, Dickman E, Ayvazyan S, Pearl M, Wu S, Rosenblum D, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. JEM. 2012 Oct;43(4):692–7.

17.Rashid A, Beswick E, Galitzine S, Fitton L. Regional analgesia in the emergency department for hip fractures: survey of current UK practice and its impact on services in a teaching hospital. Emergency Medicine Journal. 2013 Jul 22.

18.Abou-Setta AM, Beaupre LA, Rashiq S, Dryden DM, Hamm MP, Sadowski CA, et al. Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Ann Intern Med. 2011 Aug 16;155(4):234–45.

19.Parker MJ, Griffiths R, Appadu BN. Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures. Cochrane Database Syst Rev. Wiley Online Library; 2002;1.

20.Foss NB, Kristensen BB, Bundgaard M, Bak M, Heiring C, Virkelyst C, et al. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anesthesiology. 2007 Apr;106(4):773–8.

Work as an Emergency Department registrar in Dublin

MMUH resus

Are you an emigrated Irish doc in training in Oz or NZ and fancy coming home for 6 months as part of your training? Are you a kiwi or Aussie and fancy some time in Europe as part of your training?* Then these might be the jobs for you. These aren’t just the standard queue busting, service provision jobs but an opportunity to gain some new skills. If you’re working in Ireland and fancy a career development opportunity in one of the big Dublin hospitals then read on. 

[* the Mater is accredited for training in Ireland through the college of emergency medicine which is the specialist college for emergency medicine in the UK and Ireland. From communication with the Australasian College in Emergency Medicine (ACEM) we have been told that any trainee wishing to undertake training overseas and have that time accredited toward their ACEM training should apply to the college prior to beginning the post and obtain prior approval to have the training added toward their ACEM training.so as far as we know it should be approved for training by ACEM too]

MMUH CT

The Mater Misericordiae University Hospital (The Mater) in north Dublin is one of the main tertiary centres in the country. It has the national spinal injuries centre and all major specialities apart from neurosurgery and as far as I’m aware it’s the only place doing ECMO in the country. The hospital recently moved to brand new facilities including  a new Emergency Dept, theatres and ICU.

The ED encompasses a large ‘acute floor’ model with acute medicine working out of the same department.  There is a 5 bed resus with CT scanning within the resus bay. There is a dedicated ED ultrasound machine.

The hospital serves one of the more deprived areas of Dublin with the obvious result that it sees a fascinating range of pathology from stab wounds, pedestrian trauma to complications of alcohol and  intravenous drug use and all the interesting infectious disease complications that come with it. One of the emergency medicine trainees is a lead for an international HIV screening project in the department.

The ED has created several new posts at registrar level to attract new staff and facilitate career development. All posts have protected non clinical time to pursue the appropriate sub specialty. Clinical work will be on the registrar rota in the ED.

Descriptions from the job adverts below

EM/Imaging post
Clinical Fellow (Registrar level) in Emergency Medicine/Emergency Imaging – 2 positions available – These posts are designed to provide the successful candidate with specialised training in emergency medicine and imaging in one of the busiest emergency floors (including a dedicated emergency imaging department) in the country. Fellows will be exposed to all aspects of emergency care (adult) and a broad spectrum of emergency imaging, and will co-ordinate monthly Emergency Medicine/Radiology teachng meetings. Depending on the existing level of ultrasound experience, Fellows will be expected to achieve Level 1 competency in Emergency Ultrasound (ultrasound experience preferred but not necessary) or gain competency in at least 3 of 10 level 2 modalities (for a candidate already signed of at level 1). There will also be teaching and scope for education and research in all aspects of emergency imaging including CT/plain films/nuclear medicine and MRI. Successful candidates will be allocated protected weekly training time in the relevant imaging areas including ICU, ECHO, Vascular and Diagnostic imaging departments (approx. 30% of WTE). The remainder of the clinical commitment is to the emergency floor. [Worth noting that the Mater has a fellowship trained emergency radiologist who you will be working with - Ed]

EM Education post
Emergency Medicine Education Fellow (Registrar level) 1 position available a unique opportunity to engage in a quality improvement program (in keeping with new developments in career progression in Emergency Medicine) in the Mater Hospital involving protected time per week developing departmental teaching including the online SHO induction/education website, online guidelines for the department and the hospital, in addition to a clinical registrar commitment. (Approx 30% WTE in educational training).

