Teaching Attending: David Gaieski, MD
All conferences will be held in the John Pryor Conference Room on Ground Founders.
8:00 am – 8:50 am Diagnostics Conference
9:00 am – 10:00 am Grand Rounds: “Neonatal Resuscitation” Maggie Samuels-Kalow, MD
10:00 am – 10:30 am Podcast Discussion – Yolanda Michetti, MD
10:30 am – 12:00 pm Morbidity and Mortality – Nick Johnson, MD
Take home: If a patient presents to the ED with priapism after intra-corporeal injection, may try oral terbutaline while preparing for, and perhaps obviating the need for, drainage with phenylephrine.
* Reminder: There will be no conference on Wenesday, Novemember 18 due to the holiday. Happy Thanksgiving!
Wednesday, December 4, 2013
Teaching Attending: Judd Hollander, MD
All conferences will be held in the John Pryor Conference Room on Ground Founders.
8:00 am – 8:50 am Radiology Joint Conference
9:00 am – 10:00 am Grand Rounds: “Approach to the ED Patient with Chest Pain” Judd Hollander, MD
10:00 am – 11:00 am Evidence in the ED- Judd Hollander, MD Yolanda Michetti, MD and Alex Katz, MD
11:00 am – 12:00 pm Case Discussion – Jill Baren, MD and Ed Dickinson, MD
Penn EM’s own Dr. Ben Abella, an internationally recognized expert in post-arrest care, was an invited discussant on the TTM trial at AHA’s Resuscitation Science Symposium.
He graciously allowed us to post his take on the trial here:
Case: A 45 year old man collapses while jogging. A bystander witnesses his collapse and, after calling 911, initiates CPR. EMS arrives five minutes later to find him apneic and pulseless in ventricular fibrillation. He is successfully defibrillated, but remains comatose with a Glasgow Coma Scale (GCS 3) score of 3, so he is intubated and transported to the emergency department (ED). On arrival to the ED, his GCS is 3T. His temperature is 37 degrees, his cardiac rhythm is normal sinus, and his vital signs are otherwise normal. His post-arrest electrocardiogram reveals no ST-elevations. You begin to initiate therapeutic hypothermia, when a colleague asks “based on the recent TTM trial, what temperature are you targeting?”
Background: In 2002, two landmark studies were published demonstrating improved survival1 and neurologic outcome1, 2 among comatose survivors of out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) and an initial shockable rhythm treated with moderate induced hypothermia (or Targeted Temperature Management, [TTM]) to 32-34 degrees Celsius. This therapy has since been incorporated into international resuscitation guidelines.3
Study Objective: To compare the effects of two target temperatures (33 and 36 degrees) on the mortality and neurologic outcome among patients with OHCA with ROSC.
-Randomized, controlled trial of unconscious adults after OHCA with ROSC of presumed cardiac etiology
-The study included patients with all initial cardiac rhythms, not just shockable rhythms (in contrast to the Bernard et al.2 and HACA1 studies)
-Patients were randomized to TTM at either 33? C or 36? C
-Primary outcome was all-cause mortality through the end of the trial
-Secondary outcomes were a composite of poor neurologic function (as evaluated by the Cerebral Performance Category [CPC] and modified Rankin scales) or death at 180 days
-Pre-specified subgroup analyses were performed
-The study was designed to provide a 90% power to detect a 20% difference in the primary outcome
-A rigorous protocol was used to determine neurologic prognosis and appropriateness for withdrawal of care
-Prognostication was performed 72 hours after re-warming
-939 patients were included
-There was no significant mortality difference between patients in the 33? C group and 36? C (50% versus 48%, hazard ratio 1.06, 95% confidence interval 0.89-1.28, p=0.51)
-There was no significant difference in neurologic function according to CPC or modified Rankin scale scores at 180 days
-There were no significant differences in mortality or neurologic outcome in any of the pre-specified subgroups (age [?65 and >65], gender, longer time from arrest to ROSC [?25 minutes or >25 minutes], shockable verus non-shockable rhythm, presence or absence of shock on admission, study site category [two largest sites versus others])
-During the first 7 days of hospitalization, life-sustaining therapy was withdrawn in 247 patients (132 in the 33°C group and 115 in the 36°C group)
-There was a non-significant trend toward more adverse events in the 33°C group (93%) as compared with the 36°C group (risk ratio, 1.03; 95% CI, 1.00 to 1.08; P=0.09)
-Hypokalemia was more frequent in the 33°C group (19%, vs. 13% in the 36°C group, P=0.02)
-At day 3 of hospitalization, more patients in the 33°C required vasopressors or inotropes as determined by the SOFA-Cardiovascular score when compared with the 36°C (see Supplementary Appendix Table S2)
Discussion and Critiques:
-Patients maintained with induced low normothermia to 36°C had similar outcomes to patients treated with induced moderate hypothermia to 33°C
-Note that survival was 50% in the 36°C group in the TTM trial compared with 26% in Bernard et al.2 control group and 39% in HACA1 control group, and those studies included only patients with shockable rhythms. This highlights the importance of temperature management after cardiac arrest, delayed neuroprognistication, and may also reflect improvements in emergency and critical care over time
-Critique #1: The study was underpowered. For instance, if an 10% difference in the hazard ratio for the primary outcome was seen between the 33°C group (93%) as compared with the 36°C group, it may have not been detected. This is the largest study of TTM after OHCA to date. Its sample size dwarfs those of the previous two major trials1, 2, which included a combined total of 352 patients. Further, standard methodology for large-scale clinical trials was used to calculate sample size. It is, however, possible that a small difference was not detected.
-Critique #2: Perhaps there is a subgroup of patients who would benefit from cooling to 33°C. In the pre-specified subgroup analyses, no difference was seen between the 33°C group as compared with the 36°C group. This includes some of the groups in which there is biologic plausibility: longer arrest time, shockable rhythm, and presence of shock. Drs. John Rittenberger and Scott Weingart discuss on the EMCrit podcast whether patients with deeper coma might be a subset who could benefit from cooling to lower temperatures. This group was not specifically analyzed in the TTM trial. Further, if a subgroup in the 33°C arm did have improved outcomes, this must have been balanced by another subgroup in that same arm that did worse.
-Critique #3: There’s not much downside to cooling to 33°C, so why not just do it? Pooled adverse events did not reach statistical significance in this study in the 33°C group as compared with the 36°C group. However, the challenges of titrating the hemodynamics and electrolytes of patients with induced moderate hypothermia were reflected in the study: a greater number of patients in the 33°C experienced hypokalemia and required vasopressors and inotropes (as measured by SOFA-C score) by study day 3.
Discussion question: How will you manage the next OHCA with ROSC who presents to your emergency department or intensive care unit?
1. Hypothermia after Cardiac Arrest Study G. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest.[see comment][erratum appears in N Engl J Med 2002 May 30;346(22):1756]. New England Journal of Medicine. Feb 21 2002;346(8):549-556.
2.Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. Feb 21 2002;346(8):557-563.
3.Peberdy MA, Callaway CW, Neumar RW, et al. Part 9: post-cardiac arrest care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. Nov 2 2010;122(18 Suppl 3):S768-786.
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“Delaware Valley AAEM 2013″
Incredible Speakers at #DVAAEM13 @CriticalCareNow @smotovmd David Farcy MD, Onier Alejandro, MD. Join the conversation on 11/21 @TempleEM #EMConf #FOAMed