Evidence based Emergency Medicine
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Evidence based Emergency Medicine. Dr Jaycen Cruickshank Director of Emergency Medicine, Ballarat Health Services Senior Lecturer, Rural Clinical School, University of Melbourne. Introduction. Evidenced based Emergency Medicine is using validated clinical decision rules. - PowerPoint PPT Presentation
Transcript of Evidence based Emergency Medicine
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*[email protected]*Evidence based Emergency MedicineDr Jaycen CruickshankDirector of Emergency Medicine, Ballarat Health ServicesSenior Lecturer, Rural Clinical School, University of Melbourne
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*[email protected]*Introduction Evidenced based Emergency Medicine is using validated clinical decision rules.The audience will learn in this sessionWhat evidence is available and easy to useHow to find the evidenceEvidence from the patients point of viewPatient fact sheetsThere is too much to remember - students are now taught how to find it.
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*[email protected]*Overview Big picture - these mostly ignoredExplain how all the individual topics fit togetherX-ray?Admit?IV or oral?CT?PittsburghSyncopeWhat next?TIMICURB-65PSIWellsOttawaABCD2
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*[email protected]*AgendaTopicsMedical, trauma/injuryResources:www.patient.co.ukwww.betterhealth.vic.gov.auwww.scaphoidfracture.com.auhttp://emedicine.medscape.com/Googlewww.mdcalc.com
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*[email protected]*Clinical Decision RulesTIA - ABCD2PneumoniaPSICURB-65PE - Wells criteriaDVT - Wells criteriaSan francisco syncope ruleOttawa ankle and foot rulesPittsburg knee rulesCanadian neck rules vs Nexus guidelinesNICE guidelinesHead injuryRCH guidelineshttp://www.rch.org.au/clinicalguide/cpg.cfm RWH guidelines
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ABCD2 algorithm identifies risk of stroke after TIAPeople who have had a suspected TIA (that is, they have no neurological symptoms at the time of assessment [within 24 hours]) should be assessed as soon as possible for their risk of subsequent stroke using a validated scoring system, such as ABCD2Score >=4 Admit, aspirin, specialist and imaging early (=140/90 mmHg, 1 point)C - clinical features (unilateral weakness, 2 points; speech disturbance without weakness, 1 point)D - Duration of symptoms >= 60 minutes, 2 points; 10-59 minutes, 1 pointDiabetes (1 point)ABCD2 is calculated based on:total scores range from 0 (low risk) to 7 (high risk).
- General prevention of strokecontrol of risk factors: smoking, lack of exercisehypertension - target blood pressure for patients with a TIA or stroke is
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*[email protected]*CURB-65 (pneumonia)Pneumonia is not a particularly difficult diagnosis to makeAssessment of severity of disease influencesTreatmentAdmit or dischargeOutcomesDo we agree on severity?
- *[email protected]*CURB-65 predicts mortality1 point eachConfusionUrea > 7mmol/LResp rate >20, pCO2
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*[email protected]*Pneumonia Severity Index also called PORT score or CAP riskClass/mortality/Where/What1- 0.1% -home - oral antis2 - 0.3% -home-HITH - oral/IV3- 0.9%- ?? admit/IV antis4 - 9%- admit/IV antis5 - 30%- ICU/IV antis
Details in Victorian Antibiotic guidelinesBHS compliance 27%!CURB -6512345
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*[email protected]*Wells criteria -PERadiologists in Ballarat feel too many CTPAs are done, and feel that there is a lack of appropriate use and understanding of history, exam, and tests - ECG, CXR, D-Dimer They have a case, but sometimes no CT without a D-DimerBig man, 30s, wife, 2 year old, trip to south africa, new diagnoses of calf strain and then asthmaHe died. He should not have died.
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Wells score for Pulmonary Embolism
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What does the score mean?0-1 = 1.3% chance of PENegative d-dimer = rule outPositive d-dimer = PE perhaps 8%2-6 = 16% Negative d-dimer = PE perhaps 8%>6 = 37% Negative d-dimer = PE perhaps 15%Positive d-dimer = PE perhaps 60%We do not know if these % are valid in Grampians Regionhttp://www.mdcalc.com/wellscriteria
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San Francisco syncope ruleCongestive Heart Failure history?Yes +1Hematocrit < 30%? Yes +1ECG Abnormal ? Yes +1Shortness of Breath History? Yes +1Systolic BP < 90 mmHg at Triage?Yes +1Any of these = high risk
How to use this tool?You still look for features on history - e.g micturition, cough, posture, and on examination e.g aortic stenosis to make a diagnosis of serious or harmless cause, then use the tool when you have found nothing serious.If you suspect subarachnoid haemorrhage, then the tool does not help you rule it out.
Note: This rule has a 96% sensitivity and 62% specificity for serious outcome. Negative predictive value: 99.2%; positive predictive value 24.8%.Serious Outcome in this study is defined as "death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, or any condition causing a return ED visit and hospitalization for a related event."
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Characteristics of Patients Who Should Undergo Radiography After Knee TraumaOttawa knee rulesAge >55 yearsTenderness at head of fibulaIsolated tenderness of patellaInability to flex knee to 90 degreesInability to walk four weight-bearing steps immediately after the injury and in the emergency departmenthttp://www.mdcalc.com/mdcalc/wordpress/ottawa-ankle-and-pittsburgh-knee-rules
Pittsburgh decision rulesBlunt trauma or a fall as mechanism of injury plus either of the following:Age < 12 or >50 yearsInability to walk four weight-bearing steps in the emergency department
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Ottawa Ankle and Foot Rules*[email protected]*
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Canadian C-spine rules better than NEXUS to rule out neck injuryhttp://www.aafp.org/afp/20040515/tips/10.htmlCanadian rules better, used in UK guidelines alsoApprox 7500 study with 162 clinically important injuriesCanadian C-spine rule detected 161 of 162 clinically important injuriesNEXUS rule detected 147 of 162 (sensitivity = 99.4 percent versus 90.7 percent). The Canadian C-spine rule more specific than the NEXUS rule (45.1 percent versus 36.8 percent). The Canadian C-spine rule had a higher inter-rater reliability than the NEXUS rule: 0.63 versus 0.47. Physicians were slightly more uncomfortable when applying the Canadian C-spine rule (8.0 percent versus 7.1 percent using the NEXUS rule were uncomfortable or very uncomfortable; P = .03), Fewer patients required radiography based on the use of the Canadian C-spine rule than the NEXUS rule (56 percent versus 67 percent), reducing cost and length of stay in the emergency department.
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The UK NICE guidelines.http://www.nice.org.uk/nicemedia/pdf/CG56QuickRedGuide.pdf
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*[email protected]*SummaryState what has been learnedSome good clinical decision rules exist, to help our clinical judgement.They are easily accessiblePatients can find informationDefine ways to apply trainingFavourites on your computersIpod touch, other hand held device.Patient access to online information.Request feedback of training session
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*[email protected]*Where to Get More InformationOther toolsTIMI score http://www.mdcalc.com/uanstemitimiscoreList books, articles, electronic sourcesEmergency Medicine. Avoiding the pitfalls and improving the outcomes - Amal Mattu & Deepti Goyal. Blackwell publishing. BMJ Books. A short book to take the step from good to expert.Pat Standen, DHSAlways helpful in providing support in the region if asked.
