tag:blogger.com,1999:blog-12648129645858699682024-03-13T14:54:52.525-04:00EMOttawa - Emergency Medicine OttawaThis is the official blog for the Department of Emergency Medicine at the University of Ottawa. Our main goal is to share the results of our monthly Journal Club for people to view and for our staff/residents to have as a resource if the need arises to review the content. The scores and analysis of each article are derived from an initial critical review of the literature by a single reviewer, followed by a group discussion. Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.comBlogger240125tag:blogger.com,1999:blog-1264812964585869968.post-1761666129607002292017-08-10T13:46:00.000-04:002017-08-10T13:46:32.237-04:00Getting it ‘Right’: Pulmonary Hypertension in the ED<div class="MsoNormal">
<h2>
</h2>
<h2>
Objectives</h2>
<ol>
<li>Describe the pathophysiology of Pulmonary Hypertension (PH), and how it can be dangerous</li>
<li>Who to suspect and workup for PH in the ED</li>
<li>Describe the POCUS findings in PH</li>
<li>Describe the management of these patients and how to avoid causing harm</li>
</ol>
<h3>
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</h3>
<h3>
Physiology</h3>
<u>Definition</u></div>
<div class="MsoNormal">
Pulmonary hypertension (PH) is defined as a pulmonary artery mean pressure <b>>25 mmHg</b> by right heart catheterization at rest. Transthoracic echocardiography is used as a screening tool with a right ventricular systolic pressure (RVSP) <b>> 40 </b>being suggestive but not diagnostic of PH (1,2).</div>
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<div class="MsoNormal">
<u>Classification</u></div>
<div class="MsoNormal">
PH can be divided broadly into conditions primarily affecting pulmonary arterioles (Group 1) or secondary causes that progressively lead to changes in the pulmonary arteries (Groups 2-5). </div>
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<span style="font-size: 12pt;"><br />
</span></div>
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<a href="https://2.bp.blogspot.com/-pZmJCDrwGr0/WYdGA91OUKI/AAAAAAAACQs/gr4B7r00JbkRr8wr1fOVed24FuX9RTyHACLcBGAs/s1600/anatomic%2Band%2Bphysiological%2Bconsiderations.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em; text-align: center;"><img border="0" data-original-height="373" data-original-width="405" height="292" src="https://2.bp.blogspot.com/-pZmJCDrwGr0/WYdGA91OUKI/AAAAAAAACQs/gr4B7r00JbkRr8wr1fOVed24FuX9RTyHACLcBGAs/s320/anatomic%2Band%2Bphysiological%2Bconsiderations.png" width="320" /></a><span style="font-size: 12pt;"><b>Group 1</b> is pulmonary arterial hypertension that is: </span></div>
<div class="MsoNormal">
<ul>
<li>idiopathic</li>
<li>heritable</li>
<li>drug-induce</li>
<li>associated with other conditions (eg. HIV, schistosomiasis, portal hypertension)</li>
</ul>
The secondary causes include: </div>
<div class="MsoNormal">
<ul>
<li><b>Group 2:</b> Left sided heart disease (eg. valvular disease, left ventricular systolic or diastolic dysfunction)</li>
<li><b>Group 3: </b>Lung disease or chronic hypoxia (eg. Chronic obstructive lung disease, obstructive sleep apnea, interstitial lung disease etc.)</li>
<li><b>Group 4:</b> Chronic thromboembolic pulmonary hypertension (CTEPH)</li>
<li><b>Group 5:</b> Multifactorial mechanisms (eg.hematologic disorders, sarcoidosis, chronic renal failure, thyroid disorders etc) (2). </li>
</ul>
<h3>
Concerning physiology</h3>
All PH groups share a common pathway of chronic RV changes:</div>
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<div class="MsoNormal">
<br />
The right coronary artery (RCA) normal supplies the RV in both diastole and systole. In PH, the increased pressure in the RV leads to filling in diastole only, thus limiting the perfusion to the hypertrophying RV (3).<br />
<h3>
Acute RV Failure </h3>
<ul>
<li>The RV has little physiologic reserve</li>
<li>Acute illness (eg. sepsis), hyper- or hypovolemia</li>
<li>Tachydysrhythmias can lead to RV failure</li>
<li>Increased RV overload leads to: </li>
<ul>
<li>worsening LV output</li>
<li>decreased RCA perfusion</li>
<li>decreased RV perfusion --> leading to a “spiral of death” (4)</li>
</ul>
</ul>
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<h3>
Who to suspect and Workup in the ED</h3>
In dyspneic patients, suspect PH if:</div>
<div class="MsoNormal">
<ul>
<li>Predisposing comorbidities (PH Groups 2-5)</li>
<li>Physical exam: </li>
<ul>
<li>Normal respiratory exam. </li>
<li>Loud P2, holosystolic regurgitant murmur or parasternal heave.</li>
<li>Signs of right-sided heart failure (jugular venous distension, hepatomegaly, splenomegaly, peripheral edema)</li>
</ul>
<li>Investigations:</li>
<ul>
<li>Elevated troponin </li>
<li>EKG with right ventricular hypertrophy, right axis deviation, right atrial enlargement</li>
<li>Chest xray with enlarged right heart border, enlarged pulmonary artery shadow, and obliteration of the retrosternal space</li>
<li>CT chest can suggest PH (size of pulmonary artery >30mm, enlarged RV, pulmonary artery > proximal ascending aorta) (4; 5)</li>
</ul>
</ul>
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<a href="https://3.bp.blogspot.com/-FQAnR41gnmE/WYdJrZZdlfI/AAAAAAAACRI/Wx0jOvR229smfTvJMolLYUKmjsYW3qyDwCLcBGAs/s1600/CXRA.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="303" data-original-width="608" height="316" src="https://3.bp.blogspot.com/-FQAnR41gnmE/WYdJrZZdlfI/AAAAAAAACRI/Wx0jOvR229smfTvJMolLYUKmjsYW3qyDwCLcBGAs/s640/CXRA.png" width="640" /></a></div>
<div>
<br /></div>
<i>In unexplained dyspnea with a normal CT PA, what proportion of patients have PH?</i></div>
<div class="MsoNormal">
An independent, prospective validation of a clinical decision rule in patients with dyspnea by <a href="https://www.ncbi.nlm.nih.gov/pubmed/25769797">Russell et al. 2015</a><span id="goog_2021451444"></span><a href="https://www.blogger.com/"></a><span id="goog_2021451445"></span> demonstrated that patients with ongoing dyspnea and a negative CTPA had a high rate (33%) of RV dysfunction and RV overload. While the study had inherent workup and selection bias, there appears to be a high prevalence of RV dysfunction in this patient population and outpatient referral for echocardiogram should be considered (6).<br />
<h3>
What are the POCUS findings in PH?</h3>
<ul>
<li>RV dilatation with a RV end-diastolic/ LV end-diastolic Ratio > 0.9 on the apical 4 chamber view (4; 7)</li>
<li>Flattening of the interventricular septum with a “D” Sign on the parasternal short axis (4; 5; 8)</li>
<li>Thickened RV free wall >5mm on the subcostal view (8; 9)</li>
<li>Other advanced findings include: right atrial enlargement, tricuspid regurgitation, TAPSE < 15mm (7; 9)</li>
</ul>
</div>
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<span style="font-size: 12pt;">RV Dilation</span></div>
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</td> <td style="border-left: none; border: solid windowtext 1.0pt; height: 144.8pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 159.6pt;" valign="top" width="160"><div class="MsoNormal">
<a href="https://2.bp.blogspot.com/-icpiC2zCmco/WYdJ4VY5OCI/AAAAAAAACRU/Du8BF4EmoSQp8vEqVathbimSyuWUKdBMQCLcBGAs/s1600/subx2.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="226" data-original-width="224" height="200" src="https://2.bp.blogspot.com/-icpiC2zCmco/WYdJ4VY5OCI/AAAAAAAACRU/Du8BF4EmoSQp8vEqVathbimSyuWUKdBMQCLcBGAs/s200/subx2.png" width="197" /></a></div>
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<span style="font-size: 12pt;">Thickened RV Wall</span></div>
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<a href="https://1.bp.blogspot.com/-hLPl3GDWvow/WYdJ0QX1n4I/AAAAAAAACRQ/Yor3-KgA0n8uE1dlMl6t6kcVgeWvoMYeACLcBGAs/s1600/subx.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="213" data-original-width="219" height="194" src="https://1.bp.blogspot.com/-hLPl3GDWvow/WYdJ0QX1n4I/AAAAAAAACRQ/Yor3-KgA0n8uE1dlMl6t6kcVgeWvoMYeACLcBGAs/s200/subx.png" width="200" /></a></div>
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<span style="font-size: 12pt;">"D" sign - septal bowing</span></div>
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<h3>
What is the management of acute decompensated RV failure in the ED?</h3>
In a systematic review of the intensive care literature, Price et al. made the following recommendations (9):</div>
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<ul>
<li><b>Optimize volume status</b></li>
<ul>
<li>Close monitoring of fluid status with a trial of diuresis or volume loading if indicated-WEAK recommendation.</li>
</ul>
<li><b>Maximize cardiac output</b></li>
<ul>
<li>Dobutamine (start 2 mcg/kg/min up to 10mc/kg/min)-WEAK recommendation.</li>
<li>Milrinone (start 0.375 mcg/kg/min) –STRONG recommendation but caution given systemic hypotension is common.</li>
<li>Avoid Dopamine- STRONG recommendation.</li>
</ul>
<li><b>Maintain RCA perfusion</b></li>
<ul>
<li>If needed, start norepinephrine to maintain MAP >65- WEAK recommendation.</li>
<li>Add vasopressin if resistant to norepinephrine- WEAK recommendation</li>
</ul>
<li><b>Reduce Pulmonary Vascular Resistance</b></li>
<ul>
<li>Inhaled nitric oxide in select populations- WEAK recommendation</li>
<li>Correct hypoxia, hypercarbia </li>
</ul>
</ul>
<i>What is the management of sepsis and septic shock in PH patients?</i></div>
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<ul>
<li>Rapid treatment of underlying source as high mortality in PH patients (>48%) (10)</li>
<li>Cautious volume resuscitation with 250-500 ml IV boluses at a time (11)</li>
<li>Early vasopressor support with Norepinephrine +/- Vasopressin (4; 12)</li>
<ul>
<li>Phenylephrine NOT recommended (9)</li>
</ul>
</ul>
<i>What is the recommended method of intubation in PH Patients? </i><br />
<ul>
<li>Low quality evidence to make strong recommendations</li>
<li>Induction: Etomidate or ketamine (14; 15)</li>
<li>Peri-intubation: Consider NE prior to intubating to maintain MAP >65 (4)</li>
<li>Post-intubation: Avoid hypotension, consider benzodiazepines or Ketamine (3; 4)</li>
</ul>
<i>What is the management of atrial fibrillation and flutter in patients with PH?</i></div>
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<ul>
<li>Sustained atrial fibrillation has a high mortality (>80% ) so <b>CARDIOVERT</b> if you can! (14)</li>
<li>Amiodarone can be considered if cardioversion is not possible (15)</li>
<li>B-adrenergic receptor antagonists or calcium channel blockers are not recommended (15)</li>
<li>Digoxin can be used in COPD patients with Afib/flutter (15)</li>
</ul>
<i>What is the management of patients on IV epoprostenol in the ED?</i><br />
<ul>
<li>Epoprostenol (Flolan) is a prostacyclin that relaxes smooth muscle in pulmonary arteries</li>
<li>Improves survival of patients with pulmonary arterial hypertension</li>
<li>Half life of IV epoprostenol is approximately 2-5 minutes</li>
<li>If Hickman blocked, <b>start peripheral IV immediately and continue infusion of prostacyclin</b> or <a href="http://www.cpso.on.ca/uploadedFiles/members/resources/practicepartner/patientsafety/patientsafetyarticles/patient-safety-dialoguev7-iss3-11.pdf">patient will rapidly decompensate in RV failure leading to cardiac arrest from acutely increased RV afterload</a></li>
</ul>
<h2>
Take Home points:</h2>
<ul>
<li>Suspect PH in dyspneic patients and those with pre-disposing conditions </li>
<li>Use POCUS to assist in diagnosis/ workup</li>
<li>In acute RV failure, maximize volume status, start early inotropes and vasopressors </li>
<li>Consider intubation challenges</li>
<li>Cardiovert patients in atrial fibrillation/ atrial flutter</li>
<li>Do not stop IV prostacyclin (eg Epoprostenol)!!</li>
</ul>
<div>
<br /></div>
<div style="clear: left; margin-bottom: 1em; margin-right: 1em; text-align: center;">
<a href="https://4.bp.blogspot.com/-LrsZBUJOCQk/WYdMVUolgxI/AAAAAAAACRg/-_MG431XEZoc8QM-zzw8np5SD9R3GcKygCLcBGAs/s1600/BURWASH-BRENNAN-lg.jpg" imageanchor="1" style="clear: left; float: left; font-size: 12pt; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="463" data-original-width="450" height="320" src="https://4.bp.blogspot.com/-LrsZBUJOCQk/WYdMVUolgxI/AAAAAAAACRg/-_MG431XEZoc8QM-zzw8np5SD9R3GcKygCLcBGAs/s320/BURWASH-BRENNAN-lg.jpg" width="310" /></a></div>
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<div class="MsoNormal" style="text-align: center;">
Dr. Talia Burwash-Brenna, MD, CCFP-EM, is a graduate of the University of Ottawa CCFP-EM program and a current Point-of-Care Ultrasound Fellow at the University of Ottawa. </div>
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</span></div>
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<span style="font-size: x-small;"><i><br /></i></span>
<span style="font-size: x-small;"><i>Edited and Formatted by Dr. Rob Suttie, PGY3 Emergency Medicine at the University of Ottawa</i></span></div>
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<div style="text-align: center;">
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<h4>
<span style="font-size: 12pt;">References</span></h4>
</div>
<div>
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1. Rich J, Rich S. Clinical Diagnosis of Pulmonary Hypertension. Circulation 2014, 130:1820-1830.<br />
2. Galiè N, Simmonneau, G.The Fifth World Symposium on Pulmonary Hypertension. Journal of the American College of Cardiology. 2014, 62 (D1-D3).<br />
3. Hoeper MM, Granton J. Intensive care unit management of patients with severe pulmonary hypertension and right heart failure. Am J Respir Crit Care Med 2011 and 184:1114–24.<br />
4. Wilcox, S., Kabrhel, C,Channick RN.Pulmonary Hypertension and Right Ventricular Failure. Annals of Emergency Medicine 2015. 66: 619 - 628.<br />
5. Greenwood, JC., Spangler, RM. Management of Crashing Patients with Pulmonary Hypertension. Emerg Med Clin N Am 2015 and ., 33 623–643.<br />
6. Russell, F., Moore, C., Courtney, D., Kabrhel, C., Smithline, H., Nordenholz, K., Richman, P., O'Neil, B., Plewa, M., Beam, D., Mastouri, R. and Kline, J. (2015). Independent evaluation of a simple clinical prediction rule to identify right ventricular dysfunction in patients with shortness of breath. The American Journal of Emergency Medicine, 33(4), pp.542-547.<br />
7. Voelkel N, Quaife R, Leinwand L, et al. Right ventricular function and failure. Circulation 2006 and 1883-1891, 114:.<br />
8. Matthews JC, McLaughlin V. Acute Right Ventricular Failure in the Setting of Acute Pulmonary Embolism or Chronic Pulmonary Hypertension: A Detailed Review of the Pathophysiology, Diagnosis, and Management. Current Cardiology Reviews. 2008 and doi:10.2174/157340308783565384., 4(1):49-59.<br />
9. Price LC, Wort SJ, Finney SJ, et al. Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review. Crit Care. 2010 and 14:R169.<br />
10. Tsapenko MV, Herasevich V, Mour GK, . Severe sepsis and septic shock in patients with pre-existing non-cardiac pulmonary hypertension: contemporary management and outcomes. Crit Care Resusc J Australas Acad Crit Care Med. 2013 and 15(2):103–109.<br />
11. Belisha S, Kastrati A, Goda A, Popa Y. Optimal value of filling pressure in the right side of the heart in acute right ventricular infarction. Br Heart J 1990 and 98-102., 63:.<br />
12. Gold J, Cullinane S, Chen J, Seo S, Oz MC, Oliver JA, Landry DW: Vasopressin in the treatment of milrinone-induced hypotension in severe heart failure. Am J Cardiol 2000, 85:506-508, A511.<br />
13. Igarashi A, Sato T, Tsujino I, Ohira H, Yamada A, Watanabe T, et al. Four cases with group 3 out-of-proportion pulmonary hypertension with a favorable response to vasodilators. Respiratory medicine case reports. 2013 and 9:4–7.<br />
14. Olsson KM, Nickel NP , Tongers J , Hoeper M.Atrial Flutter and Fibrillation in Patients with Pulmonary Hypertension. International Journal of Cardiology 2013 and 167(5):2300-2305.<br />
15. Tongers J, Schwerdtfeger B, Klein G et al .Incidence and clinical relevance of supraventricular tachyarrhythmias in pulmonary hypertension. American Heart Journal. 2007 and 53:127–132.</div>
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</style>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-83060897537929184632017-07-13T20:34:00.000-04:002017-07-13T20:34:52.388-04:00Under Pressure: Review of Management of Hypertension in Neurological Emergencies<div class="MsoNormal">
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<tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-PwaVauAhQuo/WT9bMXf27qI/AAAAAAAACP4/XaeYn36yD2wxlf-BSYhdxxp6w2SZMS2mgCLcB/s1600/Bowie%2Band%2BMercury.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="580" data-original-width="900" height="412" src="https://1.bp.blogspot.com/-PwaVauAhQuo/WT9bMXf27qI/AAAAAAAACP4/XaeYn36yD2wxlf-BSYhdxxp6w2SZMS2mgCLcB/s640/Bowie%2Band%2BMercury.jpg" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Under Pressure, the 1981 classic by Queen in collaboration with David Bowie</td></tr>
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<br />
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<span style="font-family: "calibri"; font-size: 13.0pt;">Objectives:<o:p></o:p></span></div>
<ul type="disc">
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">Explore the data for
safety and efficacy of urgent BP lowering in hemorrhagic stroke.<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">Is there any benefit from
management of elevated BP in acute ischemic stroke that is not a candidate
for tPA?<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">What is the data for BP
target in aSAH awaiting definitive management?<o:p></o:p></span></li>
</ul>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<br />
<a name='more'></a></div>
<h3>
<span style="font-family: "calibri";"><span style="font-size: x-large;">PART 1</span><span style="font-size: 13pt;"><o:p></o:p></span></span></h3>
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<span style="font-family: "calibri"; font-size: 13.0pt;">Acute hemorrhagic stroke,<span class="apple-converted-space"> </span>which is the least treatable form of
stroke, affects more than 1 million people worldwide annually, with the outcome
determined by the volume and growth of the underlying hematoma. Blood pressure
often becomes elevated after intracerebral hemorrhage (ICH), frequently
reaching very high levels, and is associated with poor outcomes. <o:p></o:p></span><o:p></o:p></div>
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<!--StartFragment-->
<!--EndFragment--><br />
