PowerPoint Presentation medicine/Clinical Updates/504... · BP 175/105. NIHSS is 18. Brain CT shows...

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