Skip to main content

Posts

Showing posts from June, 2012

Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: brief alzheimer’s screen, short blessed test, Ottawa 3DY and the caregiver-completed AD8

Methodology: 3.5
Usefulness: 3.5  Carpenter CR, Bassett ER, Fischer GM, Shirshekan J, Galvin JE, Morris JC.  
 Acad Emerg Med 2011 April 18(4): 374-384.
 Article Link

Trained research assistants administered cognitive dysfunction screening tests (Brief Alzheimer’s Screen, Short Blessed Test and Ottawa 3DY) compared with the MMSE to ED patients over the age of 65 and found that all three tests had sensitivities of 95% but the SBT to have the best specificity at 65%.  In spite of the methodological issues (absence of documented patient characteristics, lack of blinding, no explicit cut off points for all tests and restrictive exclusion criteria) in this paper, it shows that the Ottawa 3DY is likely the easiest screening test to use given its brevity and ease of scoring with a sensitivity of 95% and specificity of 51%. 
By Dr. Debra Eagles

Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest

Methodology: 2/5    
Usefulness: 2/5 Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns Investigators. Crit Care Med. 2012 Mar;40(3):747-53.
Pubmed Link

This study looked at the use of ice-cold Hartmann's solution for induction of therapeutic hypothermia for non-VT/VF arrests in the pre-hospital setting compared to in-hospital cooling. They found a found a decrease in mean-time to therapeutic hypothermia (3.2 hrs versus 4.8 hrs, p=0.03), but no statistical difference in “favourable outcome” (12% pre-hospital versus 7% hospital cool, p=0.15). The study protocol was well designed, but unfortunately there were significant flaws in the enrollment and compliance to protocol that led to questions on the accuracy and validity of the results.  
By Dr. Andy Pan

Validation and Refinement of a Rule to Predict Emergency Intervention in Adult Trauma Patients

Methodology: 1.5/5    
Usefulness: 2/5 
Haukoos JS, Byyny RL, Erickson C, Paulson S, Hopkins E, Sasson C, Bender B, Gravitz CS, Vogel JA, Colwell CB, Moore EE. Ann Emerg Med. 2011 Aug;58(2):164-71. Article Link

This retrospective validation of two existing clinical decision rules, the Loma Linda rule and the American College of Surgeons' Major Resuscitation Criteria, found that the Loma Linda rule offered the best sensitivity (95.6%) when compared with the ACS criteria (85.5%).  JC attendees were concerned at the lack of rigorous evaluation of potential predictor variables or statistical assessment of significance when related to the outcome.  Further, the group felt that these clinical decision rules are not as useful in a Canadian centre where penetrating trauma is less frequently encountered and the need for emergent operation or procedure (thoracotomy, cesarean, or cricothyroidotomy) within one hour is infrequently required.  
By Dr. Monica Ott

Does This Patient Have a Severe Upper Gastrointestinal Bleed?

Methodology: 2.5/5    
Usefulness: 2.5/5 
Srygley FD, Gerardo CJ, Tran T, Fisher DA. JAMA. 2012 Mar 14;307(10):1072-9 Article Link

This recent installment of JAMA’s Rational Clinical Examination series found that a history or physical exam positive for melena, a nasogastric lavage with blood or coffee grounds, or a BUN:Creatinine ratio > 30 increased the likelihood of an upper GI bleed while a Blatchford score of 0 significantly decreased the likelihood that an upper GI bleed would require urgent intervention. Unfortunately this systematic review and meta-analysis had a surprisingly poor search strategy and lack of sensitivity analysis.   JC attendees agreed that despite the authors’ endorsement of the Blatchford scoring system, it alone is not sufficient enough to be used for safely discharging patients home and recent studies that have attempted to externally validate this scoring system would support this notion. 
By Dr. Tighe Crombie

Association Between Arterial Hyperoxia Following Resuscitation From Cardiac Arrest and In-Hospital Mortality

Methodology: 3/5    
Usefulness: 4/5
Kilgannon JH, Jones AE, Shapiro NI, Angelos MG, Milcarek B, Hunter K, Parrillo JE, Trzeciak S; Emergency Medicine Shock Research Network (EMShockNet) Investigators. JAMA 2010 Jun 2;303(21):2165-71. Article Link

This is the first study to use clinical data to establish an association between post-ROSC hyperoxia and increased in-hospital mortality in non-traumatic post-cardiac arrest patients (OR 1.8, CI 1.5-2.2) using multi-centre retrospective cohort data from a US ICU database. There were considerable potential confounders that limit the validity of this study's results (including CPR data, timing of ABG collection, etc); however, this was a landmark study since it suggested an association between hyperoxia & mortality and will likely prompt further research into modifiable post-ROSC mortality risk factors. 
By Dr. Aseem Bishnoi