Evidence based Emergency Medicine

1. Evidence based Emergency Medicine Dr Jaycen Cruickshank Director of Emergency Medicine, Ballarat Health Services Senior Lecturer, Rural Clinical School, University of Melbourne jaycenc@bhs.org.au

2. jaycenc@bhs.org.au Introduction • Evidenced based Emergency Medicine is using validated clinical decision rules. • The audience will learn in this session • What evidence is available and easy to use • How to find the evidence • Evidence from the patient’s point of view • Patient fact sheets • There is too much to remember - students are now taught how to find it.

3. jaycenc@bhs.org.au Overview • Big picture - these mostly ignored • Explain how all the individual topics fit together • X-ray? • Admit? • IV or oral? • CT? Ottawa ABCD2 Wells TIMI Pittsburgh CURB-65 What next? PSI Syncope

4. jaycenc@bhs.org.au Agenda • Topics • Medical, trauma/injury • Resources: • www.patient.co.uk • www.betterhealth.vic.gov.au • www.scaphoidfracture.com.au • http://emedicine.medscape.com/ • Google • www.mdcalc.com

5. jaycenc@bhs.org.au TIA - ABCD2 Pneumonia PSI CURB-65 PE - Wells criteria DVT - Wells criteria San francisco syncope rule Ottawa ankle and foot rules Pittsburg knee rules Canadian neck rules vs Nexus guidelines NICE guidelines Head injury RCH guidelines http://www.rch.org.au/clinicalguide/cpg.cfm RWH guidelines Clinical Decision Rules

6. ABCD2 algorithm identifies risk of stroke after TIA People 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 ABCD2 Score >=4 Admit, aspirin, specialist and imaging early (<24 hrs) Score <4 Discharge, Review within 1 week General preventative measures A - age (>=60 years, 1 point) B - blood pressure at presentation (>=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 point Diabetes (1 point) ABCD2 is calculated based on:total scores range from 0 (low risk) to 7 (high risk).

7. General prevention of stroke control of risk factors: smoking, lack of exercise hypertension - target blood pressure for patients with a TIA or stroke is <130/<80 mmHg hyperlipidaemia - ideal targets? treatment of symptomatic vascular disease such as giant cell arteritis antiplatelet therapy is most effective in patients in sinus rhythm: the combination of modified-release (MR) dipyridamole and aspirin is recommended for people who have had an ischaemic stroke or a transient ischaemic attack (TIA) for a period of 2 years from the most recent event. Thereafter, or if MR dipyridamole is not tolerated, preventative therapy should revert to standard care (including long-term treatment with low-dose aspirin) clopidogrel - clopidogrel alone (within its licensed indications) is recommended for people who are intolerant of low-dose aspirin anticoagulant therapy is effective in patients in atrial fibrillation and can reduce the likelihood of further vascular events there is no place for anticoagulant therapy in managing patients with a stroke or TIA in the absence of atrial fibrillation. carotid endarterectomy - highly beneficial in symptomatic patients with 70-99% stenosis of the internal carotid ACE inhibitition - using a combination of long-acting ACE inhibitor (e.g. perindopril or ramipril) and a thiazide diuretic (e.g.indapamide) has been suggested

8. jaycenc@bhs.org.au CURB-65 (pneumonia) • Pneumonia is not a particularly difficult diagnosis to make • Assessment of severity of disease influences • Treatment • Admit or discharge • Outcomes • Do we agree on severity?

9. jaycenc@bhs.org.au 1 point each Confusion Urea > 7mmol/L Resp rate >20, pCO2 <32 Blood pressure <90mmHg 65 - Age >65 http://www.mdcalc.com/mdcalc/wordpress/curb-65 Mortality Score 0 = 0.7% 1 = 3.2% 2 = 13% 3 = 17% 4 = 42% 5 = 57% CURB-65 predicts mortality

10. jaycenc@bhs.org.au Class/mortality/Where/What 1- 0.1% -home - oral antis 2 - 0.3% -home-HITH - oral/IV 3- 0.9%- ?? admit/IV antis 4 - 9%- admit/IV antis 5 - 30%- ICU/IV antis Details in Victorian Antibiotic guidelines BHS compliance 27%! CURB -65 1 2 3 4 5 Pneumonia Severity Index – also called PORT score or CAP risk

11. jaycenc@bhs.org.au Well’s criteria -PE • Radiologists 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-Dimer” • Big man, 30’s, wife, 2 year old, trip to south africa, new diagnoses of calf strain and then asthma • He died. He should not have died.

12. Well’s score for Pulmonary Embolism

13. What does the score mean? 0-1 = 1.3% chance of PE Negative d-dimer = rule out Positive 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 Region http://www.mdcalc.com/wellscriteria

14. San Francisco syncope rule Congestive Heart Failure history? Yes +1 Hematocrit < 30%? Yes +1 ECG Abnormal ? Yes +1 Shortness of Breath History? Yes +1 Systolic BP < 90 mmHg at Triage? Yes +1 Any 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."

15. jaycenc@bhs.org.au Characteristics of Patients Who Should Undergo Radiography After Knee Trauma • Ottawa knee rules • Age >55 years • Tenderness at head of fibula • Isolated tenderness of patella • Inability to flex knee to 90 degrees • Inability to walk four weight-bearing steps immediately after the injury and in the emergency department • http://www.mdcalc.com/mdcalc/wordpress/ottawa-ankle-and-pittsburgh-knee-rules • Pittsburgh decision rules • Blunt trauma or a fall as mechanism of injury plus either of the following: • Age < 12 or >50 years • Inability to walk four weight-bearing steps in the emergency department

16. jaycenc@bhs.org.au Ottawa Ankle and Foot Rules

17. Canadian C-spine rules better than NEXUS to rule out neck injury http://www.aafp.org/afp/20040515/tips/10.html Canadian rules better, used in UK guidelines also Approx 7500 study with 162 clinically important injuries Canadian C-spine rule detected 161 of 162 clinically important injuries NEXUS 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.

18. The UK NICE guidelines. http://www.nice.org.uk/nicemedia/pdf/CG56QuickRedGuide.pdf

21. jaycenc@bhs.org.au Summary • State what has been learned • Some good clinical decision rules exist, to help our clinical judgement. • They are easily accessible • Patients can find information • Define ways to apply training • Favourites on your computers • Ipod touch, other hand held device. • Patient access to online information. • Request feedback of training session

22. jaycenc@bhs.org.au Where to Get More Information • Other tools • TIMI score http://www.mdcalc.com/uanstemitimiscore • List books, articles, electronic sources • Emergency 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, DHS • Always helpful in providing support in the region if asked.