Grand Rounds Recap 7.5.17

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The History of Emergency Medicine - Dr. Pancioli

The Past

  • The first ER groups started in the 1960s in large, academic centers
  • In the 1960s, UC hospital was known as the "General Hospital;" the Emergency Department saw >100,000 visits per year and was staffed primarily by interns and junior residents
  • In the late 1960s, Dr. Bruce Janiak began to develop a curriculum for an Emergency Medicine residency at UC; around the same time, ACEP was founded
  • As the residency and department developed, the field of Emergency Physicians expanded in scope and practice 
  • In 1984, AirCare was established, staffed by nurses and Emergency Physicians

Current Challenges and the Future

  • Now, there are approximately 120 million ED visits each year in the United States, which represents a 20% increase over the past 5 years
  • At the same time, there has been an 8% decline in the number of EDs
  • This mismatch overwhelms the ED vis-a-vis its role as the health care safety net in society
  • The ED continues to face challenges such as boarding, physical space limitations, financial difficulties and increasing patient volume
  • Our field lends itself well to pursuing particular interests that intersect with the field of Emergency Medicine, such as neurology and acute stroke research, which allow us to stay on the cutting edge
  • The field remains competitive and expectations are always changing
  • We must continue to provide excellent care to all patients while continuing to push ourselves and advance the field and practice of Emergency Medicine

Playing Nice in the Sandbox - Dr. Palmer

  • The ED works as a team for every patient in the department, and highly functioning teams perform better
  • The ED continues to face increasing challenges such as rising volume, billing and documentation demands, and increasing acuity of patient presentations
  • Poor communication can lead to adverse patient events 
  • Well-functioning teams lead to better patient satisfaction, improved staff satisfaction and retention and better financial performance
Individual commitment to a group effort - that is what makes a team work, a company work, a society work, a civilization work. -- Vince Lombardi
  • Our team in the ED includes physicians, nurses, techs, radiology, lab, respiratory therapists, pharmacy, medics, security, environmental services, and social work... but the most important people on our team are the patients and their families
  • Continued excellence requires continued efforts at self-improvement
  • Social competence involves social awareness and relationship management -- to be a good team leader and member of a team, you must be able to read individuals well and adapt
  • Common themes of highly successful healthcare teams involve shared goals, clear roles, mutual trust, and effective communication 
  • An ED physician is in the unique role of developing and maintaining relationships with members of many interdisciplinary teams
  • By remembering to always put the patient first, we will not lose sight of our shared goal

Discharge, Cath or Admit - Dr. LaFollette

Case One: 49 y/o male with a history of HTN, obesity and a significant family history of CAD who presents with burning, exertional chest pain that occurred at work and a recent negative stress test. His initial EKG was normal and his initial troponin was negative.

  • The HEART Score for this patient is four (1 for a moderately suspicious story, 0 for his EKG, 1 for his age, 2 for his risk factors, and 0 for his troponin)
  • This patient was admitted to cardiology; his second EKG revealed inferior MI
  • The Heart Score does have definitive criteria and must be applied objectively
  • Male gender was recently shown to be a significant independent risk factor of MACE in addition to HEART and may be some worth considering in addition to the score

Case Two: 29 y/o female with a history of smoking and a family history of CAD who presents with cough and pleuritic chest pain. Her initial troponin was negative, and her initial EKG did reveal isolated T wave inversion in lead III.

  • Sent home and did well.
  • Isolated T wave inversion in otherwise healthy individuals may be benign, although should be interpreted in the correct clinical context. Elderly males and young athletes have both been shown to have increased risk of sudden cardiac death with these findings.

Case Three: 78 y/o male with multiple comorbidities who presents with exertional chest pain relieved by nitroglycerin. His initial EKG revealed biphasic T wave inversion in V1-V3.

  • EKG consistent with Wellens, a reperfusion injury pattern concerning for LAD disease
  • While not a STEMI, these patients merit an emergent conversation with an interventionalist for cath

Case Four: You are handed a fax of a prehospital EKG for a 56 y/o patient with a "STEMI alert." The rhythm is a LBBB, and you do not know the patient's baseline EKG.

  • Sgarbossa criteria, which can help identify a STEMI in the setting of a LBBB, focuses on concordant elevation of the ST segment, concordant depression of the ST segment, and excessive discordance. See the EKG focus on page 16 of the Winter 2016 Edition of Annals of B Pod for more details.
  • This patient's EKG was positive by Modified Sgarbossa criteria and went to the cath lab.

Case 5: An elderly female who presents with weight gain and orthopnea. She is chest pain free. She reports that she has a history of PCI of both the LAD and LCx in the past at an outside hospital. Her EKG is notable for ST segment elevation in the precordial leads with some depression in I and aVL. 

  • This patient had deep q waves in her precordial leads as well, and a troponin of 0.3, while remaining chest pain free
  • After discussion with interventional cardiology, the patient went to cath
  • Cath reviewed diffuse triple vessel disease and was sent to CABG
  • Keep in mind that women do have different EKG criteria for STEMI than men

Case 6: A young female in her 20s who presented with pleuritic chest pain and a new oxygen requirement. Her EKG was notable for sinus tachycardia with TWI in lead III. 

  • Her initial troponin was 0.21. A CTPA was notable for a saddle embolus.
  • She was started on heparin and transferred to a tertiary academic facility on heparin for EKOS evaluation 

Target-Specific Oral Anticoagulant Reversal - Chris Droege, PharmD

  • There is a global trend towards increasing anticoagulation use, with a focus on target-specific oral anticoagulant usage (TSOAC)
  • For example, the prevalence of atrial fibrillation is increasing; numbers on track to top 12M in the year 2030
  • TSOAC and warfarin usage are equalizing in the United States 
  • The need to reverse these agents will also be increasing, and we need to know our options

Dabigatran (Pradaxa)

  • Direct thrombin (IIa) inhibitor
  • FDA approved for stroke prevention in non-valvular a fib, acute VTE treatment and prevention of recurrence
  • Renally eliminated; contraindicated with CrCl < 15 mL/min
  • Effect can be measured via thrombin time (TT), aPTT and INR, although not always a linear relationship to drug plasma concentration; more of a linear relationship with ecarin clotting time (ECT)
  • Reversal options include dialysis (iHD or CRRT); 4-factor PCC (which includes factors II, VIII, IX, X, as well as protein C,S and antithrombin) was less effective based on human data
  • Idarucizumab (Praxbind) is a monoclonal antibody developed to reverse Pradaxa; rapidly reduces dabigatran concentrations

Oral Direct Xa Inhibitors 

  • Xa is the first step in the common pathway of coagulation
  • These include rivaroxaban (Xarelto), apixaban (Eliquis) and edoxaban (Savaysa)
  • These drugs do have different half lives, volumes of distribution and percentages of protein binding, all of which can affect reversal strategies
  • They are all renally cleared and their dosage should be based on CrCl; toxicity of these drugs can dramatically change in patients with acute kidney injury
  • Effect best measured via anti-Xa levels, the latter which must be calibrated to the individual drug; protime assays must be developed specifically for the drug as well
  • 4-factor PCC can be used for reversal of Xa agents, with variable effects

Andexanet Alfa

  • Designed to reverse direct and indirect Factor Xa inhibitors
  • No intrinsic pro- or anti-coagulant activity
  • Annexa-4 looked at reversal of apixaban and rivaroxaban, with rapid reversal of Xa inhibitors 
  • Significant promise with this drug but more data needed about the duration of effect