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<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<span style="font-family: "calibri"; font-size: 13.0pt;">There have been two major trials
looking at modifying BP in ICH,<span class="apple-converted-space"> </span><b>ATACH2</b><span class="apple-converted-space"> </span>in 2016 <o:p></o:p></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<span style="font-family: "calibri"; font-size: 13.0pt;">and <b>INTERACT2</b><span class="apple-converted-space"> </span>in 2013.<o:p></o:p></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<br /></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<b><i><span style="font-family: "calibri"; font-size: 13.0pt;">Background:</span></i></b><o:p></o:p><span style="font-family: "calibri"; font-size: 13.0pt;"><o:p></o:p></span></div>
<ul type="disc">
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-fareast-font-family: "Times New Roman";">Elevated
BP is very common in acute hemorrhagic stroke</span><span lang="EN-CA" style="font-family: "times new roman"; font-size: 13.0pt;"><o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-fareast-font-family: "Times New Roman";">There
is an association with elevated BP and:<o:p></o:p></span></li>
<ul type="circle">
<li class="MsoNormal" style="mso-list: l0 level2 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 72.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-fareast-font-family: "Times New Roman";">Increase
in hematoma size<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l0 level2 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 72.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-fareast-font-family: "Times New Roman";">Neuro-deterioration<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l0 level2 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 72.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-fareast-font-family: "Times New Roman";">Dependency<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l0 level2 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 72.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-fareast-font-family: "Times New Roman";">Death<o:p></o:p></span></li>
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<br /></div>
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<o:p></o:p><b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span style="font-family: "calibri"; font-size: 13.0pt;"><o:p></o:p><o:p></o:p><o:p></o:p><o:p></o:p>In
terms of guidance, the 2015 AHA guidelines are mainly based on the 2013
Interact 2 study. <span class="apple-converted-space"> </span>They
recommend that for patients presenting with a systolic BP 150-220 that you aim
for a systolic reduction to less than 140 and that this might be a reasonable
option for patients who present with a BP > 220 as well.</span><o:p></o:p></i></b><span style="font-family: "calibri"; font-size: 13.0pt;"><o:p></o:p></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<br /></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<span style="font-family: "calibri"; font-size: 13.0pt;">There are 2 main questions which
studies have looked at in regards to BP reduction in hemorrhagic stroke and for
various neurological conditions in general. They include:<o:p></o:p></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<span style="font-family: "calibri"; font-size: 13.0pt;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l1 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<!--[if !supportLists]--><span lang="EN-CA" style="font-family: "times new roman"; font-size: 13.0pt;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span lang="EN-CA" style="font-size: 13.0pt; mso-fareast-font-family: "Times New Roman";">Is blood pressure reduction safe?</span><span lang="EN-CA" style="font-family: "times new roman"; font-size: 13.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l1 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<!--[if !supportLists]--><span lang="EN-CA" style="font-size: 13.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span lang="EN-CA" style="font-size: 13.0pt; mso-fareast-font-family: "Times New Roman";">Does BP reduction improve outcomes?<o:p></o:p></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<br /></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<b style="mso-bidi-font-weight: normal;"><i><span style="font-family: "calibri";"><span style="font-size: large;">Safety:</span></span></i><o:p></o:p></b><span style="font-family: "calibri"; font-size: 13.0pt;"><o:p></o:p></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<b style="mso-bidi-font-weight: normal;"><i><span style="font-family: "calibri";"><span style="font-size: large;"><br /></span></span></i></b></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<span style="font-family: "calibri"; font-size: 13.0pt;">In animal models of ICH and human
imaging studies there is a zone of hypoperfusion surrounding a clot. So the
questions is, will rapid reduction of BP in ICH result in infarction around the
area of hemorrhage? There have been several studies which have looked at this
question.<o:p></o:p></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<o:p></o:p><i><span style="font-family: "calibri"; font-size: 13.0pt;"><a href="https://www.ncbi.nlm.nih.gov/pubmed/11435792">Zazulia et al 2001</a><span class="apple-converted-space"> </span>and<span class="apple-converted-space"> </span><a href="http://stroke.ahajournals.org/content/strokeaha/35/8/1879.full.pdf">Butcher
et al 2004</a><span class="apple-converted-space"> </span></span></i><span style="font-family: "calibri"; font-size: 13.0pt;">were two imaging based studies
which both seemed to suggest that rapid BP reduction could be safe in ICH.<o:p></o:p></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<span style="font-family: "calibri"; font-size: 13.0pt;"><br /></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<b><u><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">SAMURAI Study:</span></u></b><u1:p></u1:p><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">The<span class="apple-converted-space"> </span><a href="http://stroke.ahajournals.org/content/strokeaha/44/7/1846.full.pdf">Stroke
Acute Management with Urgent Risk-factor Assessment and Improvement</a> or
(SAMURAI)-ICH Study was a non-randomized, multi-centre, observational study to
determine the safety and feasibility of SBP reduction<span class="apple-converted-space"> </span>to <160 mm Hg<span class="apple-converted-space"> </span>within 3 hours of symptoms onset with
intravenous nicardipine for acute hypertension in patients with spontaneous ICH.<u1:p></u1:p><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">They concluded that high SBP after initiation of standardized
antihypertensive treatment was independently associated with neurological
deterioration, hematoma expansion, and unfavourable functional outcome in acute
ICH. A mean SBP ≈130 mm Hg was associated with the lowest odds ratios for worse
clinical outcomes.<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">There are a lot of limitations of this non-randomized study but they
theorized that<span class="apple-converted-space"> </span><b>aggressive
antihypertensive treatment for such patients MAY improve clinical outcomes.</b><o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<b><u><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">ICH ADAPT:</span></u></b><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">The<span class="apple-converted-space"> </span><a href="https://www.ncbi.nlm.nih.gov/pubmed/23391776">ICH ADAPT study</a><span class="apple-converted-space"> </span>was a multi-centre, prospective,
randomized, open-label, with blinded evaluation study. One of the
authors was<span class="apple-converted-space"> </span><a href="http://www.ohri.ca/profile/ddowlatshahi">Dr. Dowlatshahi</a><span class="apple-converted-space"> </span>one of our stroke neurologist here at
the The Ottawa Hospital who has a special interest in ICH. We will get to some
of his recommendations later on.<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">In this study eligible patients were those with spontaneous ICH
diagnosed on CT < 24 hours after onset with SBP ≥150 mm Hg. Patients with
evidence of secondary ICH (eg, vascular malformation), planned surgical
resection, or contraindications to CT perfusion were excluded.<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">Their hypothesis was that early acute BP reduction would not result in
significantly lower peri-hematoma CBF compared to patients managed
conservatively.<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">Their<span class="apple-converted-space"> </span><b>primary outcome<span class="apple-converted-space"> </span></b>was to look at CBF in the
peri-hematomal region using CT-perfusion scans in an aggressively treated vs
non aggressively treated group. <span class="apple-converted-space"> </span>They
looked at secondary end points of<span class="apple-converted-space"> </span><b>clinical
outcomes and ICH expansion</b><span class="apple-converted-space"> </span>but
this was a small study and was not powered to detect any differences<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">This study essentially showed<span class="apple-converted-space"><b> </b></span><b>no
difference in perihematomal CBF.</b><span class="apple-converted-space"> </span>There
was no statistical difference<span class="apple-converted-space"> </span>in
clinical outcomes or ICH size increase which is maybe not surprising given
their small numbers.<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<b><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">This study supported that rapid lowering of BP in ICH is likely safe</span></b><span class="apple-converted-space"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;"> </span></span><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">and we needed more trials to figure out if it might be helpful.<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<b><u><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">INTERACT Trial</span></u></b><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">The precursor to the INTERACT 2 trial was<span class="apple-converted-space"> </span><a href="https://www.ncbi.nlm.nih.gov/pubmed/18396107">The Intensive Blood
Pressure Reduction In Acute Cerebral Haemorrhage trial (INTERACT)</a>. This was
a randomized controlled trial that demonstrated that early intensive BP
reduction was clinically feasible and well tolerated.<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<b><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">It also appeared to reduce hematoma growth in patients treated within
6 hours after the onset of acute ICH.</span></b><u1:p></u1:p><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">They<span class="apple-converted-space"> </span>randomized patients
to guideline therapy based on the 1999 AHA guidelines of systolic BP <
180 <span class="apple-converted-space"> </span>vs intensive therapy of
sBP < 140 with the goal to reach target within 1 hour and maintain target
for 7 days.<span class="apple-converted-space"> </span><b>The primary
outcome they were looking at was the size of the hematoma and perihematomal
edema</b>. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">They did NOT look at clinical outcomes but we will look at their
follow up study later (INTERACT-2).<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<u1:p></u1:p><b><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">They did find a statistically significantly difference in the hematoma
size after 24 and 72 hours</span></b><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">. <span class="apple-converted-space"> </span>Once again this was a pilot and
feasibility study and with no real clinical outcomes this should be interpreted
with caution. But these studies do give us some valuable information on the
natural clinical course of hematoma formation and growth.<o:p></o:p></span><u1:p></u1:p></div>
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<br /></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<b><i><span style="font-family: "calibri";"><span style="font-size: large;">Efficacy</span></span></i></b></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<br /></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<b><u><span style="font-family: "calibri"; font-size: 13.0pt;"><a href="http://www.nejm.org/doi/pdf/10.1056/NEJMoa1214609">INTERACT-2 Trial</a></span></u></b><span style="font-family: "calibri"; font-size: 13.0pt;"><o:p></o:p></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm; mso-line-height-alt: 11.75pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">So that brings us to INTERACT 2 <span class="apple-converted-space"> </span>which is the largest RCT evaluating
the efficacy of intensive BP reduction. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">They enrolled 2839 patients with SBP between 150 and 220 mm Hg within<span class="apple-converted-space"> </span><b>6 hours of ICH</b>.<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<b><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">They found that that (52.0%) receiving intensive treatment (to an SBP
target of <140 mm Hg within 1 hour of randomization) compared
with (55.6%) receiving standard treatment (SBP <180 mm Hg) had a
primary outcome of death or major disability</span></b><span class="apple-converted-space"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;"> </span></span><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">(OR, 0.87; 95% CI, 0.75–1.01; P=0.06)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<u1:p></u1:p><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">They had a very large sample size with 1399 in the intensive group at
1430 in the guideline based group. The majority of the patients in the study
were recruited in China and as you would expect most had a history of
HTN. <span class="apple-converted-space"> </span>The mean age was 63
years old with a mean systolic BP of 179. Median NIHSS score was 10 and median
GCS was 14.<o:p></o:p></span><u1:p></u1:p></div>
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<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">The most common agent used was an alpha blocker which is only
available in China called Urapadil, <span class="apple-converted-space"> </span>in
terms of how sick the groups were in regards to ICU admission and surgical
interventions the two groups were very similar.<o:p></o:p></span><u1:p></u1:p></div>
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<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">Looking at the above graph, you can see that at 1 hour, the mean
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mm Hg in the standard-treatment group (a difference of 14 mm Hg, P<0.001).<o:p></o:p></span><u1:p></u1:p></div>
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hour (half achieved the target by 6 hours), and most (75%) presented with mild
to moderate size (<20 mL) hematomas.<o:p></o:p></span></div>
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<i><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">Outcomes:</span></i><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;"><o:p></o:p></span></div>
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<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">For the primary outcome there was a slight trend towards benefit for
the intensive group with 52% vs 55.6% of the guideline group suffering death or
major disability (p 0.06). There was no difference in Death at 90 days or
duration of stay in hospital. <span class="apple-converted-space"> </span>If
you look through the modified Rankin scores the 2 groups look roughly similar.<o:p></o:p></span><u1:p></u1:p></div>
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<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">So overall, this was a negative study with a trend towards benefit
from aggressive treatment. <span class="apple-converted-space"> </span><b>In
patients with ICH, intensive BP lowering did not reduce risk of death of major
disability. </b><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">After the trial was started they decided to include the ordinal
analysis of the Rankin Scale which showed a marginally significant result in
favour of the intensive group with a<span class="apple-converted-space"> </span><i>p<span class="apple-converted-space"> </span></i>value of 0.04. There were no
differences noted in adverse events.<o:p></o:p></span></div>
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<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">So after this large study it seems like a overall rapid reduction of
BP to less < 140 is safe. It is possible there is a slight trend towards
decreased disability.<o:p></o:p></span></div>
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<i><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">Criticisms</span></i><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;"><o:p></o:p></span></div>
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<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">The main criticism of the study was the fact the improvement in
functional outcome was based on an ordinal analysis which was only considered
after the trial had started. Additionally, the vast majority of patients were
from China which may limit generalizability.<o:p></o:p></span><u1:p></u1:p></div>
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<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">The most common IV agent used in the study was Urapadil (alpha blocker)
which is not used in North America. It also ended up taking awhile to get
patients to target and by the time most patients they reached target
it was approximately 8 hours post event.<o:p></o:p></span><u1:p></u1:p></div>
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<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">Looking at the natural progression of ICH it looks like under 6 hours
1/3 of hematomas will expand, after 6 hours the vast majority aren’t going to
change,<span class="apple-converted-space"> </span><b>so the delay in
reduction could have hidden some benefit.</b><o:p></o:p></span></div>
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<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">This data is what the 2<i>015 AHA guidelines</i><span class="apple-converted-space"> </span>are based on, which state:<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<b><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">ICH patients presenting with SBP between 150 and 220 mm Hg and without
contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is
safe (Class I; Level of Evidence A) and can be effective for improving
functional outcome (Class IIa; Level of Evidence B).</span><u1:p></u1:p></b><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<b><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">For ICH patients presenting with SBP >220 mm Hg, it may be
reasonable to consider aggressive reduction of BP with a continuous intravenous
infusion and frequent BP monitoring (Class IIb; Level of Evidence C).</span><u1:p></u1:p></b><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;"><o:p></o:p></span></div>
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<span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">But there has been another large trial looking at this, the ATACH 2
trial.<o:p></o:p></span><u1:p></u1:p></div>
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<tr><td style="text-align: center;"><a href="https://4.bp.blogspot.com/-8uQLUuAAve4/WSOQDLCIrqI/AAAAAAAACOk/7MFLMnVtnkktiuUwnNZzA4OdWDORvBduACLcB/s1600/Atach%2B2.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="73" src="https://4.bp.blogspot.com/-8uQLUuAAve4/WSOQDLCIrqI/AAAAAAAACOk/7MFLMnVtnkktiuUwnNZzA4OdWDORvBduACLcB/s400/Atach%2B2.png" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-size: xx-small;"><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1603460#t=article">Qureshi A, Palesch Y, Barsan W, Hanley D, Hsu C, Martin R et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. New England Journal of Medicine. 2016;375(11):1033-1043.</a></span></td></tr>
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<br />
<ul>
<li>Large
randomized, multi-centere, open label, international study</li>
<li>Like
INTERACT, the outcome assessors were blinded</li>
<li>N
was 1000 – stopped early for futility of primary outcome</li>
<li>Compared
intensive 110-139 systolic vs 140-179 systolic</li>
<li>Initially
included from 3 hours of onset, increased to 4.5 hours</li>
<li>Primary
outcome was death or major disability</li>
</ul>
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<br /></div>
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<span lang="EN-CA" style="font-size: 13pt;"><u1:p style="font-size: 14.6667px;"></u1:p><u1:p></u1:p><u1:p></u1:p><u1:p></u1:p><u1:p></u1:p><u1:p></u1:p>Their
inclusion criteria was anyone over the age of 18 with ICH and a GCS of 6 and
above with at least one BP of > 180 systolic. They initially included
only patients within 3 hours of onset but stretched that to 4.5
hours. <o:p></o:p></span></div>
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<span lang="EN-CA" style="font-size: 13pt;">Their exclusion criteria included: <o:p></o:p></span></div>
<span style="font-size: 13pt;"></span><br />
<ul><span style="font-size: 13pt;">
<li>sBP
>240 x 2 measurements</li>
<li>known
neoplasm/AVM/aneurysm</li>
<li>trauma</li>
<li>candidate
for immediate neurosurgical intervention</li>
<li>not
a ICU candidate. </li>
</span></ul>
<span style="font-size: 13pt;">
</span>
<br />
<div>
<span style="font-size: 13pt;"><br /></span></div>
<span style="font-size: 13pt;">
</span><span style="font-size: 13pt;">This study was more standardized in terms of drug usage
with IV nicardipine being used as first line and labetalol added if BP target
not reached within 30mins.</span></div>
<div class="MsoNormal">
<span style="font-size: 13pt;"><br /></span><span style="font-size: 13pt;">They screened 8500 patients and recruited 1000 patients.
The initial goal was 1280. The mean SBP on presentation was just over 200
systolic. The baseline characteristics were very similar to both groups.</span></div>
<div class="MsoNormal">
<span style="font-size: 13pt;"><br /></span><span style="font-size: 13pt;">Comparing this population to the INTERACT study they were
less sick with 56% having a GCS of 15.</span></div>
<div class="MsoNormal">
<span style="font-size: 13pt;"><br /></span><span style="font-size: 13pt;">The INTERACT study also included patients with lower BP
whereas to be included in this study your arrival BP had to be >180.</span></div>
<div class="MsoNormal">
<span style="font-size: 13pt;"><br /></span><span style="font-size: 13pt;">The other very important point here is the</span><span class="apple-converted-space" style="font-size: 13pt;"> </span><b style="font-size: 13pt;">mean hematoma volume.</b><span class="apple-converted-space" style="font-size: 13pt;"> </span><span style="font-size: 13pt;">Dr Dowlatshahi</span><span class="apple-converted-space" style="font-size: 13pt;"> </span><span style="font-size: 13pt;">has looked at a few studies in terms
of the natural progression of these small volume hematomas and it seems that
under 10 cc these hematomas don’t tend to expand, so they may not be the ones
to benefit from rapidly decreasing the BP.</span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-UqnyfovWr0Q/WT9Qt4bsMVI/AAAAAAAACPA/427Q4mklFI4lK2ZfB68vz1zrKx1gJy_oQCLcB/s1600/figure%2B1.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="514" data-original-width="649" height="506" src="https://1.bp.blogspot.com/-UqnyfovWr0Q/WT9Qt4bsMVI/AAAAAAAACPA/427Q4mklFI4lK2ZfB68vz1zrKx1gJy_oQCLcB/s640/figure%2B1.png" width="640" /></a></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">The mean interval between symptom onset and randomization
was 182.2 minutes in the intensive-treatment group and 184.7 minutes in the
standard-treatment group. So this was good because they got patients early in
the window under 6 hours where hematoma expansion occurs.<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">The mean values of hourly minimum systolic blood pressure
for the first 24 hours after randomization according to treatment group are
shown above in Figure. 1. The mean systolic blood pressure during the first 2
hours was 128.9 in the intensive treatment group<span class="apple-converted-space"> </span>141.1<span class="apple-converted-space"> </span>in the standard-treatment group.<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<b><span lang="EN-CA" style="color: black; font-size: 13.0pt;">This is really important, Essentially what this trial was
looking at was guideline treatment <140 <span class="apple-converted-space"> </span>versus very aggressive therapy.</span></b><span lang="EN-CA" style="color: black; font-size: 13.0pt;"> <span class="apple-converted-space"> </span><b>Once
people saw it was safe to drop to <140 from the INTERACT study they did so.</b><o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<br /></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<i><span lang="EN-CA" style="color: black; font-size: 13.0pt;">Results</span></i><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">This was a negative study which was stopped early for
futility for the primary outcome which was death or disability which was seen
38.7% of the intensive group vs 37.7% of the standard group for an Relative
Risk of 1.02.<o:p></o:p></span></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<u1:p></u1:p><span lang="EN-CA" style="color: black; font-size: 13.0pt;">If you look at the remainder of the secondary outcome
there was no statistical difference in Death, Neurological deterioration in the
first 24 hours or serious adverse events (SAE) within the first 72 hours. <o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">There was a statistical difference in SAE at 3 months
which was worse in the intensive group which was driven mainly by worse renal
function in that group.<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">Having a look at the modified Rankin scores between the 2
groups they are roughly comparable.<o:p></o:p></span></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">So overall this study was negative but with a caveat in
that the ‘less intensive group’ was actually treated quite aggressively to
reduce their BP.<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<br /></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<i><span lang="EN-CA" style="color: black; font-size: 13.0pt;">Expert Opinion</span></i><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">From speaking with Dr. Dowlatshahi, one of our Stroke
Neurologists at The Ottawa Hospital, his opinion is that, unfortunately, <b>we
have 2 negative trials looking at aggressive BP reduction so likely the next
practice guidelines will say to aim for BP < 180.</b><o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">There is a population of patients who likely would benefit
from rapid acute BP management. What number to aim for will depend on the
patient. <span class="apple-converted-space"> </span>If there is a
small volume hematoma < 10cc in a stable patient then < 180 is
reasonable, If there is a large volume hematoma, if it is near ventricles or
the patient is worsening then a more aggressive target would be reasonable:<span class="apple-converted-space"> </span><b>He would choose <160 and
states some of his more aggressive colleagues may choose <140.</b><o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">From an ICU perspective, I spoke with ED physician and
intensivist at TOH/The Monfort Hospital, Dr Andy Pan. Obviously sBP has
limitations and there has been a fair bit of talk in the ICU world about the
use of ICP monitors and cerebral oxygenation monitors. That being said we
aren’t going to have the benefit of those in the ED and his target would be to
target 140-160.<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<br /></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<b><span lang="EN-CA" style="color: black; font-size: 13.0pt;">Recommendations:</span><u1:p></u1:p></b><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><o:p></o:p></span></div>
<ul style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;" type="disc">
<li class="MsoNormal" style="color: black; mso-line-height-alt: 11.75pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">Standard
therapy should target systolic BP <180<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-line-height-alt: 11.75pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">Consider
<160 in large hematomas/worsening clinically/sick enough for ICU<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-line-height-alt: 11.75pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">I
would say the current guidelines have this one incorrect. <span class="apple-converted-space"> </span>There is insufficient evidence to
rapidly reduce to < 140 systolic<o:p></o:p></span></li>
</ul>
<h3 style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; mso-line-height-alt: 11.75pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">
<span style="font-size: x-large;">PART 2</span></h3>
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Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 9"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 5"/>
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<b><span lang="EN-CA" style="color: black; font-size: 13.0pt;">What to do about BP control in ischemic stroke that is not
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<span lang="EN-CA" style="color: black; font-size: 13.0pt;">Blood pressure in ischemic stroke:<o:p></o:p></span></div>
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commonly elevated<o:p></o:p></span></li>
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<u1:p></u1:p><b><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><u1:p></u1:p><u1:p></u1:p>Blood pressure is increased in
up to 75% to 80% of patients with acute stroke and usually decreases
spontaneously over the next few days. </span></b><span lang="EN-CA" style="color: black; font-size: 13.0pt;">This is often due to non-stroke factors such as headache,
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<span lang="EN-CA" style="color: black; font-size: 13.0pt;">Data from observational studies have consistently shown
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edema and hemorrhagic transformation in the freshly infarcted brain tissue.<o:p></o:p></span><u1:p></u1:p></div>
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<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">However, there are concerns that lowering blood pressure
reduces blood flow from collateral vessels to the ischemic penumbra and
increases the size of the brain infarction of the stroke.<u1:p></u1:p><o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-CA"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://3.bp.blogspot.com/-5I_ScZDldCQ/WT9TXn0YWPI/AAAAAAAACPM/DxQ92FR2BUwAGJDwBC_Gg00PUTWaIYOCwCLcB/s1600/figure%2B2.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="363" data-original-width="418" height="553" src="https://3.bp.blogspot.com/-5I_ScZDldCQ/WT9TXn0YWPI/AAAAAAAACPM/DxQ92FR2BUwAGJDwBC_Gg00PUTWaIYOCwCLcB/s640/figure%2B2.png" width="640" /></a></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><br /></b></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">Regarding this issue the 2015 AHA Guidelines state:<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<b><span lang="EN-CA" style="color: black; font-size: 13.0pt;">Do not lower the blood pressure during the initial 24 hours
of acute ischemic stroke unless the blood pressure is >220/120 mm Hg or
there is a concomitant specific medical condition that would benefit.<u1:p></u1:p></span></b><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<b><span lang="EN-CA" style="color: black; font-size: 13.0pt;">Theses are<span class="apple-converted-space"> </span>essentially
identical to the Canadian Hypertension guidelines which state that you can
consider reducing the BP if it is 220/120 by 15-25% over the first 24 hours.</span><u1:p></u1:p></b><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span style="font-size: 13pt;">Let's have a look at the evidence. There are</span><span class="apple-converted-space" style="font-size: 13pt;"> </span><span style="font-size: 13pt;">some relatively recent studies which
may be relevant to the emergency department as they started BP control acutely
in the course of ischemic stroke.</span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<b><u><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60104-9/abstract">The
Angiotensin-Receptor Blocker Candesartan for Treatment of Acute Stroke (SCAST):</a></span></u></b><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><o:p></o:p></span></div>
<ul type="disc">
<li class="MsoNormal" style="color: black; mso-line-height-alt: 11.75pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">2011
Lancet Study<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-line-height-alt: 11.75pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">9
Northern European Countries<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-line-height-alt: 11.75pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">Double
blind RCT<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-line-height-alt: 11.75pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">Looked
at candesartan vs placebo in acute ischemic and hemorrhagic stroke<o:p></o:p></span></li>
</ul>
<div>
<span style="font-size: 17.3333px;"><br /></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<u1:p></u1:p><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><u1:p></u1:p><u1:p></u1:p><u1:p></u1:p>SCAST was a large,
multicenter, randomized placebo controlled, double-blind trial that enrolled
patients with acute ischemic (85%) or hemorrhagic (14%) stroke and systolic
blood pressure of above 140 mm Hg. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">A total of 2029 patients were randomly assigned within 30
hours of symptom onset (average 18 hours) to either candesartan cilexetil (1017
patients) or placebo (1012 patients) for 7 days with doses increasing from 4 mg
on Day 1 to 16 mg on Days 3 to 7.<u1:p></u1:p><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">Overall this study showed<span class="apple-converted-space"> </span><b>no difference in composite end
point of stroke, myocardial infarction, or vascular death and analyses of
functional outcomes suggested a trend toward higher risk of poor outcome in the
candesartan group</b><u1:p></u1:p><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-line-height-alt: 11.75pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<b><u><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><a href="https://www.ncbi.nlm.nih.gov/pubmed/24240777">CATIS-
Effects of Immediate Blood Pressure Reduction on Death and Major Disability in
PatientsWith Acute Ischemic Stroke </a></span></u><u1:p></u1:p></b><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><o:p></o:p></span></div>
<ul type="disc">
<li class="MsoNormal" style="color: black; mso-line-height-alt: 11.75pt; mso-list: l1 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">Single
Blind RCT<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-line-height-alt: 11.75pt; mso-list: l1 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">Used
multiple antihypertensives<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-line-height-alt: 11.75pt; mso-list: l1 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">2014
study in JAMA<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-line-height-alt: 11.75pt; mso-list: l1 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">Primary
outcome was death or major disability at discharge or 14 days<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-line-height-alt: 11.75pt; mso-list: l1 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span lang="EN-CA" style="font-size: 13.0pt; mso-ascii-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">Target
reduce BP by 10-25% in first 24 hours<o:p></o:p></span></li>
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<div>
<span style="font-size: 17.3333px;"><br /></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<u1:p></u1:p><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><u1:p></u1:p><u1:p></u1:p><u1:p></u1:p><u1:p></u1:p>Patients
were randomly assigned to receive antihypertensive treatment (aim to lower BP
by 10% to 25% within the first 24 hours after randomization, and achieve BP of
140/90mmHg within 7 days and/or to discontinue all antihypertensive medications
(control) during hospitalization.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<u1:p></u1:p><b><span lang="EN-CA" style="color: black; font-size: 13.0pt;">Death or disability did not differ at all between
treatment groups with an odds ratio of 1.00 at 14 days or hospital discharge.
