Week 4 of “52 in 52”
o In pt with bleeding peptic ulcers, improvements in clinical outcomes appreciated with those who received pretreatment with omeprazole prior to endscopy
o Optimal acid suppression with omeprazole aids in clot formation showing
• Fewer actively bleeding ulcers were seen on endoscopy
• Reduction in the need for endoscopic treatment
• Accelerates signs of bleeding resolution (ulcers with clean bases)- allowing for early discharge
o Omeprazole proves to stabilize clots, prevent recurrent bleeding, initiate healing
Our second week installment of ALiEM’s 52 Articles in 52 Weeks.
(More info @ http://academiclifeinem.com/52-articles-in-52-weeks-landmark-em-articles-2013/)
Previous studies demonstrated the superiority of PCI over thrombolytics in treating STEMIs. Not all hospitals have cath labs, so is there benefit to transferring STEMI pts presenting in the community to facilities that can perform PCI?
This study’s composite endpoint demonstrated there was a benefit; the composite consisted of mortality, reinfarction, and stroke. There was a 75% relative risk reduction of reinfarction seen in PCI over ‘Lytics. However, “the reduction in the risks of death and stroke did not reach statistical significance.”
It’s also worth mentioning that 4% of the pts screened were not stable enough to be transferred. Of 559 pts who eventually did get transferred, 35 developed arrhythmias, with no deaths en route, leading the authors to conclude “the transfer of patients was found to be safe.“
An idea from Dr. Emily Junck out of Univ of Washington EM, linked below is a list of 52 landmark studies which helped evolve the practice of EM. This week’s read is from the ARDSnet trial, which showed low tidal volumes decreased mortality in ARDS and acute lung injury patients.
Past mechanical ventilation tidal volumes (TV) were 10-12 cc/kg of ideal body weight. Mortality was observed to range from 40-50% in pts with Acute Lung Injury (ALI) and Acute Resp Distress Syndrome (ARDS). Compared to the physiological 7-8 cc/kg TVs, it was hypothesized that the excessive lung stretch cause an inflammatory surge, resulting subsequent organ injury. The study hypothesized that maybe less stretch = better (lower TV), even if at the expense of decreased oxygenation or increased acidosis.
The two compared groups observed were high TV (12 cc/kg, goal plateau pressure of less/equal to 50 cc of H2O) and low TV (6 cc/kg, goal plateau pressure of less/equal to 30 cc of H2O).
Amongst several other end points, the study saw in comparison that the low TV group had:
– decreased mortality (P = 0.007), noting a 22% reduction.
– increased no. of vent-free days (P = 0.007).
– decreased no. of days of non-pulmonary organ failure (P = 0.006).
– decrease concentrations of Interleukin-6, a surrogate marker of inflammation (P = 0.002).
However, there was no statistical difference in the incidence of barotrauma, most commonly manifesting as pneumothorax (P = 0.43).
Plus ARDSnet introduced the “PEEP Ladder” used to sequentially improve oxygenation by incrementally augmenting FiO2 and PEEP.
(image from: http://crashingpatient.com/ventilator-management/ventilator-management.htm/)
Bottom Line: Lower TV = Better for injured lungs.