Indication For Urgent Intervention Research Articles

Analgesic refractory colic pain: Is prolonged conservative management appropriate?

To propose a clear definition and management pathway of patients with analgesic refractory colic pain (ARCP). Prospective cohort study from February 2018 to February 2019 including patients with ARCP defined as ongoing renal colic pain after one dose of IV NSAID, IV paracetamol, and a parenteral opioid, given sequentially in that order. Patients were observed in-hospital under full parenteral analgesic management for 8-12h, whenever patients had minimal or absent pain after conservative management (CM) they were discharged, and followed-up with new imaging within four weeks. If the pain was not controlled after CM, surgical management (double-J stent or ureteroscopy) was performed. We excluded patients with any other indication for urgent intervention or in cases where CM was deemed inappropriate (sepsis, acute renal failure, stones >10mm in size, suspected concomitant urinary tract infection, bilateral ureteral stones, pregnancy, patients with a single kidney, kidney transplant recipients, difficult access to medical care or refusal to undergo CM). Data from 60 patients was collected. The only variable associated with an increased risk of failed CM was a history of previous renal colic (OR 3.98 [95% CI 1.14-13.84], p=0.02). Neither gender, age, stone size, location, or hydronephrosis grade were able to predict CM failure. 41.6% of patients were successfully managed conservatively and only 8% of them required scheduled surgical management at follow-up. Our results show that a high proportion of patients with ARCP may be successfully managed conservatively with an extended observation period without complications at follow-up. These results should be replicated in a randomized controlled trial to confirm them.

Small Bowel Obstruction

Identifying patients with small bowel obstruction who need operative intervention and those who will fail nonoperative management is a challenge. Without indications for urgent intervention, a computed tomography scan with/without intravenous contrast should be obtained to identify location, grade, and etiology of the obstruction. Most small bowel obstructions resolve with nonoperative management. Open and laparoscopic operative management are acceptable approaches. Malnutrition needs to be identified early and managed, especially if the patient is to undergo operative management. Confounding conditions include age greater than 65, post Roux-en-Y gastric bypass, inflammatory bowel disease, malignancy, virgin abdomen, pregnancy, hernia, and early postoperative state.

Venous Thromboembolism

Deep vein thrombosis (DVT) and pulmonary embolism (PE) comprise venous thromboembolism (VTE). Together, they comprise a serious health problem as there are over 275,000 new VTE cases per year in the United States, resulting in a prevalence of one to two per 1,000 individuals, with some studies suggesting that the incidence may even be double that. This review covers assessment of a VTE event, initial evaluation of a patient suspected of having VTE, medical history, clinical presentation of VTE, physical examination, laboratory evaluation, imaging, prophylaxis against perioperative VTE, indications for immediate intervention (threat to life or limb), indications for urgent intervention, and management of nonemergent VTE. Figures show a modified Caprini score questionnaire used at the University of Michigan to determine individual risk of VTE and the indicated prophylaxis regimen; Wells criteria for DVT and PE; phlegmasia cerulea dolens secondary to acute left iliofemoral DVT after thigh trauma; compression duplex ultrasonography of lower extremity veins; computed tomographic angiogram of the chest demonstrating a thrombus in the pulmonary artery, with extension into the right main pulmonary; management of PE according to Wells criteria findings; management of PE with right heart strain in cases of massive or submassive PE; treatment of DVT according to clinical scenario; a lower extremity venogram of a patient with May-Thurner syndrome and its subsequent endovascular treatment; and various examples of retrievable vena cava filters (not drawn to scale). Tables list initial clinical assessment for VTE, clinical scenarios possibly benefiting from prolonged anticoagulation after VTE, indications for laboratory investigation of secondary thrombophilia, venous thromboembolic risk accorded to hypercoagulable states, and Pulmonary Embolism Rule-out Criteria Score to avoid the need for D-dimer in patients suspected of having PE. This review contains 11 highly rendered figures, 5 tables, and 167 references. Key words: anticoagulation; deep vein thrombosis; postthrombotic syndrome; pulmonary embolism; recurrent venous thromboembolism; thrombophilia; venous thromboembolism; PE; VTE; DVT

Aortic Aneurysm as a Cause of Hemoptyses

Infected aortic aneurysms are a clinical condition associated with high morbidity and mortality. Hemoptysis has been reported following erosion of the aneurysm into the lung parenchyma. We present a 79-years-old woman, with history of a pseudoaneurysm of the descending aorta submitted to an endovascular correction with tubular stent in 2010. She arrived at the emergency department, in January/2016, referring asthenia and weight loss, with three months of evolution, associated with small volume hemoptysis, that had begun that day. The patient presented anemia and with hypoxemic respiratory failure. Angio-CT scan revealed hematoma of the aneurysmal sac, without indication for urgent intervention. She was admitted at an intermediate care unit. The patient kept small volume hemoptysis. A new thoracoabdominal angio-CT was performed compatible with infectious process/abscess of the periprosthetic aortic wall, associated with areas of parenchyma necrosis of the left lower pulmonary lobe, that may be the origin of hemoptysis. Empirical antibiotic therapy was instituted with pipracilina/tazobactam and linezolid. A methicillin resistant Staphylococcus aureus was identified in bronchial lavage, and piperacillin/tazobactam was suspended. After 6 weeks of antimicrobial therapy, she presented clinical improvement. This case demonstrates the complexity of managing a patient in which the infectious focus control is not possible, given the high surgical risk in a patient with multiple comorbidities. Doubts remain about the antibiotic therapy to be maintained and its duration.