There was also no difference in death or the secondary composite outcome of
death and major disability at 3-month post-treatment follow-up with an odds
ratio of 0.99</span></b><u1:p></u1:p><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<i><span lang="EN-CA" style="color: black; font-size: 13.0pt;">Conclusions</span></i><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">My conclusion from these studies and the prior data that
we have is that<span class="apple-converted-space"> </span><b>there is no
evidence to support BP reduction in acute ischemic stroke that isn’t a tPA
candidate unless there is another indication such as acute MI, unstable angina,
or another clinical reason to reduce BP. <span class="apple-converted-space"> </span>If BP is less than 220 systolic or
less than 120 diastolic leave it be.</b></span></div>
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<br /></div>
<h3 style="mso-line-height-alt: 11.75pt;">
<span style="color: black; font-family: "calibri";"><span style="font-size: x-large;">PART
3</span><span style="font-size: 13pt;"><o:p></o:p></span></span></h3>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">Aneurysmal SAH:<o:p></o:p></span><u1:p></u1:p></div>
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<!--EndFragment--></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<i><span lang="EN-CA" style="color: black; font-size: 13.0pt;">What should your blood pressure goals be in acute
aneurysmal SAH awaiting definitive care?</span></i><u1:p></u1:p><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><o:p></o:p></span></div>
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<i><span lang="EN-CA" style="font-size: 13.5pt;"><br /></span></i></div>
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<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/--Qw3EP6a39w/WT9Vkf0cMwI/AAAAAAAACPY/6J_d20WadesDg3J2adNnOGHh9Qb-LopjwCLcB/s1600/SAH.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="745" data-original-width="647" height="400" src="https://2.bp.blogspot.com/--Qw3EP6a39w/WT9Vkf0cMwI/AAAAAAAACPY/6J_d20WadesDg3J2adNnOGHh9Qb-LopjwCLcB/s400/SAH.png" width="346" /></a></div>
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<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">What do the guidelines say?<o:p></o:p></span></div>
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<u1:p></u1:p><b><span lang="EN-CA" style="color: black; font-size: 13.0pt;">AHA Guidelines 2012:</span><u1:p></u1:p></b><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<b><span lang="EN-CA" style="color: black; font-size: 13.0pt;">Between the time of aSAH symptom onset and aneurysm
obliteration, blood pressure should be controlled with a titratable agent to
balance the risk of stroke, hypertension-related rebleeding, and maintenance
of cerebral perfusion pressure (<i>Class I; Level of Evidence B)</i>.</span><u1:p></u1:p></b><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><o:p></o:p></span></div>
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<b><span lang="EN-CA" style="color: black; font-size: 13.0pt;">The magnitude of blood pressure control to reduce the risk
of rebleeding has not been established, but a decrease in systolic blood
pressure to <160 mm Hg is reasonable (<i>Class IIa; Level of Evidence C).</i></span><u1:p></u1:p></b><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><o:p></o:p></span></div>
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<span lang="EN-CA" style="color: black; font-size: 13.0pt;">Goal is to prevent rebleeding. <span class="apple-converted-space"> </span>The risk of rebleeding is maximal in
the first 12 hours, Recurrence rates between 4% and 13.6% within the first 24
hours.</span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">Most of the data for the systolic target comes from a
Japanese study done by Okhuma et al in 2001. They reviewed 273 cases of SAH
which were transferred to their center for definitive treatment. <span class="apple-converted-space"> </span>Of the 273 patients, 37 had
rebleeding. They then compared the rebleed group to the non-rebleed group to
see which patient variables were associated with rebleeding.<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">The mean value of systolic arterial blood pressure in the
rebleed group, which was measured within 20 minutes before rebleeding, was<span class="apple-converted-space"> </span><b>172 mmHg</b>. The mean value of the
maximum value of sBP in the non-rebleed group was<span class="apple-converted-space"> </span><b>153 mmHg</b><span class="apple-converted-space"> </span>which was statistically significantly.<o:p></o:p></span><u1:p></u1:p></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<span lang="EN-CA" style="color: black; font-size: 13.0pt;">They also looked at the distribution of the values of
systolic blood pressure in the rebleed group and in the non-rebleed group were
compared at various cutoff points. <span class="apple-converted-space"> </span>For
BP above 160 the OR was 3.1 of rebleed. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 8.0pt; mso-line-height-alt: 11.75pt;">
<b><span lang="EN-CA" style="color: black; font-size: 13.0pt;">Their conclusion was that systolic BP over 160 was
associated with increased risk of rebleeding.<u1:p></u1:p></span></b><span lang="EN-CA" style="color: black; font-size: 13.0pt;"><o:p></o:p></span></div>
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<span lang="EN-CA" style="color: black; font-size: 13.0pt;">There are<span class="apple-converted-space"> </span><i>no
RCTs</i><span class="apple-converted-space"> </span>looking at this so in
the meantime we are forced to use this limited observational study as our guide.<u1:p></u1:p><o:p></o:p></span></div>
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Dr. Rory Connolly is a 4th year Emergency Medicine Resident at the University of Ottawa and The Ottawa Hospital. He has an interest in trauma and sports medicine.</div>
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<span style="font-size: x-small;">Edited, Formatted and References by Dr. Rob Suttie, PGY2, Emergency Medicine</span></div>
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<span style="font-size: x-small;">References</span></h2>
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<span style="font-size: x-small;">1. Zazulia A, Diringer M, Videen T, Adams R, Yundt K, Aiyagari V et al. Hypoperfusion Without Ischemia Surrounding Acute Intracerebral Hemorrhage. Journal of Cerebral Blood Flow & Metabolism. 2001;:804-810.</span></div>
<div style="box-sizing: border-box; font-family: "Times New Roman"; margin-bottom: 12px; margin-left: 30px; text-indent: -30px;">
<span style="font-size: x-small;">2. Butcher K, Baird T, MacGregor L, Desmond P, Tress B, Davis S. Perihematomal Edema in Primary Intracerebral Hemorrhage Is Plasma Derived. Stroke. 2004;35(8):1879-1885.</span></div>
<div style="box-sizing: border-box; font-family: "Times New Roman"; margin-bottom: 12px; margin-left: 30px; text-indent: -30px;">
<span style="font-size: x-small;">3. Sakamoto Y, Koga M, Yamagami H, Okuda S, Okada Y, Kimura K et al. Systolic Blood Pressure After Intravenous Antihypertensive Treatment and Clinical Outcomes in Hyperacute Intracerebral Hemorrhage: The Stroke Acute Management With Urgent Risk-Factor Assessment and Improvement-Intracerebral Hemorrhage Study. Stroke. 2013;44(7):1846-1851.</span></div>
<div style="box-sizing: border-box; font-family: "Times New Roman"; margin-bottom: 12px; margin-left: 30px; text-indent: -30px;">
<span style="font-size: x-small;">4. Butcher K, Jeerakathil T, Hill M, Demchuk A, Dowlatshahi D, Coutts S et al. The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial. Stroke. 2013;44(3):620-626.</span></div>
<div style="box-sizing: border-box; font-family: "Times New Roman"; margin-bottom: 12px; margin-left: 30px; text-indent: -30px;">
<span style="font-size: x-small;">5. Anderson C, Huang Y, Wang J, Arima H, Neal B, Peng B et al. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial. The Lancet Neurology. 2008;7(5):391-399.</span></div>
<div style="box-sizing: border-box; font-family: "Times New Roman"; margin-bottom: 12px; margin-left: 30px; text-indent: -30px;">
<span style="font-size: x-small;">6. Anderson C, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C et al. Rapid Blood-Pressure Lowering in Patients with Acute Intracerebral Hemorrhage. New England Journal of Medicine. 2013;368(25):2355-2365.</span></div>
<div style="box-sizing: border-box; font-family: "Times New Roman"; margin-bottom: 12px; margin-left: 30px; text-indent: -30px;">
<span style="font-size: x-small;">7. Qureshi A, Palesch Y, Barsan W, Hanley D, Hsu C, Martin R et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. New England Journal of Medicine. 2016;375(11):1033-1043.</span></div>
<div style="box-sizing: border-box; font-family: "Times New Roman"; margin-bottom: 12px; margin-left: 30px; text-indent: -30px;">
<span style="font-size: x-small;">8. Sandset E, Bath P, Boysen G, Jatuzis D, Kõrv J, Lüders S et al. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial. The Lancet. 2011;377(9767):741-750.</span></div>
<div style="box-sizing: border-box; font-family: "Times New Roman"; margin-bottom: 12px; margin-left: 30px; text-indent: -30px;">
<span style="font-size: x-small;">9. He J, Zhang Y, Xu T, Zhao Q, Wang D, Chen C et al. Effects of Immediate Blood Pressure Reduction on Death and Major Disability in Patients With Acute Ischemic Stroke. JAMA. 2014;311(5):479.</span></div>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="header"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footer"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index heading"/>
<w:LsdException Locked="false" Priority="35" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of figures"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope return"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footnote reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="line number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="page number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of authorities"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="macro"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="toa heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/>
<w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/>
<w:LsdException Locked="false" Priority="1" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
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<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
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<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
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<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
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<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
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<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
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</style>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-54498102372175869292017-06-19T11:22:00.000-04:002017-06-19T11:22:38.636-04:00Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial<h4>
<a href="https://3.bp.blogspot.com/-_WtLfSKF8B0/WUfrvr7oKxI/AAAAAAAAB6U/IAhB30VwXAEYiFWnXWmqyvDMR-sTTR3FgCLcBGAs/s1600/Suboxone_SL_Tabs.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="1200" data-original-width="1600" height="240" src="https://3.bp.blogspot.com/-_WtLfSKF8B0/WUfrvr7oKxI/AAAAAAAAB6U/IAhB30VwXAEYiFWnXWmqyvDMR-sTTR3FgCLcBGAs/s320/Suboxone_SL_Tabs.jpg" width="320" /></a><span style="font-family: Arial, Helvetica, sans-serif;">Journal Club Summary</span></h4>
<div>
<span style="color: red; font-family: Arial, Helvetica, sans-serif;"><b>Methodology Score: 4/5 </b></span><div>
<span style="font-family: Arial, Helvetica, sans-serif;"><b><span style="color: red;">Usefulness Score: 4.5/5</span></b><br /><br />D'Onofrio G, et al<br />JAMA. 2015 Apr 28;313(16):1636-44.<br /><a href="http://jamanetwork.com/journals/jama/fullarticle/2279713">Full Article</a><br /><a name='more'></a></span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;">This single, urban center RCT including 329 patients showed that buprenorphine initiated in the ED was more likely to increase engagement in addiction care at 30 days (78%) compared to referral (37%) or brief intervention (45%), with a NNT of 2 for the buprenorphine vs referral groups. There were some concerns raised around the slightly greater proportion of patients seeking addiction treatment in the buprenorphine group and the possibility of crossover between the three arms, but buprenorphine/naloxone is a lifesaving intervention that can be initiated from the ED with proper training. <br /><b><i>By: Dr. Isabelle Miles</i></b> </span><h4>
<span style="font-family: Arial, Helvetica, sans-serif;"><br />Epi lesson</span></h4>
</div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;"><a href="http://emottawa.blogspot.ca/2015/06/epi-lessons-part-2-therapy-articles.html">Sample Size in Clinical Trials </a><br />All intervention studies should indicate how the sample size was estimated including the desired alpha error (usually 0.05), power (usually 80-90%), and expected outcome rate in the control group. Most important is a statement of the minimal clinically important difference (MCID) that would have to be shown by the study intervention for clinicians to accept the new treatment as better. In an effort to keep sample size low, investigators sometimes estimate an MCID much larger than is reasonable.<br /><b><i>By: Dr. Ian Stiell</i></b></span><style>
