powerpoint presentation medicine/clinical updates/504... · bp 175/105. nihss is 18. brain ct shows...
TRANSCRIPT
2017
Articles from 2017 that should guide practice
• Blood transfusion
• Stroke• Thrombectomy
• Contrast nephropathy
• DVT/PE• Short and long term benefit of
thrombolysis• DVT prevention after leg casting• Thrombophillia testing• Adjusted d-dimer threshold• Sub segmental PE and calf DVT
• Decision aids v gestalt
• Airway• Video v direct laryngoscopy
• Pain management• Opioid overprescribing• Lyrica overprescribing• Imaging over ordering
• Acute coronary syndrome• Accelerated diagnostic pathways• Troponin interpretation• Non invasive testing – CCTA, EST• When PCI/stenting doesn’t help
• Discrimination/bullying/ harassment
Using freshest available blood for transfusion to ICU patients improves outcomesA. True
B. False
True
False
0%0%
RBCs stored for
•11.8 days v
•22.4 days.
ICU patients
Kaplan–Meier Survival Analysis of Time to Death.
Cooper DJ et al. N Engl J Med 2017;377:1858-1867
Conclusions
The age of transfused red cells did not affect 90-day mortality among critically ill adults.
A74 year old Chinese man presents 5 hours after onset of dense right hemiplegia with aphasia. He is previously well on no medications. BP 175/105. NIHSS is 18. Brain CT shows evidence of acute infarct. What is your approach?
A. Refer to neurology for admission
B. Refer to neurology for thrombolysis because radiology report a small infarct core with potential for salvage
C. Refer for thrombectomy because the NIHSS is out of proportion to the small infarct core
Refer to neuro
logy for a
dmission
Refer to neuro
logy for t
hrombol...
Refer for t
hrombecto
my beca
us...
33% 33%33%
A 76 year woman with abdominal pain and fever is planned for a CT-abdomen. Her eGFR is 35. Which approach would you use.
A. Get a non contrast CT
B. Adopt a renal protective strategy using saline rehydration; and N-AC if GFR were <30
C. Get a contrast CT
D. Postpone CT until next day and re-check renal function
Get a
non co
ntras
t CT
Adopt a re
nal p
rote
ctive
stra
teg.
..
Get a
contra
st C
T
Postpone C
T until
next
day a
nd ...
0% 0%0%0%
A 47yr-F presents with dyspnoea 5 days after sustaining an undisplaced # ankle which was managed with a backslab in ED. BP is 105/65, HR 95 bpm, hs-troponin T 132, right heart strain on bedside echo.
Thrombolysis will improve survival and should be given.
A. True
B. False
True
False
0%0%
A 47yr-F presents with dyspnoea 5 days after sustaining an undisplaced # ankle which was managed with a backslab in ED. BP is 105/65, HR 95 bpm, hs-troponin T 132, right heart strain on bedside echo.
Thrombolysis should be given to improve long term respiratory function.
A. True
B. False
True
False
0%0%
4 weeks later a letter is received from the patients lawyer saying she should have been given anticoagulation on discharge from ED.
Anticoagulation following plaster casting for lower limb # has been shown to reduce subsequent DVT/PE.
A. True
B. False
True
False
0%0%
http://www.nejm.org.virtual.anu.edu.au/do/10.1056/NEJMdo005122/full/
The case is thrown out. However the RCA has raised some queries
Thrombophilia testing should have been done to guide follow up.
A. True
B. False
True
False
0%0%
A 37yr-F presents with shortness of breath, pleuritic chest pain and cough. Temp is 37.4 C. HR 86, RR 18. CXR is clear. CRP 96, D-dimer 0.68. There are no risk factors for DVT-PE. Management should be:
A. Doxycycline for respiratory infection
B. Amoxicillin/clavulanic acid for respiratory infection
C. Symptomatic treatment for viral infection
D. CT-PA for PE due to d-dimer
Doxycy
cline
for r
espira
tory
infe
...
Amoxi
cillin
/cla
vula
nic acid
for r
...
Sym
ptom
atic
treat
men
t for v
iral..
.
CT-PA fo
r PE
due to
d-d
imer
25% 25%25%25%
You are supervising a junior doctor preparing for intubation. They ask if they should use direct or video laryngoscopy to improve first pass success. What do you say?
A. Direct laryngoscopy – it was developed in WWII and has never been bettered
B. Video laryngoscopy – duh!
C. There’s not tuppence worth of difference
Direct
laryngosc
opy – it w
as de...
Video la
ryngosc
opy – duh!
There’s
not tuppence
worth
of d...
33% 33%33%
A 53yr-woman presents with ongoing back pain radiating down the right thigh. It is not responding to tramadol, endone and chiropractic treatment from her GP. Optimal management should be:
A. Increase dose of endone and add oxycontin
B. Do MRI before increasing dose of endone
C. Add lyrica
D. Limit ongoing analgesia to paracetamol and NSAID, and encourage mobility with appropriate limits to activity
Incr
ease
dose
of e
ndone an
d ad...
Do MRI b
efore
incr
easin
g dose
..
Add lyric
a
Limit
ongoin
g analg
esia
to p
ara...
0% 0%0%0%
57yr-F presents with intermittent central chest tightness during the morning. Is diabetic on metformin. Serial ECGs and hs-tpn normal. What is the next step
A. Admit to SSU for an EST
B. CT-coronary angiogram
C. Outpatient EST
D. GP follow up
Admit
to SS
U for a
n EST
CT-co
ronar
y angi
ogram
Outpatie
nt EST
GP follo
w u
p
25% 25%25%25%
A 62yr man presents with exertional chest pain, eased with rest. He attend ED and has normal ECG and serial hs-troponin. A stress test is +ve for ischaemia.
Angiogram shows 80% stenosis of the left circumflex artery. The next step should be:
A. Stenting of stenotic lesion
B. Optimise medical management
Stentin
g of ste
notic le
sion
Optimise
medical m
anagement
50%50%
PCI did not increase exercise time by more a placebo procedure
Quotes
Do you really think cardiologists are doing studies or discussing how to less angiograms?
Articles from 2017 that should guide practice
• Blood transfusion
• Stroke• Thrombectomy
• Contrast nephropathy
• DVT/PE• Short and long term benefit of
thrombolysis• DVT prevention after leg casting• Thrombophilia testing• Adjusted d-dimer threshold• Sub segmental PE and calf DVT
• Decision aids v gestalt
• Airway• Video v direct laryngoscopy
• Pain management• Opioid overprescribing• Lyrica overprescribing• Imaging over ordering
• Acute coronary syndrome• Accelerated diagnostic pathways• Troponin interpretation• Non invasive testing – CCTA, EST• When PCI/stenting doesn’t help
• Discrimination/bullying/ harassment