Cardiology / Trauma (March 2017)
AIR: Trauma
For a Review Article
- How has reading the article changed your practice?
- What information had you believed in previously that were debunked by reading this article?
- What new information did you learn from reading this article?
- What are current areas of uncertainty on this topic that can be potential areas for research?
For an Original Research Article
- What are some strengths of the study?
- What are the limitations?
- What are the main outcomes of the study?
- Does reading this article change your practice? If so, how?
15 comments
As Jordon (Sparks) says “Tell me how I’m supposed to breathe with no air. Cant live, can’t breathe with no air” – fortunately for her, supplemental o2 probably wont be necessary if her heart is broken again. Though if its traumatic from her relationship with co-artist feat on the track Chris Brown, perhaps we might be concerned with an intramural aortic hematoma.
great succinct articles. with regard to practice change, I think its important to always remember the atypical presentation of dissection/hematoma as the common findings of widened mediastinum or ekg changes may be absent in a large percentage of changes. information contained was in line with previous knowledge but did learn more about the completely different pathologies of hematoma vs dissection and the graphics were a great educational tool. additionally we might include a map to TUFTS since our surgeons don’t appear to ever be here for these types of procedures.
We have been led to believe that O2 is a core component of appropriate treatment for ACS, quite a stimulating article to suggest doing harm in this case. Seems to have been a well designed randomized trial with good outcomes (Mi size based on cardiac MRI @ 6 mo), though noting that their trial was not powered for clinical end points. important also to note in the trial that they were unable to control for oxygen admin in the pre-hospital setting. one more thing, we rarely employ NRB masks in these patients, so perhaps NC doesn’t suggest the same conclusions. Limitations here really surround the significance of these findings in clinical medicine. certainly, it appears that we are not doing harm by withholding Oxygen and potentially are creating complications. Clever title of the trial AVOID which certainly lends it conclusions to its name
Very funny and thoughtful replies.
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To add to that, there’s oxygen in the air too! And it seems to suffice most of the time.
Mussa et al.
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Nice review of dissection, wish it had more on what to do with chronic atherosclerotic plaques that we see incidentally at times on CT. Sometimes those can be managed outpatient by a cardiology or CT surgery.
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Nevertheless, acute intramural hematomas we need to take seriously.
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And certainly the endovascular techniques, esp with severe Type B dissections looks promising.
Stub et al.
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Another study showing that oxygen is a drug, with potential for harm, such as in hyperoxia cardiac arrest.
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Nevertheless, is troponin really a good measure of infarct size? Esp in setting of renal failure etc. The study really didn’t look at clinical end points.
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And 8 L/min of oxygen seems a lot. A lot of times our medics put patients on 2L “for comfort”. Hard to say if there’s benefit or harm to that yet.
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I wonder how well this extrapolates to NSTEMI etc.
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Lets think twice before “MONA”, that’s all.
Mussa et al
1. How has reading the article changed your practice?
-Hadn’t had must experience with intramural hematomas, learned to treat aggressively as with dissection since the majority of them progress to dissection in acute and delayed presentations, many may have associated intimal tears
-also reinforced that idea that some dissections may present painless, 6% per the article, if risk factors especially HTN, smoking are present, concerning story with syncope, BP differential exist then dissection will be higher on differential
-20-30% of patients with neurological deficits, important to check LE strength, sensation as my favorite Polish artery may be involved in dissection…artery of Adamkiewicz which comes off the thoracic or lumbar aorta and supplies anterior spinal cord
2. What information had you believed in previously that were debunked by reading this article?
-I thought type A were open repairs, interesting to learn that TEVAR may have a place in type A dissection repairs
3. What new information did you learn from reading this article?
-see Q1
4. What are current areas of uncertainty on this topic that can be potential areas for research?
-TEVARs in type A dissection
-TEVAR vs medical management in type B dissection
Stub -sorry Alex, going to reiterate most of the same points you made
What are some strengths of the study?
-no randomized trials have evaluated the risks of oxygen therapy in recent years
What are the limitations?
-8L/min???? and facemask, that’s overkill
-small study
-trop and CK as a measure of MI size? I wasn’t sure about this so I looked it up. Apparently well studied in STEMI and can correlate to infarct size as seen on CMR and SPECT.