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Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-62196842536828071562017-06-12T11:00:00.000-04:002017-06-19T11:23:01.370-04:00A Randomized Controlled Noninferiority Trial of Single Dose of Oral Dexamethasone Versus 5 Days of Oral Prednisone in Acute Adult Asthma<h4>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Journal Clubs Summary<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-wYa5qo4uXss/WT6sNdG2XjI/AAAAAAAAB5k/zsbGKxb1qiw0f_x2QiVDe-2gL4N9sSjfACLcB/s1600/Asthma_%2528Lungs%2529.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="768" data-original-width="1024" height="240" src="https://2.bp.blogspot.com/-wYa5qo4uXss/WT6sNdG2XjI/AAAAAAAAB5k/zsbGKxb1qiw0f_x2QiVDe-2gL4N9sSjfACLcB/s320/Asthma_%2528Lungs%2529.png" width="320" /></a></div>
</span></h4>
<span style="color: red; font-family: "arial" , "helvetica" , sans-serif;"><b>Methodology Score: 3/5 </b></span><br />
<div>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><b><span style="color: red;">Usefulness Score: 3.5/5</span></b></span></div>
<div>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Rehrer MW, et al. <br />Ann Emerg Med. 2016 Nov;68(5):608-613.<br /><a href="http://www.sciencedirect.com/science/article/pii/S0196064416002158">Abstract Link</a></span><br />
<br />
<a name='more'></a></div>
<div>
<span style="font-family: "arial" , "helvetica" , sans-serif;">This single centre, randomized, triple-blinded, control trial did not demonstrate noninferiority of a single dose of dexamethasone compared to standard 5 day course of prednisone for adult asthma exacerbations. In most patients, prednisone for 5 days should still be used. A select group of patients with poor compliance may still benefit from a single dose of dexamethasone although further studies are needed. </span></div>
<div>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><i>By: Dr. Simeon Mitchell </i></span></div>
<div>
<h4>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Epi lesson </span></h4>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="http://emottawa.blogspot.ca/2015/06/epi-lessons-part-2-therapy-articles.html">Equivalence or Non-Inferiority Trials </a><br />Most RCTs aim to determine whether one intervention is superior to another (superiority trials). Often a non-significant test of superiority is wrongly interpreted as proof of no difference between the two treatments. By contrast, equivalence trials aim to determine whether one (typically new) intervention is therapeutically similar to another (usually existing) treatment. A non-inferiority trial seeks to determine whether a new treatment is no worse than a reference treatment. Because proof of exact equality is impossible, a pre-stated margin of non-inferiority (delta) for the treatment effect in a primary patient outcome must be defined a priori. Equivalence trials are very similar, except that equivalence is defined as being within pre-stated a two-sided treatment effect. True (2-sided) equivalence therapeutic trials are rare. <br /><i>By: Dr. Ian Stiell</i></span><style>
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Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-25790891214439435902017-06-08T21:05:00.001-04:002017-06-08T21:07:19.153-04:00The ABCDE’s of Quality Improvement<br />
<h3>
<span style="font-family: "arial" , "helvetica" , sans-serif;">What is Quality Improvement (QI)? </span></h3>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: "arial" , "helvetica" , sans-serif; margin-left: 1em; margin-right: 1em;"><a href="https://1.bp.blogspot.com/-_2tHhluSDJw/WTnwdKkOC8I/AAAAAAAAB4w/CB1GtLYfoGkAKuabb7alTG4AdzHl8AGSACLcB/s1600/quality-1714376_960_720.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="720" data-original-width="720" height="200" src="https://1.bp.blogspot.com/-_2tHhluSDJw/WTnwdKkOC8I/AAAAAAAAB4w/CB1GtLYfoGkAKuabb7alTG4AdzHl8AGSACLcB/s200/quality-1714376_960_720.jpg" width="200" /></a></span></div>
<span style="font-family: "arial" , "helvetica" , sans-serif;">You have all heard the latest buzzword in healthcare: “quality improvement”, or QI. Yet many healthcare professionals still only have a vague idea of what that truly means, and likely an even poorer understanding of how it might apply to their frontline practice. Conceptually, QI can be defined as the “combined and unceasing efforts of everyone - healthcare professionals, patients and their families, researchers, payers, planners and educators - to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)”1. </span><br />
<a name='more'></a><div>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Practically, QI now often refers to a proven structured methodology to assist any healthcare team in developing and implementing interventions that continuously improves clinical care. Borrowing from the ABC’s of ATLS, some of the key elements in QI are explored below.</span></div>
<div>
<h3>
<span style="font-family: "arial" , "helvetica" , sans-serif;">ABCDE: A Structured Approach to QI </span></h3>
<h4>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><u>A - Aim </u></span></h4>
<span style="font-family: "arial" , "helvetica" , sans-serif;">The first step in any QI effort involves identifying what exactly are you trying to achieve. Do you want to increase the proportion of blunt trauma patients receiving tranexamic acid in a timely manner? Are you trying to decrease post-operative wound infections rates? Perhaps your team wishes to improve appropriateness of trauma code activations? Be as concise and specific as you can. What is the magnitude of the improvement you seek; 15% or 30%? Over what period of time; 6 months, or 2 years? Try and articulate your Aim in as concrete and clinically relevant terms as possible, with clear goals and targets in mind. </span><br />
<h4>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><u>B - Background </u></span></h4>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Once you’ve fleshed out what your team wants to improve, it is important to do some background research and data collection. How do you know how well/poorly you are currently performing? It can be very helpful to have baseline data to support the targets set in your Aim. A quick literature scan may review similar problems experienced by other centres - in fact, there may even be proven solutions and strategies published, that you can easily adopt! </span><br />
<h4>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><u>C - Change </u></span></h4>
<span style="font-family: "arial" , "helvetica" , sans-serif;">With your knowledge of the current state, you and your team can start developing potential change ideas and interventions to help move closer to your Aim. Gather all the relevant stakeholders and brainstorm; there are many QI tools (e.g. process mapping) that are freely available to assist your team in this process. Once you’ve got a reasonable idea, get started and actually put it into place as a test! Many QI efforts start with small scale interventions and tests of change - this is not a randomized controlled trial, it’s okay to take little baby steps. </span><br />
<h4>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><u>D - Discover </u></span></h4>
<span style="font-family: "arial" , "helvetica" , sans-serif;">As you start trialing different potential interventions, make sure your team is keeping track of what effects those little changes are having on different outcomes. Is your main Aim outcome changing the way you want? Are the interventions actually being implemented and working as expected in theory? How are your providers and patients feeling about the new changes? And are you noticing any unexpected consequences as a result of your changes? </span><br />
<h4>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><u>E - Edit & Evolve </u></span></h4>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Armed with the learnings you gathered from these small tests of change, your team can go back and revise your interventions as needed. Perhaps a certain process would work better if done differently, or by different people. Maybe that paper-based checklist turned out to be too time-consuming, and an electronic solution needs to be developed. One of the key pillars of good QI work is a commitment to continuous evaluation and evolution of these small tests of change, as you march steadily towards improving that ultimate Aim.</span><br />
<h3>
<span style="font-family: "arial" , "helvetica" , sans-serif;">How do I get started? </span></h3>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Getting a formal QI initiative up and running can sound like a daunting task - but it doesn’t have to be! There are many resources and supports available to help you along the way. There is a very good <a href="https://youtu.be/nPysNaF1oMw">YouTube video by Dr. Mike Evans</a> and the institute for Healthcare Improvement (IHI) that summarizes the key concepts of QI in a fun way</span></div>
<div>
<span style="font-family: "arial" , "helvetica" , sans-serif;"> Health Quality Ontario (HQO) also provides a number of easy to use <a href="http://www.hqontario.ca/portals/0/documents/qi/qi-quality-improve-guide-2012-en.pdf">introductory materials</a> for anyone interested in the topic.</span></div>
<div>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Finally, there are numerous QI courses available such as the <a href="https://www.ideasontario.ca/">IDEAS course</a> for those of you looking for a more formal training program. The most important step is to just get started! <br /></span></div>
<div>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Post by: Dr. Edmund SH Kwok, MD MHA MSc FRCPC, Director of Quality Improvement Unit, TOH </span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://3.bp.blogspot.com/-8nHn3KwsxB0/WTnyYHTKf-I/AAAAAAAAB48/O5WPvbVzUrM8FFtMc0s-Q-SQYvwLZ0_WACLcB/s1600/KWOK.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1067" height="320" src="https://3.bp.blogspot.com/-8nHn3KwsxB0/WTnyYHTKf-I/AAAAAAAAB48/O5WPvbVzUrM8FFtMc0s-Q-SQYvwLZ0_WACLcB/s320/KWOK.JPG" width="213" /></a></div>
<div>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span></div>
<div>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><i>Courtesy of <a href="https://www.ottawahospital.on.ca/wps/portal/Base/TheHospital/ClinicalServices/DeptPgrmCS/Departments/Trauma">The Ottawa Hospital Trauma</a> Newsletter - Spring/Summer </i></span></div>
<div>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><i><br /></i><span style="font-size: x-small;"><u>Reference:</u><br />1 Batalden PB, Davidoff F. What is “quality improvement” and how can it transform healthcare? (Editorial) Qual Saf Health Care 2007;16:2-3 </span></span></div>
Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-4149799694265029722017-05-29T18:02:00.000-04:002017-05-29T18:02:17.466-04:00Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study.<h4 style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Journal Club Summary<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-1itNcgcZKHQ/WSyZ-w6aynI/AAAAAAAAB34/IWkYlYo0MjIV8HKjhH9gMZfl732mKXPgQCLcB/s1600/MALT_4.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="410" data-original-width="398" height="320" src="https://2.bp.blogspot.com/-1itNcgcZKHQ/WSyZ-w6aynI/AAAAAAAAB34/IWkYlYo0MjIV8HKjhH9gMZfl732mKXPgQCLcB/s320/MALT_4.jpg" width="310" /></a></div>
</span></h4>
<div class="Title11" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><b><span style="color: red;">Methodology Score:</span><span style="color: red;"> </span><span style="color: red;">4/5</span><span style="color: red;"> </span></b></span></div>
<div class="Title11" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><b><span style="color: red;">Usefulness Score:</span><span style="color: red;"> </span><span style="color: red;">4/5</span></b></span></div>
<div class="Title11" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Stanley AJ, et al.</span></div>
<div class="details" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><span class="jrnl"><span style="color: black;">BMJ</span></span><span style="color: black;">.
2017 Jan 4;356:i6432.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="background: white;">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><a href="http://www.bmj.com/content/356/bmj.i6432.long">Full Article</a></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">This multicentre, multinational study assessed the ability
of five upper gastrointestinal bleeding scores to predict outcomes including
death, re-bleeding, need for endoscopy, transfusion, surgery or interventional
radiology, and length of hospital stay, finding that the Glasgow Blatchford
score is best at predicting the composite outcome of intervention or death,
although AIMS65 was best at predicting mortality. While applying the scores as
recommended may result in missing a small number of significant outcomes, they
are easy to apply and can help expedite disposition planning, whether
outpatient management or hospital-based intervention.</span></div>
<div class="MsoNormal">
<b style="font-family: Arial, Helvetica, sans-serif;"><i><span style="font-size: large;">By: <span lang="EN-CA">Dr. </span>Daniel James</span></i></b></div>
<div class="MsoPlainText">
<br /></div>
<h4 style="mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-fareast-language: EN-CA;"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Epi lesson</span></span></h4>
<h4 style="mso-layout-grid-align: none; text-autospace: none;">
<span style="font-size: large;"><a href="http://emottawa.blogspot.ca/2015/06/epi-lessons-part-1-diagnosis-articles.html" style="background-color: white; font-family: Arial, Helvetica, sans-serif;"><u><b>Composite Outcomes</b></u></a><span style="background-color: white; font-family: Arial, Helvetica, sans-serif;"> </span></span></h4>
<div class="MsoNormal" style="background: white;">
<span style="mso-bidi-font-style: italic;"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">It is not unusual for studies to select a composite outcome as their
primary outcome measure. The necessity to do so is often justified by the rare
occurrence of the primary outcome of true interest (for e.g. death or
survival), and by the otherwise very large sample size required to measure it.