Trauma clinical fellow
Clinical Fellow (Registrar level) in Emergency Trauma – 1 position available – the successful candidate will have protected weekly teaching in trauma/plastic surgery clinics and will have responsibility for co-ordinating trauma team organisation, audit and research, with opportunities for training in emergency trauma and musculoskeletal radiology in addition to a clinical registrar commitment (Approx. 30% WTE dedicated to Trauma training).

EM/ICM post
Emergency Medicine/Critical  Care Registrar comprising 9 months Registrar in Emergency Department plus 3 months in ICU, involving collaboration with Critical Care department for joint educational meetings and protocol guideline development offering opportunities for inter/intradepartmental quality improvement programs in keeping with new developments in career progression in Emergency Medicine.

Salaries are on the registrar scale which can be found in the appendix of this document.

Interested?
Feel free to send me an email at emergencymedicineireland (@) gmail.com and I can write or Skype you with more info. If you’re at SMACC then I’d love to chat to you about it there.

Conflicts of interest
I work in the Mater and really quite enjoy it and it’d be lovely to have some more FOAMites to work with ;-) However my opinions are my own and do not necessarily represent that of the hospital.

MMUH Majors

Tasty Morsels of EM 034 – HIV Emergencies

I keep a little, ever-expanding note on my phone where I jot down little morsels of goodness that I pick up while listening to or reading one of the many excellent sites/podcasts in the useful resource section. They’re useful in a kind of “board review” way. I tend to skip the really basic stuff and try and focus on what I didn’t know.

I’ll try and transfer them here for your enlightenment.

From the AFJEM series on HIV emergencies. Well worth a read [Free Full Text]:

  • Acute HIV usually within 3 weeks. No antibodies as yet therefore antibody tests will be negative. Viral loads however will be very high for the same reason

  • Recurrent severe bacterial pneumonia (>2 in 12 mths) is a who stage four diagnosis (what you could call AIDS defining)

  • TB may present as lobar pneumonia esp in lower lobes

  • LDH greater than 500 supports diagnosis of PCP

  • Commonest HIV associated neurological conditions

    • Cryptococcal meningitis

    • Toxoplasmosis

    • TB

    • Lymphoma

  • In cryptococcal meningitis the opening pressure is usually raised. A key treatment goal is reduction of that pressure by CSF drainage

  • People with HIV have four times risk of DVT. Reason unclear.

  • The major AIDS defining malignancies are all virally mediated

  • Acute red eye means two things

    • CMV retinitis

    • Zoster Ophthalmicus

  • Diarrhoea is common and may be acute infection, HAART related or due to HIV itself

  • HIV medications are complex with a bewildering range of them with unpronounceable names and a cornucopia of side effects. The good news is they work

  • IRIS = immune reconstitution inflammatory syndrome

    • Following initiation of HAART CD4 improves and viral loads fall

    • Paradoxically there can be a worsening of condition typically manifested by an opportunistic infection

References:

Chandra, Amit, Jacqueline Firth, Abid Sheikh, and Premal Patel. “Emergencies Related to HIV Infection and Treatment (Part 1)” African Journal of Emergency Medicine 3, no. 3 (September 1, 2013): 142–149. doi:10.1016/j.afjem.2013.03.005. [Free Full Text]

Chandra, Amit, Jacqueline Firth, Abid Sheikh, and Premal Patel. “Emergencies Related to HIV Infection and Treatment (Part 2)” African Journal of Emergency Medicine (May 30, 2013): 1–6. doi:10.1016/j.afjem.2013.04.001. [Free Full Text]

 

Anatomy for Emergency Medicine 027: Basic Anatomy of Abdomen and Pelvic Trauma

This is the second part of a recent lecture I gave to some first year med students to get across how important their anatomy is to understanding trauma.

First part lives here

You may have to click through to the GMEP site to see the full HD version

PDF of slides