Scientific Assembly Wednesday Pearls
(there’s too much to choose from, so follow #ACEP14)
Debating Clinical Policies: Implications for tPA and Beyond – Drs. David Newman, David Seaberg, and Edward Sloan
- The ACEP clinical policy on TPA is hotly debated, as it gives Level A evidence to TPA in acute ischemic stroke. This policy is being reconsidered and big props to ACEP for doing this, most professional organizations aren’t that responsive.
- TPA has a NNT of 8 and a NNH of 16. The TPA supporters typically reference NINDS, ignoring the other RCTs. They also reference large sets of registry data.
- Check out his SMART EM podcast on the topic
Evidence-Based Approach to the “Other” Stroke – Dr. Jon Edlow
- Prothrombin complex concentrate (PCCs) are all the rage, particularly since the 4 factor PCC was approved last year in the United States. It improves patients numbers of coagulopathy, but not necessarily patient outcomes (Dr. Rory Spiegel on the topic).
- Fresh frozen plasma, dosing is based on INR and the patient’s weight, it’s not an empiric “2 units.”
- Blood pressure control may be safe in Intracerebral hemorrhage, but the studies such as INTERACT don’t show that it benefits patients (The SGEM).
Chest Pain in the ED: Is One Troponin Enough? – Dr. David Newman
- The miss rate for MI is often quoted as 2%, but it’s more like 0.2% per the Pope et al study. So, we’re pretty good at this.
- ACEP has a policy stating that a single troponin after 8 hours of chest pain is sufficient
- States that have tort reform have shown fewer lawsuits and less money without compromising patient outcomes.
- See the SMART EM talk on this
Clinical Pearls From the Recent Medical Literature – Drs. Jerome Hoffman and Richard Bukata (#hofkata)
- Topical analgesia for corneal abrasions – the FOAM world has been buzzing with the notion of using tetracaine for corneal abrasions (Rebel EM, The SGEM). Hofkata reviewed this paper by Waldman et al that showed no difference in visual analog scores for normal saline compared with tetracaine for corneal abrasions. Tetracaine was perceived more effective so there may be a role for dilute proparacaine but we’ll need some more studies.
- Cough medicines don’t work, as demonstrated by Smith et al but honey might per Cohen et al (The SGEM)