Caveats to using composite outcomes include the inability to attribute
associated risk or benefit of the intervention with the main (rare) outcome of
interest itself. Similarly, it is possible to erroneously conclude to the
benefit of an intervention where such benefit may only be true for “surrogate”
components of the composite outcomes and not the main outcome of interest.</span></span></div>
<div class="MsoNormal" style="background: white;">
<b style="font-family: Arial, Helvetica, sans-serif;"><i><span style="font-size: large;"><span lang="EN-CA">By: </span>Dr. Christian
Vaillancourt</span></i></b></div>
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</style>Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-22635380044772046482017-05-15T09:37:00.001-04:002017-05-15T09:37:54.901-04:00Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial. <h4 style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<a href="https://2.bp.blogspot.com/-Up2UfScosuo/WRmt279aRBI/AAAAAAAAB28/At9EFaC6wcAPybxoO-TR-oh9YbUTo-VKwCLcB/s1600/Iv1-07_014.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="320" src="https://2.bp.blogspot.com/-Up2UfScosuo/WRmt279aRBI/AAAAAAAAB28/At9EFaC6wcAPybxoO-TR-oh9YbUTo-VKwCLcB/s320/Iv1-07_014.jpg" width="180" /></a><b><span lang="EN-US"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Journal Club Summary</span></span></b></h4>
<div>
<b><span lang="EN-US"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><br /></span></span></b></div>
<div class="Title11" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<b><span lang="EN-US" style="color: red;"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Methodology Score: 3/5 </span></span></b></div>
<div class="Title11" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<b><span lang="EN-US" style="color: red;"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Usefulness Score: 3.5/5</span></span></b></div>
<div class="desc" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><span lang="EN-US" style="color: black; mso-bidi-font-weight: bold;">Nijssen</span><span class="apple-converted-space"><span lang="EN-US" style="color: black;"> </span></span><span lang="EN-US" style="color: black;">EC, et al <o:p></o:p></span></span></div>
<div class="details" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><span class="jrnl"><span lang="EN-US" style="color: black;">Lancet</span></span><span lang="EN-US" style="color: black;">.<span class="apple-converted-space"> </span><span style="mso-bidi-font-weight: bold;">2017</span><span class="apple-converted-space"> </span>Feb
20. [Epub ahead of print]<o:p></o:p></span></span></div>
<div class="MsoNormal" style="background: white;">
</div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: red;"><o:p><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30057-0/fulltext">Abstract Link</a> </span></o:p></span></b></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: red;"><o:p><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"></span></o:p></span></b></div>
<a name='more'></a><b style="mso-bidi-font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><br /></span></b><br />
<div class="MsoNormal">
<span style="font-size: large;"><span lang="EN-US"><span style="font-family: Arial, Helvetica, sans-serif;">This prospective,
open-l</span></span><span style="font-family: Arial, Helvetica, sans-serif;">abel, single centre, randomized trial of 660 patients found no hydration
(2.7% incidence CIN) to be non-inferior compared to iv hydration (2.6%
incidence CIN) in preventing contrast induced nephropathy in patients with
reduced renal function undergoing elective procedures requiring contrast; there
were no related deaths and no patients required haemodialysis within 35 days.
While the study excluded patients with eGFR<30 and ER patients, the results
are reassuring and will be helpful in shared decision making with patients and
our radiology colleagues. </span></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span lang="EN-US">By: <span style="mso-bidi-font-style: italic;">Dr. Rebecca
Brown </span></span></i></b><span lang="EN-US"><o:p></o:p></span></span></div>
<h4 style="background: white;">
<span style="font-size: large;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-CA" style="mso-ansi-language: EN-CA;"><o:p><span style="font-family: Arial, Helvetica, sans-serif;"> </span></o:p></span></b><b><span lang="EN-CA"><span style="font-family: Arial, Helvetica, sans-serif;"><u>Epi lesson</u></span></span></b></span></h4>
<div class="MsoNormal" style="background: white;">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><b style="mso-bidi-font-weight: normal;"><u><span lang="EN-US"><a href="http://emottawa.blogspot.ca/2015/06/epi-lessons-part-2-therapy-articles.html">Minimization</a></span></u></b><span lang="EN-US"> <o:p></o:p></span></span></div>
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<span lang="EN-US"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The purpose of
randomization is to minimize imbalance between groups. Sometimes, we know
certain factors are likely to influence outcomes and ought to be equally
distributed (e.g. male, female). A strategy to ensure this stratifies
participants according to important factors, then uses separate randomization
lists for each sub-groups. This becomes impractical when a large number of
factors need to be taken into account. Minimization calculates the imbalance
between groups that would result from a particular assignment, and uses a
strategy favoring assignment to the group that would minimize this imbalance
between comparison groups. <o:p></o:p></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><b><i style="mso-bidi-font-style: normal;"><span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-fareast-font-family: "MS 明朝"; mso-fareast-language: EN-CA; mso-fareast-theme-font: minor-fareast;">By: </span></i></b><b><i><span lang="EN-US">Dr. Christian Vaillancourt </span></i></b></span><span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-bidi-font-weight: bold; mso-fareast-font-family: "MS 明朝"; mso-fareast-language: EN-CA; mso-fareast-theme-font: minor-fareast;"><o:p></o:p></span></div>
Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-24392126750570421522017-05-11T09:00:00.000-04:002017-05-08T09:30:24.964-04:00Zika Virus – What we know and what we don’t<div class="MsoNormal">
<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">The Zika Virus exploded onto the
international health scene in the last several months. It was first discovered
in humans in 1951 and remained limited to Africa and Asia until the first major
outbreak in Micronesia in 2007. Since then the virus has continued to evolve
and spread from the Pacific Islands and French Polynesia to the main major
outbreak in South America in early 2015 and finally to the US in January 2016.<o:p></o:p></span></div>
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<br />
<a name='more'></a><br /></div>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">The virus itself is a single stranded RNA
virus from the flavivirus family. This family also includes dengue,
chikungunya, West Nile and yellow fever. Zika is mainly transmitted by the <i>Aedes
aegypti</i> mosquito.<sup>2</sup><o:p></o:p></span></div>
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<br /></div>
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<b><span style="color: black; font-family: "times new roman"; font-size: 15.0pt;">Zika Symptoms</span></b><span style="color: black; font-family: "times new roman"; font-size: 15.0pt;"><o:p></o:p></span></div>
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<br /></div>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">Approximately 20-25% of patients who
contract Zika will have symptoms. Most will experience a self-resolving viral
illness. Symptoms usually last 2-7 days.<sup>2</sup><o:p></o:p></span></div>
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<br /></div>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">The symptoms of Zika include:<sup>2,3</sup><o:p></o:p></span></div>
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<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Low grade fever (usually
<38.5C)<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Myalgias/arthralgias
(hands/feet)<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Retro-orbital pain<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Conjunctivitis<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Maculopapular rash<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Lymphadenopathy<o:p></o:p></span></li>
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<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-4ZevYKBPmBk/WP5XG3HdfVI/AAAAAAAACM4/MqqpDTG03NYgqqFoJwGXXPikeF6KBUAHgCLcB/s1600/zika%2Bsx.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="358" src="https://1.bp.blogspot.com/-4ZevYKBPmBk/WP5XG3HdfVI/AAAAAAAACM4/MqqpDTG03NYgqqFoJwGXXPikeF6KBUAHgCLcB/s400/zika%2Bsx.png" width="400" /></a></div>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">The symptoms of Zika are very similar to
dengue and chikungunya. It is very difficult to tell these viral infections
apart on the basis of history and physical exam alone.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="color: black; font-family: "times new roman"; font-size: 15.0pt;">Canadian Statistics</span></b><span style="color: black; font-family: "times new roman"; font-size: 15.0pt;"><o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">As of November 3, 2016 Canada has
experienced:<sup>1</sup><o:p></o:p></span></div>
<ul type="disc">
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">359 Zika travel related cases<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">2 sexually transmitted cases<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">16 Zika infected pregnancies<o:p></o:p></span></li>
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<li class="MsoNormal" style="color: black; mso-list: l0 level2 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 72.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Of these 16 pregnancies 2 had
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<li class="MsoNormal" style="color: black; mso-list: l0 level2 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 72.0pt;">1 of these neonates had
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://4.bp.blogspot.com/-gYoZ737N5OI/WP5XgO2Vt9I/AAAAAAAACM8/Tw99iVh-mM05GeFXvVPw2GyGiqX8s2HzgCLcB/s1600/map.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="368" src="https://4.bp.blogspot.com/-gYoZ737N5OI/WP5XgO2Vt9I/AAAAAAAACM8/Tw99iVh-mM05GeFXvVPw2GyGiqX8s2HzgCLcB/s640/map.png" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Current Worldwide Status of Zika<br />
<br />
<div style="text-align: left;">
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<b><span style="font-family: "times new roman"; font-size: 15.0pt;">Current known routes of transmission<sup>2</sup></span></b><span style="font-family: "times new roman"; font-size: 15.0pt;"><o:p></o:p></span></div>
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<b><span style="font-family: "times new roman";"><sup><br /></sup></span></b></div>
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<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Mosquito bites<o:p></o:p></span></li>
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<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Most common<o:p></o:p></span></li>
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<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Vertical transmission<o:p></o:p></span></li>
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<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Between mother and baby<o:p></o:p></span></li>
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<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Sexual transmission<o:p></o:p></span></li>
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<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Currently known cases of
male to female, male to male and female to male transmissions<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">As of Nov 2, 2016 there were
12 worldwide cases of sexual transmission of Zika<sup>6</sup><o:p></o:p></span></li>
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<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Blood products<sup>7</sup><o:p></o:p></span></li>
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<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Zika RNA has been detected
in blood<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">There has been no known case
of transmission through blood products but the possibility exists<o:p></o:p></span></li>
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<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Breast milk<o:p></o:p></span></li>
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<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Zika RNA detected in breast
milk<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">There has been no known case
reports of Zika transmission from breast milk<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">The WHO recommends
continuing breastfeeding as risks of Zika transmission through
breastmilk < risks of not breastfeeding</span></li>
</ul>
</ul>
<div>
<span style="font-family: "times new roman";"><span style="font-size: 18px;"><br /></span></span></div>
</td></tr>
</tbody></table>
</div>
<div class="MsoNormal">
<b><span style="font-family: "times new roman"; font-size: 13.5pt;">Prevention of Zika Infection – General<sup>2</sup></span></b><span style="font-family: "times new roman"; font-size: 13.5pt;"><o:p></o:p></span></div>
<ul style="font-size: 12.8px;" type="disc">
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">No available vaccine<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">No immunoprophylaxis<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Likely long term immunity post
infection<o:p></o:p></span></li>
<ul type="circle">
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Based on experience with
other, better studied, flaviviruses<o:p></o:p></span></li>
</ul>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Avoid travel if possible<o:p></o:p></span></li>
<ul type="circle">
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Especially in women who are
pregnant or trying to get pregnant<o:p></o:p></span></li>
</ul>
</ul>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-family: "times new roman"; font-size: 13.5pt;">Prevent mosquito bites<sup>2</sup></span></b><span style="font-family: "times new roman"; font-size: 13.5pt;"><o:p></o:p></span></div>
<ul style="font-size: 12.8px;" type="disc">
<li class="MsoNormal"><i><span style="font-family: "times new roman"; font-size: 13.5pt;">Aedes aegypti</span></i><span style="font-family: "times new roman"; font-size: 13.5pt;"> are <u>day</u> biters<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Loose, light coloured clothing
with closed toed shoes, long sleeves and pants<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Wear DEET or icaridin mosquito
repellant (DEET preferred)<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Prevent entry into buildings<o:p></o:p></span></li>
<ul type="circle">
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Repair netting, screen
protectors, close doors and windows<o:p></o:p></span></li>
</ul>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Permethrin can be used to
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<ul type="circle">
<li class="MsoNormal"><u><span style="font-family: "times new roman"; font-size: 13.5pt;">Not</span></u><span style="font-family: "times new roman"; font-size: 13.5pt;"> to be used on skin<o:p></o:p></span></li>
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</ul>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-family: "times new roman"; font-size: 13.5pt;">Prevent sexual transmission<sup>2</sup></span></b><span style="font-family: "times new roman"; font-size: 13.5pt;"><o:p></o:p></span></div>
<ul style="font-size: 12.8px;" type="disc">
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Zika has been detected in semen
for at least 2 months post infection<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Condoms should minimize risk<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">What we don’t know:<o:p></o:p></span></li>
<ul type="circle">
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">How long Zika can stay in
semen post infection (at least 69 days)<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">How often it can be
transmitted in asymptomatic patients<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">How easy is sexual
transmission<o:p></o:p></span></li>
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<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Current recommendations for
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<ul type="circle">
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Wait at least 2 months in
women post return from Zika area<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Wait at least 6 months for men
post return<o:p></o:p></span></li>
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<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Men who are sexual partners of
pregnant women and who have potentially contracted Zika should use condoms
for the remainder of the pregnancy<o:p></o:p></span></li>
<ul type="circle">
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">No current testing of
asymptomatic men available</span></li>
</ul>
</ul>
<div style="font-size: 12.8px;">
<span style="font-family: "times new roman";"><span style="font-size: 18px;"><br /></span></span></div>
<div style="font-size: 12.8px;">
<b style="font-family: Calibri; font-size: 12pt;"><span style="font-family: "times new roman"; font-size: 15pt;">Diagnosis of Zika<sup>2</sup></span></b></div>
</div>
</td></tr>
</tbody></table>
<div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "times new roman";"><sup><br /></sup></span></b></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://4.bp.blogspot.com/-PSfOt07lGkU/WP5ZovS5UEI/AAAAAAAACNU/hETb0EiWS24YKeR9lsCuBB2p--wu2fAFQCLcB/s1600/PCR_tubes.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="327" src="https://4.bp.blogspot.com/-PSfOt07lGkU/WP5ZovS5UEI/AAAAAAAACNU/hETb0EiWS24YKeR9lsCuBB2p--wu2fAFQCLcB/s400/PCR_tubes.png" width="400" /></a></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "times new roman";"><sup><br /></sup></span></b></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "times new roman";"><sup><br /></sup></span></b></div>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">There are currently 2 different categories
of tests:<o:p></o:p></span></div>
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<li class="MsoNormal" style="color: black; mso-list: l2 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">PCR to detect the virus itself<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l2 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Serology to detect antibodies
to the virus<o:p></o:p></span></li>
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<span style="font-family: "times new roman";"><span style="font-size: 18px;"><br /></span></span></div>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">Antibodies appear 5-6 days post symptom