-Alex, correlations between trop and infarct size are significantly weaker in non-STEMI patient, less studied, NSTEMI involves less infarcted tissue so it’s more difficult to identify ischemic tissue on imaging and correlate it to trop, also the timing of ischemia onset is not always clear in NSTEMI so biomarkers are less helpful
What are the main outcomes of the study?
-STEMI size based on biomarkers
-size of infarct on CMR 6 months out from event
Does reading this article change your practice? If so, how?
-oxygen only if hypoxemic which I feel like we have been practicing. Need to educate nursing about this.
Mussa, et al
How has reading the article changed your practice?
I learned that there are indications for surgical management of Type B dissections (primarily with TEVAR) – those being malperfusion, pregression of dissection, enlarging aneurysm, inability to control BP or sx with medical management
What information had you believed in previously that were debunked by reading this article?
I previously believed that Type B AAS were exclusively managed medically.
What new information did you learn from reading this article?
In addition to the above mentioned, I was reminded that pain control is an important part of medical management of AAS in helping to reduce HR and blood pressure quickly.
What are current areas of uncertainty on this topic that can be potential areas for research
As the article mentions in the conclusion, more data on the safety and efficacy of endovascular repair are needed
Late to the game —
Mussa et al.
1. How has reading the article changed your practice? The article provides a new frame of reference (“acute aortic syndrome”) in which to think about aortic dissection and intramural hematoma, as well as “penetrating ulcer” which I had never heard of before.
2. What information had you believed in previously that were debunked by reading this article? In one study d-dimer had a sensitivity of only 51.7% for AAS. I didn’t think it was that low.
3. What new information did you learn from reading this article?
Intramural hematoma can be thought of as potentially leading to an aortic dissection (up to 47% cause dissection).
4. What are current areas of uncertainty on this topic that can be potential areas for research? Would like to see RCTs for biomarkers that could be used in aortic dissection in a similar way that d-dimer is currently used for PE.
Stub et al.
1. What are some strengths of the study? Challenges medical dogma (MONA for MI). I also like how the study addresses the phenomenon of oxygen “for comfort” by comparing pain scales and use of analgesia between oxygen and non-oxygen groups.
2. What are the limitations? The study’s definition of STEMI is slightly different than that of the AHA 2013 guidelines where 2mm is the cutoff for STEMI only in V2-V3 in males (not all precordial leads in both genders as the study uses). Also, patient population in Australia presumably would be different than that of the USA.
3. What are the main outcomes of the study? Levels of troponin I and creatine kinase as marker for infarct size.
4. Does reading this article change your practice? If so, how? Currently I don’t put patients with ACS on oxygen unless hypoxic. I have had patients request oxygen and so can use this paper to educate patient regarding potential harm with O2 use.
#aorta #dissection
-Change in practice? The article makes a point (and provides evidence) recommending a rapid diagnosis given the a/w morbidity and mortality w/ delay. It’s also interesting to see that it can present with acute decompensated heart failure why may delay surgery. Take away point: make sure that dissection is on the differential and make sure you undergo the requisite exam, dx testing to rule it in/out. I also need to do a better job of keeping it on the ddx if pt p/w neurological sxs.
-Debunked info? Previously thought that medical tx was preferred vs endovascualr repair in type B aortic dissection. The article points to several papers where TEVAR performed better than medical management with respect to morbidity/mortality.
-New info? Hadn’t ever really heard of the acronym AAS before, particularly the other 2 pathologies it includes (intramural hematoma, penetrating atherosclerotic ulcer). Therefore all the info, particularly the management of intramural hematoma (and its ability to regress!) was all new info. Was also unaware of the significant percent of painless aortic dissection at 6.4% – scary!
-Current research? Per the authors, much of the research is observational and otherwise limited. Obviously more studies, especially RCTs, are needed to assess management strategies particularly for type B dissections given that management for type A dissections is more established.
#AVOIDTrial
-Strengths? Multicenter RCT; It’s a good hypothesis given the data and challenges the status quo; there was a good lit review and summarization of prior work. Not necessarily a strength but I thought the inclusion of pre-hospital staff was interesting and perhaps may be a positive trend given that so many interventions that can reduce morbidity/mortality occur in the pre-hospital setting.