Venous Thromboembolism

Deep vein thrombosis (DVT) and pulmonary embolism (PE) comprise venous thromboembolism (VTE). Together, they comprise a serious health problem as there are over 275,000 new VTE cases per year in the United States, resulting in a prevalence of one to two per 1,000 individuals, with some studies suggesting that the incidence may even be double that. This review covers assessment of a VTE event, initial evaluation of a patient suspected of having VTE, medical history, clinical presentation of VTE, physical examination, laboratory evaluation, imaging, prophylaxis against perioperative VTE, indications for immediate intervention (threat to life or limb), indications for urgent intervention, and management of nonemergent VTE. Figures show a modified Caprini score questionnaire used at the University of Michigan to determine individual risk of VTE and the indicated prophylaxis regimen; Wells criteria for DVT and PE; phlegmasia cerulea dolens secondary to acute left iliofemoral DVT after thigh trauma; compression duplex ultrasonography of lower extremity veins; computed tomographic angiogram of the chest demonstrating a thrombus in the pulmonary artery, with extension into the right main pulmonary; management of PE according to Wells criteria findings; management of PE with right heart strain in cases of massive or submassive PE; treatment of DVT according to clinical scenario; a lower extremity venogram of a patient with May-Thurner syndrome and its subsequent endovascular treatment; and various examples of retrievable vena cava filters (not drawn to scale). Tables list initial clinical assessment for VTE, clinical scenarios possibly benefiting from prolonged anticoagulation after VTE, indications for laboratory investigation of secondary thrombophilia, venous thromboembolic risk accorded to hypercoagulable states, and Pulmonary Embolism Rule-out Criteria Score to avoid the need for D-dimer in patients suspected of having PE. This review contains 11 highly rendered figures, 5 tables, and 167 references. Key words: anticoagulation; deep vein thrombosis; postthrombotic syndrome; pulmonary embolism; recurrent venous thromboembolism; thrombophilia; venous thromboembolism; PE; VTE; DVT

LO026: Outcomes of a provincial cardiac reperfusion strategy: a population-based, retrospective cohort study

Introduction: Nova Scotia has a province wide reperfusion strategy for the treatment of patients presenting with acute ST-Elevation Myocardial Infarction (STEMI). Patients are referred for primary percutaneous coronary intervention (PPCI) if a first medical contact to device time can be achieved within 90 to 120 minutes; otherwise, fibrinolytic therapy is administered, as per guideline recommendations. Since 2011, Nova Scotian paramedics have been providing prehospital fibrinolysis (PHF) and prehospital catheterization (cath) lab activation for STEMI patients outside and within the PPCI catchment area, respectively. Patients who received fibrinolysis are transferred to a PCI facility if rescue PCI is required or if there are other indications for urgent intervention. This province wide approach is unique and the objective of this retrospective cohort study is to compare the impact of this approach on the primary outcome of 30-day mortality. Methods: For the study period, July 2011 to July 2013, STEMI patients who were diagnosed prehospital or in the ED who subsequently underwent reperfusion therapy were identified in the Emergency Health Services (EHS), Cardiovascular Information Systems (CVIS) and Cardiovascular Health Nova Scotia (CVHNS) databases. Baseline demographics and outcomes were then compared according to the treatment received: 1) PHF; 2) ED Fibrinolysis (EDF); 3) prehospital activated PPCI (EHS PPCI); and 4) ED activated PPCI (ED PPCI). Results: There were a total of 1107 STEMI patients identified during the study period, of whom 742 received lytic therapy (146 PHF; 596 EDF) and 332 underwent PPCI (202 EHS PPCI; 130 ED PPCI). Demographic variables were similar across the groups. The primary outcome of 30-day mortality was not significantly different across groups: 5 (3%) in PHF, 26 (4%) in EDF, 8 (4%) in EHS to PPCI and 2 (2%) in ED to PPCI. The number of rescue PCIs was 28 (19%) in PHF and 102 (17%) in EDF. Other outcomes (key timestamps) are pending. Conclusion: Our results show that the 30-day mortality was lowest for patients undergoing PPCI and slightly less for patients receiving pre-hospital fibrinolytic compared to those receiving ED fibrinolytic with no difference in the proportion requiring subsequent rescue PCI. The majority of patients in rural areas received EDF as opposed to PHF; pending results will show if this represents a delay in patient presentation after symptom onset.

Vestibular Schwannoma

Treatments for vestibular schwannomas include surgical removal and radiotherapy. Observation is a reasonable alternative, given the slow growth of these tumors. The goal of this study was to determine the 5-year no-growth rate in patients managed initially by observation in attempts to define indications for treatment. Retrospective chart analysis of prospectively collected patient database. Patients with unilateral vestibular schwannomas who presented in the last 10 years were reviewed. Those managed initially by observation were reviewed. At least 2 consecutive imaging studies were required. The following information was recorded from the charts: age, sex, tumor size at presentation and subsequent follow-up sessions, treatment in the event of growth, and time interval between presentation and last imaging available. The institutional ethics committee approved the study. One hundred ten patients were included. There were 65 male patients and 45 female patients. The mean age was 62.4 years (range, 32-91 yr). The mean follow-up was 31.4 months (range, 6-156 mo). Twenty-three patients demonstrated evidence of growth, with an overall 5-year no-growth rate of 70.6%. Despite growth, the 5-year no-intervention rate was 81.3%. Interestingly, 11 patients (10%) demonstrated tumor regression. Patients with intracanalicular tumors had a 5-year no-growth rate of 89.8% compared with 73.9% and 45.2% for Grade I and Grade II or larger tumors, respectively. The difference between intracanalicular and Grade II or larger tumors was statistically significant (p = 0.0196). Our data suggest that treatment can be delayed in a large proportion of vestibular schwannoma patients and that this is particularly true in patients with small tumors. Despite growth, only a small percentage of patients require intervention. Thus, we recommend a period of observation to determine the need for treatment in patients without indications for urgent intervention.