onset. There is some known cross-reactivity between the assays used to detect
antibodies against Zika and other flaviviruses (especially dengue).<o:p></o:p></span></div>
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<br /></div>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">For patients presenting with:<o:p></o:p></span></div>
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and serology needs to be completed<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">> 10 days of symptoms – only
serology needed<o:p></o:p></span></li>
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<br /></div>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">Chikungunya and dengue testing are
automatically added to any Zika tests sent.<sup>8</sup><o:p></o:p></span></div>
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<br /></div>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">The current turn-around times are:<o:p></o:p></span></div>
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<li class="MsoNormal" style="color: black; mso-list: l1 level1 lfo3; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">PCR – up to 14 days<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l1 level1 lfo3; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Serology – 3-8 weeks<o:p></o:p></span></li>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">In addition to the general Public
Health requisition there is a specific “Mandatory Information Intake Form for
Zika Virus Testing” that <u>must</u> also be completed with any blood
work sent. This form can be found online at <a href="https://www.publichealthontario.ca/en/ServicesAndTools/LaboratoryServices/Documents/Zika_Information_Intake_Form_04-26-2016.pdf">Public Health Ontario.</a><o:p></o:p></span></div>
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<br /></div>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 9"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 3"/>
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<!--EndFragment--></div>
<div class="MsoNormal">
<b><span style="color: black; font-family: "times new roman"; font-size: 15.0pt;">Current Diagnostic Approach to Zika Virus
at The Ottawa Hospital<sup>8</sup></span></b><span style="color: black; font-family: "times new roman"; font-size: 15.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "times new roman";"><sup><br /></sup></span></b></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-oyEnQqKi9Ls/WP5as6In3zI/AAAAAAAACNg/8GjHvjN_DfA2sT2_vy4yonSa6LVsD7jjgCLcB/s1600/Civic_Hospital_Ottawa-1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="329" src="https://2.bp.blogspot.com/-oyEnQqKi9Ls/WP5as6In3zI/AAAAAAAACNg/8GjHvjN_DfA2sT2_vy4yonSa6LVsD7jjgCLcB/s640/Civic_Hospital_Ottawa-1.jpg" width="640" /></a></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "times new roman";"><sup><br /></sup></span></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">There is currently <u>no universal
screening</u> of returned travellers or patients with potential Zika
contact. This has been decided at the national level.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">The only patients currently being tested
include:<o:p></o:p></span></div>
<ul type="disc">
<li class="MsoNormal" style="color: black; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Patients with symptoms<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Asymptomatic pregnant women<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Asymptomatic women who may
become pregnant<o:p></o:p></span></li>
</ul>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;"><br /></span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">Potential Zika cases or pregnant
asymptomatic patients with possible Zika contact are all currently being
referred to the TOH Tropical Disease Clinic. Zika blood work drawn in the ED
can be followed at this clinic.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">If pregnant women are found to have Zika,
or their symptoms are very suggestive of Zika, they will be referred by the
Tropical Disease Clinic to Maternal Fetal Medicine (MFM). <u>There is no
need to refer these patients directly from the ED to Maternal Fetal Medicine</u>.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: 18.0pt;">
<br /></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">On the referral form please include:<o:p></o:p></span></div>
<ul type="disc">
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Travel location<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Dates of travel<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Symptoms & onset<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Pregnancy status<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Flavivirus vaccinations<o:p></o:p></span></li>
<ul type="circle">
<li class="MsoNormal" style="color: black; mso-list: l0 level2 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 72.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Japanese encephalitis<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level2 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 72.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Yellow fever<o:p></o:p></span></li>
</ul>
</ul>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="color: black; font-family: "times new roman"; font-size: 15.0pt;">Treatment of Zika Virus<sup>2</sup></span></b><span style="color: black; font-family: "times new roman"; font-size: 15.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">There is currently no specific antiviral
treatment for Zika. The treatment is supportive, similar to treatment for other
viral illnesses. The patient should be advised to rest, stay hydrated and take
acetaminophen if needed for pain or fever. <u>They should avoid NSAIDs
until dengue is ruled out.</u> Symptoms should resolve within 7 days.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="color: black; font-family: "times new roman"; font-size: 15.0pt;">Complications – GBS</span></b><span style="color: black; font-family: "times new roman"; font-size: 15.0pt;"><o:p></o:p></span></div>
<ul type="disc">
<li class="MsoNormal" style="color: black; mso-list: l2 level1 lfo3; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Guillain-Barre syndrome is the
most commonly reported and most researched serious complication of Zika
virus<sup>2</sup><o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l2 level1 lfo3; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;"><a href="https://www.ncbi.nlm.nih.gov/pubmed/26948433">Cao-Lormeau et al., 2016</a>
conducted a case control study in French Polynesia<sup>9</sup><o:p></o:p></span></li>
<ul type="circle">
<li class="MsoNormal" style="color: black; mso-list: l2 level2 lfo3; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 72.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">2 sets of controls<o:p></o:p></span></li>
<ul type="square">
<li class="MsoNormal" style="color: black; mso-list: l2 level3 lfo3; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 108.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">1 – patients with non-febrile
illness who presented to ED<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l2 level3 lfo3; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 108.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">2 – patients with Zika but no
GBS symptoms<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="color: black; mso-list: l2 level2 lfo3; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 72.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Had 42 patients with GBS
during study<o:p></o:p></span></li>
<ul type="square">
<li class="MsoNormal" style="color: black; mso-list: l2 level3 lfo3; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 108.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">98% had anti-Zika 1gM or IgG<o:p></o:p></span></li>
<ul type="square">
<li class="MsoNormal" style="color: black; mso-list: l2 level4 lfo3; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 144.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">All had neutralizing
antibodies<o:p></o:p></span></li>
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<li class="MsoNormal" style="color: black; mso-list: l2 level3 lfo3; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 108.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Found incidence of GBS during
outbreak was 1 in 4 000 Zika infected patients<o:p></o:p></span></li>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">Zika has been implicated in a variety of
pregnancy complications.<sup>2</sup><o:p></o:p></span></div>
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<br /></div>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">Currently this list includes:<o:p></o:p></span></div>
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<li class="MsoNormal" style="color: black; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Microcephaly<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Fetal death<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Placental insufficiency<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Fetal growth restriction<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">CNS injury<o:p></o:p></span></li>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;"><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1602412#t=article">Brasil et al. 2016</a> enrolled 88 pregnant
women into a prospective clinical trial. Of 88 pregnant women who presented to
the study clinics with a new rash 72 were found to be positive for Zika in
blood or urine. 42 of the 77 completed the required US.<sup>3</sup><o:p></o:p></span></div>
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<br /></div>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">Of these 42 women 12 had fetal
abnormalities on US:<o:p></o:p></span></div>
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<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">2 fetal deaths (36 + 38 wks GA)<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">5 IUGR (+/- microcephaly)<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">4 ventricular calcifications<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">4 abnormal cerebral or
umbilical artery flow<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">2 abnormal amniotic fluid
volume<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">2 CNS lesions<o:p></o:p></span></li>
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<!--StartFragment-->
<span lang="EN-GB" style="font-family: "times new roman"; font-size: 13.5pt;"><br />Abnormalities on US were
found in women who contracted the virus through all trimesters (see figure
below).</span><!--EndFragment-->
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<span style="font-family: "times";">Brasil P, Pereira J,Jose P., Raja Gabaglia C, Damasceno L,
Wakimoto M, Ribeiro Nogueira RM, et al. Zika Virus Infection in Pregnant Women
in Rio de Janeiro — Preliminary Report. N Engl J Med 2016;ePub. <o:p></o:p></span></div>
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<!--StartFragment-->
<br />
<div class="MsoNormal">
<span style="font-family: "times new roman"; font-size: 13.5pt;"><br /></span></div>
<div class="MsoNormal">
<div style="text-align: left;">
<span style="font-family: "times new roman"; font-size: 13.5pt;"><a href="https://www.ncbi.nlm.nih.gov/pubmed/26993883">Cauchemez etal. 2016</a> conducted a retrospective analysis looking at the gestational age at which
the risk of Zika induced microcephaly peaks.<sup>10</sup> They collected
serological and surveillance data to estimate infection risk. They then used
this data in conjunction with information regarding 8 cases of microcephaly
found during the outbreak to find the best mathematical model to predict
periods of risk during pregnancy.<o:p></o:p></span></div>
</div>
<div class="MsoNormal">
<div style="text-align: left;">
<br /></div>
</div>
<div class="MsoNormal">
<div style="text-align: left;">
<span style="font-family: "times new roman"; font-size: 13.5pt;">The best
model found <u>risk highest in 1<sup>st</sup> trimester</u> and
possibly early 2<sup>nd</sup> trimester. The <u>risk of microcephaly
was predicted to be 1% in women who contract Zika in the 1<sup>st</sup> trimester</u>.<o:p></o:p></span></div>
</div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<div class="MsoNormal">
<div style="text-align: left;">
<b><span style="font-family: "times new roman"; font-size: 13.5pt;">Top 5 Take Home Points</span></b><span style="font-family: "times new roman"; font-size: 13.5pt;"><o:p></o:p></span></div>
</div>
<div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<div style="text-align: left;">
<!--[if !supportLists]--><span style="font-family: "times new roman"; font-size: 13.5pt;">1.<span style="font-size: 7pt; font-stretch: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "times new roman"; font-size: 13.5pt;">List of Zika infected countries is
constantly changing<o:p></o:p></span></div>
</div>
<div class="MsoNormal" style="margin-left: 72.0pt; mso-list: l0 level2 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 72.0pt; text-indent: -18.0pt;">
<div style="text-align: left;">
<!--[if !supportLists]--><span style="font-family: "courier new"; font-size: 10.0pt;">o<span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "times new roman"; font-size: 13.5pt;">Refer
patients to the Zika websites at WHO, CDC or Health Canada for current
information<o:p></o:p></span></div>
</div>
<div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<div style="text-align: left;">
<!--[if !supportLists]--><span style="font-family: "times new roman"; font-size: 13.5pt;">2.<span style="font-size: 7pt; font-stretch: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "times new roman"; font-size: 13.5pt;">Most patients who contract Zika will
have a benign viral illness<o:p></o:p></span></div>
</div>
<div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<div style="text-align: left;">
<!--[if !supportLists]--><span style="font-family: "times new roman"; font-size: 13.5pt;">3.<span style="font-size: 7pt; font-stretch: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "times new roman"; font-size: 13.5pt;">Risk of GBS with Zika is 1 in 4 000<o:p></o:p></span></div>
</div>
<div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<div style="text-align: left;">
<!--[if !supportLists]--><span style="font-family: "times new roman"; font-size: 13.5pt;">4.<span style="font-size: 7pt; font-stretch: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "times new roman"; font-size: 13.5pt;">Zika causes microcephaly, especially
in 1<sup>st</sup> trimester<o:p></o:p></span></div>
</div>
<div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<div style="text-align: left;">
<!--[if !supportLists]--><span style="font-family: "times new roman"; font-size: 13.5pt;">5.<span style="font-size: 7pt; font-stretch: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "times new roman"; font-size: 13.5pt;">In the ED for a patient suspected of
having Zika:<o:p></o:p></span></div>
</div>
<div class="MsoNormal" style="margin-left: 72.0pt; mso-list: l0 level2 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 72.0pt; text-indent: -18.0pt;">
<div style="text-align: left;">
<!--[if !supportLists]--><span style="font-family: "courier new"; font-size: 10.0pt;">o<span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "times new roman"; font-size: 13.5pt;">Draw blood
work (and complete the 2 requisitions)<o:p></o:p></span></div>
</div>
<div class="MsoNormal" style="margin-left: 72.0pt; mso-list: l0 level2 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 72.0pt; text-indent: -18.0pt;">
<div style="text-align: left;">
<!--[if !supportLists]--><span style="font-family: "courier new"; font-size: 10.0pt;">o<span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "times new roman"; font-size: 13.5pt;">Refer to
Tropical Medicine Clinic<o:p></o:p></span></div>
</div>
<!--EndFragment--></div>
<div style="text-align: start;">
<div style="font-size: medium;">
<br /></div>
<div class="separator" style="clear: both; font-size: medium; text-align: center;">
<a href="https://4.bp.blogspot.com/-QFdF4W4XuiY/WP5dPxlM8tI/AAAAAAAACN4/gYhQ19hMTRUlDmYNz8nPi2xbRuzywXSiQCLcB/s1600/TRAER-sm.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="https://4.bp.blogspot.com/-QFdF4W4XuiY/WP5dPxlM8tI/AAAAAAAACN4/gYhQ19hMTRUlDmYNz8nPi2xbRuzywXSiQCLcB/s320/TRAER-sm.jpg" width="256" /></a></div>
<div style="font-size: medium;">
<br /></div>
<div style="font-size: medium;">
<br /></div>
<div style="font-size: medium;">
<br /></div>
<div style="font-size: medium; text-align: center;">
Dr. Julia Traer, MD, CCFP is a 3rd year resident in the CCFP-EM Program at the University of Ottawa.</div>
<div style="font-size: medium; text-align: center;">
<span style="font-size: x-small;"><br /></span></div>
<div style="font-size: medium; text-align: center;">
<span style="font-size: x-small;">-- Edited and Formatted by Dr. R Suttie, PGY2 at the University of Ottawa</span></div>
<div>
<span style="font-size: x-small;"><br /></span></div>
<div>
<span style="font-size: small;"><br /></span></div>
<div>
<span style="font-size: small;"><br /></span></div>
<div>
<span style="font-size: small;">References:</span></div>
<div>
<span style="font-size: 12.8px;">1.</span><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal;"> </span><span style="font-size: 12pt; text-indent: -18pt;">Government of
Canada. Surveillance of Zika virus.<span class="apple-converted-space"> </span></span><span style="font-family: "times new roman"; font-size: 12pt; text-indent: -18pt;">http://www.healthycanadians.gc.ca/diseases-conditions-maladies-affections/disease-maladie/zika-virus/surveillance-eng.php#s2-1.
Accessed November 7, 2016.</span></div>
<div>
<span style="font-size: 9.5pt; text-indent: -18pt;">2.<span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><span style="font-size: 12pt; text-indent: -18pt;">Zika
Working Group on behalf of the Committee to Advise on Tropical Medicine and
Travel (CATMAT). Canadian recommendations on the prevention and treatment of
Zika virus: Update. Can Comm Dis Rep 2016;42:101-11</span></div>
<div>
<span style="font-family: "times new roman"; font-size: 12pt; text-indent: -18pt;">3.</span><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal; text-indent: -18pt;"> </span><span style="font-size: 12pt; text-indent: -18pt;">Brasil
P, Pereira J,Jose P., Raja Gabaglia C, Damasceno L, Wakimoto M, Ribeiro
Nogueira RM, et al. Zika Virus Infection in Pregnant Women in Rio de Janeiro —
Preliminary Report. N Engl J Med 2016;ePub.</span></div>
<div>
<span style="font-family: "times new roman"; font-size: 12pt; text-indent: -18pt;">4.</span><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal; text-indent: -18pt;"> </span><span style="font-size: 12pt; text-indent: -18pt;">Centers
for Disease Control and Prevention. Zika Basics: Flipbook for Community Health
Workers. https://www.cdc.gov/zika/pdfs/zika_basics_low-literacy_flipbook.pdf.
Accessed November 7, 2016.</span></div>
<div>
<span style="font-family: "times new roman"; font-size: 12pt; text-indent: -18pt;">5.</span><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal; text-indent: -18pt;"> </span><span style="font-size: 12pt; text-indent: -18pt;">European
Centre for Disease Prevention and Control. Current Zika transmission.
http://ecdc.europa.eu/en/healthtopics/zika_virus_infection/zika-outbreak/pages/zika-countries-with-transmission.aspx.