-Limitations? A lot. Study was not powered for clinical endpoints, impact of lower oxygen concentrations was not assessed; there were some noted ethical issues given that informed consent prior to enrollment was challenging in the pre-hospital setting; furthermore, the study was limited since treatment allocation was not blinded to paramedics, patients, or cardiology teams; lastly, not all pts underwent cardiac MRI at 6 months
-Outcomes? Supplemental oxygen therapy in STEMI pts w/o hypoxia may increase early myocardial injury and was associated with larger myocardial infarct size assessed at 6 months.
-Change in practice? While I was aware of the effects of oxygen in creating ROS, I had not known that additional oxygen can lead to reduced coronary blood flow and increased vascular resistance. Will continue to only give oxygen if pt requires it.
Dissection!
1. Good introduction to penetrating ulcers and intramural hematomas- 2 things I hadn’t known about prior to reading this article. I was surprised how many hematomas progress to dissection after medical management. In general, there seems to be good evidence for surgical intervention in most of these cases. I will be less reassured by normal EKG/chest x-ray in a pt with hypertension and chest pain- more likely to get that chest CT.
2. Medical management can prevent progression of disease. It seems that individuals with hematomas or severe atherosclerotic disease need very close monitoring- especially if they smoke.
3. Options for surgical repair for these lesions- specifically endovascular vs. open. That not all dissections are surgical emergencies, although they have the potential to be. ~25% of ascending aortic dissections do not have radiographic evidence on x-ray.
4. What pt characteristics make medical management more likely to be safe? What factors lead to progression of intramural hematomas?
Oxygen in STEMI
Woohoo Australia!
1. Strengths: Pre-hospital randomization, good patient follow up with solid end-point assessment after 6 months (although more CMR data would have been preferable), robust objective data, 9 hospitals
2. Limitations: Small study w/ exclusion criteria that pertains to many pts, high O2 rate, not blinded, difficulty obtaining informed consent in this environment, many different interventions used to treat patients- may effect recurrence rate of MI and mortality (confound link between O2 and outcome)
3. Main outcomes: Rate of recurrent MI greater in pts who received oxygen. No sig difference in mortality at 6 months between groups. Geometric mean peak of CK less for no oxygen group. Median infarct size greater for oxygen group at 6 mo using CMR.
4. This is a good reminder to take oxygen off of patients if they do not need it- that supplemental O2 may be doing harm.
Air vs O2 in STEMI
1. I think this study is great because they used robust methodology (an RCT) to debunk a widespread myth (using O2 in normoxic STEMI patients). The intervention group and the control group were also quite well matched considering how many steps it took to actually make it into the cohort (235 got angiography in each arm even after multiple exclusion rounds!)
2. They named their study “AVOID” – clearly this acronym doesn’t work with the study title and is quite the stretch. Ok, that isn’t really a limitation I suppose. The RCT wasn’t blinded, but that would have been difficult. Also, less than half of enrolled patients ended up getting the cardiac MRI. And the study was only powered to detect differences in cardiac biomarkers (not a patient centered outcome), and CK isn’t cardiac specific.
3. There are no benefits to providing supplemental O2 in normoxic STEMI patients, and increased CK levels suggest that O2 may increase early myocardial injury.
4. Not really, I think most people have already moved away from providing supplemental O2 to normoxic STEMI patients. I guess this is another tool to use to support my decision not to.
Aortic Dissection
1. I will think more about intramural hematomas after reading this article – other than that, it hasn’t really.
2. Nothing – unfortunately it’s pretty well known that aortic dissection can present in varied ways, and there are no absolutes when it comes to signs and symptoms. CTA is gold standard, and everything else is subpar.
3. I learned that intramural hematomas form as a result of rupture of the vasa vasorum.
4. I think that the use of biomarkers, whether d-dimer (sensitivity of 51.7% to 100.0%, not promising) or novel biomarkers should be (and are) an area of continued research. It would be helpful to have a test for this rare, life threatening condition that is not CTA or MRI! (or maybe we just need to have more accessible TEE)