Accessed November 7, 2016.</span></div>
<div>
<span style="font-family: "times new roman"; font-size: 12pt; text-indent: -18pt;">6.</span><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal; text-indent: -18pt;"> </span><span style="font-size: 12pt; text-indent: -18pt;">World
Health Organization. Zika virus, Microcephaly and Guillain-Barré Syndrome
Situation Report 3 November 2016. 2016;
http://apps.who.int/iris/bitstream/10665/250724/1/zikasitrep3Nov16-eng.pdf?ua=1
Accessed November 7, 2016.</span></div>
<div>
<span style="font-family: "times new roman"; font-size: 12pt; text-indent: -18pt;">7.</span><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal; text-indent: -18pt;"> </span><span style="font-size: 12pt; text-indent: -18pt;">Musso
D, Nhan T, Robin E, Roche C, Bierlaire D, Zisou K, et al. Potential for Zika
virus transmission through blood transfusion demonstrated during an outbreak in
French Polynesia, November 2013 to February 2014. Euro Surveil
2014;19(14):20761.</span></div>
<div>
<span style="font-family: "times new roman"; font-size: 12pt; text-indent: -18pt;">8.</span><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal; text-indent: -18pt;"> </span><span style="font-size: 12pt; text-indent: -18pt;">The
Ottawa Hospital. TOH Zika Management Plan & Information for Health Care
Providers. The Ottawa Hospital intranet. Accessed November 20, 2016.</span></div>
<div>
<span style="font-family: "times new roman"; font-size: 12pt; text-indent: -18pt;">9.</span><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal; text-indent: -18pt;"> </span><span style="font-size: 12pt; text-indent: -18pt;">Cao-Lormeau
V, Blake A, Mons S, Lastere S, Roche C, Vanhomwegen J, et al. Guillain-Barré Syndrome
outbreak associated with Zika virus infection in French Polynesia: a case-
control study. Lancet 2016;ePub.</span></div>
<div>
<span style="font-size: 9.5pt; text-indent: -18pt;">10.<span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><span style="font-size: 12pt; text-indent: -18pt;">Cauchemez
S, Besnard M, Bompard P, Dub T, Guillemette-Artur P, Eyrolle-Guignot D, et al.
Association between Zika virus and microcephaly in French Polynesia, 2013–15: a
retrospective study. Lancet 2016;ePub. </span><br />
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</style>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-18798974966855606852017-05-08T09:00:00.000-04:002017-05-08T09:00:29.247-04:00Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients: A Randomized Clinical Trial <h4 style="background: white;">
<a href="https://3.bp.blogspot.com/-ZpPr8-LNAYQ/WQ_JkHIwawI/AAAAAAAAB2M/Gkh0uRAGbYgXGSYWGYG7z3me-0slCDF2gCLcB/s1600/4th_generation_Video_Laryngoscope.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="240" src="https://3.bp.blogspot.com/-ZpPr8-LNAYQ/WQ_JkHIwawI/AAAAAAAAB2M/Gkh0uRAGbYgXGSYWGYG7z3me-0slCDF2gCLcB/s320/4th_generation_Video_Laryngoscope.jpg" width="320" /></a><span lang="EN-US"><b style="background-color: transparent;"><span lang="EN-US"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Journal Club Summary</span></span></b></span></h4>
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<span lang="EN-US"><b style="background-color: transparent;"><span lang="EN-US" style="color: red;"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Methodology Score: 4/5 </span></span></b></span></div>
<div class="MsoNormal" style="background: white;">
<span lang="EN-US"><b style="background-color: transparent;"><span lang="EN-US" style="color: red;"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Usefulness Score: 3/5</span></span></b></span></div>
<div class="MsoNormal" style="background: white;">
<span lang="EN-US"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><br /></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><span lang="EN-US">Lascarrou JB, et al. </span><span class="jrnl"><span lang="EN-US" style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial;">JAMA</span></span><span lang="EN-US" style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial;">. 2017 Feb 7;317(5):483-493.</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><a href="http://jamanetwork.com/journals/jama/article-abstract/2598718">Abstract Link</a></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: red;"><o:p><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"></span></o:p></span></b></div>
<a name='more'></a><b style="mso-bidi-font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"> </span></b><br />
<div class="MsoNormal">
<span lang="EN-CA" style="mso-ansi-language: EN-CA;"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">This study
was an open-label, randomized clinical trial conducted at 7 ICUs in France that
found video laryngoscopy compared with direct laryngoscopy did not improve
first-pass orotracheal intubation rates or median time to successful intubation
in an ICU population. Overall, this study adds to a growing body of evidence
that video laryngoscopy does not improve first pass orotracheal intubation
rates.<o:p></o:p></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span lang="EN-CA" style="mso-ansi-language: EN-CA;">By: </span><span lang="EN-US" style="mso-bidi-font-style: italic;">Dr. Jeffrey Landreville<span style="mso-spacerun: yes;"> </span></span></i></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US"><o:p></o:p></span></b></span></div>
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<br /></div>
<h4 style="mso-layout-grid-align: none; text-autospace: none;">
<b><span lang="EN-CA"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Epi lesson</span></span></b></h4>
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<b><u><span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-fareast-language: EN-CA;"><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><a href="http://emottawa.blogspot.ca/2015/06/epi-lessons-part-2-therapy-articles.html">Clinically Important Outcomes</a><o:p></o:p></span></span></u></b></div>
<div class="MsoNormalCxSpMiddle" style="margin-bottom: 10.0pt; mso-add-space: auto;">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-bidi-font-weight: bold; mso-fareast-language: EN-CA;">Outcomes may include survival, clinical events (e.g.
strokes or myocardial infarction), patient-reported outcomes (e.g. symptoms,
quality of life), process outcomes (length of stay, intubation, imaging),
adverse events, and economic outcomes (e.g. cost and resource use). Ideally the
most important relevant outcome will be the primary outcome of the study, e.g.
mortality for cardiac arrest, pain relief for analgesic studies. Be cautious of
studies where processes are the primary outcome because these are of little
interest to patients or their families. For example, it would be of little
consolation to a family to hear that their loved one was intubated on the first
pass but subsequently died</span>.<br /><b><i><span lang="EN-CA">By: </span></i></b><b><i><span lang="EN-US">Dr. Ian Stiell</span></i></b></span></div>
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Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-40405711118469901372017-05-01T10:26:00.000-04:002017-05-01T10:38:16.302-04:00Risk of Acute Kidney Injury After Intravenous Contrast Media Administration<h4 style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<a href="https://2.bp.blogspot.com/-bl-4kvqsE-4/WQdCkudZpDI/AAAAAAAAB1k/l1eryLkKQhgyNdDCxed24LUK5sjg4PmgACLcB/s1600/140603-F-ES880-033.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="212" src="https://2.bp.blogspot.com/-bl-4kvqsE-4/WQdCkudZpDI/AAAAAAAAB1k/l1eryLkKQhgyNdDCxed24LUK5sjg4PmgACLcB/s320/140603-F-ES880-033.JPG" width="320" /></a><b><span lang="EN-US"><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: small;">Journal Club Summary</span></span></b></h4>
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<b><span lang="EN-US" style="color: red;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: small;">Methodology Score: 4/5 </span></span></b></div>
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<b><span lang="EN-US" style="color: red;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: small;">Usefulness Score: 3.5/5</span></span></b></div>
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<span lang="EN-US" style="color: black;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: small;"><br /></span></span></div>
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<span lang="EN-US" style="color: black;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: small;">Hinson JS, et al. <span class="jrnl">Ann Emerg Med</span>.
2017 Jan 19 [Epub ahead of print]<o:p></o:p></span></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif; font-size: small;"><a href="http://www.sciencedirect.com/science/article/pii/S0196064416313889">Full Article</a> </span></div>
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<span lang="EN-US"><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: small;">In this large, well-designed retrospective study of AKI following
contrast administration for CT in ED patients, IV contrast was not found to be
associated with an increased frequency of AKI or subsequent renal failure. When
combining this data with emerging recent evidence, local protocols should be
updated to reflect that we should not delay emergent contrast-enhanced CT scans
waiting for serum creatinine, considering IV fluid administration for patients
at moderate to high risk for AKI given other patient factors and co-morbidities
(ie advanced age, CHF, HTN, DM, CKD).<o:p></o:p></span></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif; font-size: small;"><b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span lang="EN-US">By: </span></i></b><b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span lang="EN-CA" style="mso-ansi-language: EN-CA;">Dr. </span><span lang="EN-US" style="mso-bidi-font-style: italic;">Lauren Lacroix</span></i></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-CA" style="mso-ansi-language: EN-CA;"><o:p></o:p></span></b></span></div>
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<b><span lang="EN-CA"><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: small;">Epi Lesson</span></span></b></h4>
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<span style="font-family: "arial" , "helvetica" , sans-serif; font-size: small;"><b><u><span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-fareast-language: EN-CA;"><a href="http://emottawa.blogspot.ca/2015/07/epi-lessons-part-5-prognosis-and-other.html">Propensity Score Matching</a></span></u></b><span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-bidi-font-weight: bold; mso-fareast-language: EN-CA;"> <o:p></o:p></span></span></div>
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<span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-bidi-font-weight: bold; mso-fareast-language: EN-CA;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: small;">In the statistical analysis of observational data,
propensity score matching is one of a family of multivariate statistical
techniques that attempts to estimate the effect of a treatment or other
intervention by accounting for the covariates that predict receiving the
treatment. Compared to the gold standard of a randomized controlled trial, any
observational analysis and interpretation of the usefulness of an intervention
must be viewed with a large degree of healthy skepticism.<b><u> </u></b><o:p></o:p></span></span></div>
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Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-40816485865406426452017-04-25T09:41:00.000-04:002017-04-25T09:41:45.614-04:00Pediatric Airway Management in the Emergency Department<div style="text-align: center;">
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Name="envelope return"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footnote reference"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation reference"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="line number"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="page number"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote reference"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of authorities"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="macro"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="toa heading"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/> <w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/> <w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/> <w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/> <w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/> <w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/> <w:LsdException Locked="false" Priority="39" Name="Table Grid"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 9"/> <w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/> <w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading"/> <w:LsdException Locked="false" Priority="61" Name="Light List"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/> <w:LsdException Locked="false" SemiHidden="true" Name="Revision"/> <w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/> <w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/> <w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/> <w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/> <w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/> <w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/> <w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/> <w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/> <w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/> <w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/> <w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/> <w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/> <w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/> <w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/> <w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/> <w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/> <w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/> <w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="46"
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">Pediatric endotracheal intubation is an uncommon procedure in the Emergency Department (ED); even in high volume tertiary pediatric centres the incidence has been reported at 8-10/10,000 patients. While infrequent, pediatric airway management is an essential and life-saving skill that all ER physicians must be prepared for. Much of the knowledge and skill set from the adult world is applicable here, however there are several important differences that are unique to the pediatric population.<o:p></o:p></span><br />
<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;"></span></div>
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<br />
<a name='more'></a><br /></div>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">This blog post aims to:<o:p></o:p></span></div>
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<li class="MsoNormal" style="color: black; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Provide a basic review of pediatric airway physiology + anatomy<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Discuss predictors of the pediatric difficult airway<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Review the literature on pediatric ER intubation practices and associated complications<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Review Delayed Sequence Intubation (DSI) and the pediatric surgical airway<o:p></o:p></span></li>
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<span style="font-family: "times new roman";"><span style="font-size: 18px;"><br />
</span></span></div>
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<b><span style="color: black; font-family: "times new roman"; font-size: 18.0pt;">Pediatric Airway Anatomy and Physiology Review<o:p></o:p></span></b></div>
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<b><span style="color: black; font-family: "times new roman"; font-size: 18.0pt;"><br />
</span></b></div>
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<b><span style="color: black; font-family: "times new roman"; font-size: 14.0pt;">1. Anatomic differences in the pediatric airway are more pronounced in younger children, especially under 1 year, and have important implications for airway management</span></b><b><span style="color: black; font-family: "times new roman"; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman";">. </span></b><b><span style="color: black; font-family: "times new roman"; font-size: 18.0pt;"><o:p></o:p></span></b></div>
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<b><span style="color: black; font-family: "times new roman"; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman";"><br />
</span></b></div>
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<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;">These include:</span></div>
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</style> <![endif]--> <!--StartFragment--> <br />
<ul type="disc">
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Large occiput + head </span><span style="font-family: "wingdings"; font-size: 13.5pt;">à</span><span style="font-family: "times new roman"; font-size: 13.5pt;"> Add a shoulder roll to align the airway axes<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Large Tongue </span><span style="font-family: "wingdings"; font-size: 13.5pt;">à</span><span style="font-family: "times new roman"; font-size: 13.5pt;"> obstruction more common, maneuvers to open the airway may be necessary (eg jaw thrust)<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Superior larynx and anterior vocal cords + floppy epiglottis </span><span style="font-family: "wingdings"; font-size: 13.5pt;">à</span><span style="font-family: "times new roman"; font-size: 13.5pt;"> visualization can be more challenging, consider a straight blade in younger children to lift the large epiglottis<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;">Large stomach with relatively small lungs </span><span style="font-family: "wingdings"; font-size: 13.5pt;">à</span><span style="font-family: "times new roman"; font-size: 13.5pt;"> consider early NG tube<o:p></o:p></span></li>
</ul>
<div>
<span style="font-family: "times new roman";"><span style="font-size: 18px;"><br />
</span></span></div>
<!--EndFragment--><br />
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Name="index heading"/> <w:LsdException Locked="false" Priority="35" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="caption"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of figures"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope address"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope return"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footnote reference"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation reference"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="line number"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="page number"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote reference"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of authorities"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="macro"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="toa heading"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/> <w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/> <w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/> <w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/> <w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/> <w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/> <w:LsdException Locked="false" Priority="39" Name="Table Grid"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 9"/> <w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/> <w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading"/> <w:LsdException Locked="false" Priority="61" Name="Light List"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/> <w:LsdException Locked="false" SemiHidden="true" Name="Revision"/> <w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/> <w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/> <w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/> <w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/> <w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/> <w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/> <w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/> <w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/> <w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/> <w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/> <w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/> <w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/> <w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/> <w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/> <w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/> <w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/> <w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/> <w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="46"
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<b><span style="color: black; font-family: "times new roman"; font-size: 14.0pt;">2. Physiologically, kids have a considerably shorter time to desaturation than adults and their relatively larger extracellular fluid compartment means a quicker onset and shorter duration of RSI drugs<sup>16</sup></span></b><b><span style="color: black; font-family: "times new roman"; font-size: 10.0pt;">. </span></b><span style="color: black; font-family: "times new roman"; font-size: 10.0pt;"><o:p></o:p></span></div>
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<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">There are many different equations out there to figure out sizing of tubes, blades, masks, etc., but the bottom line is that it’s too much to memorize for something you won’t need to use often, so to reduce error in critical situations use memory aids such as the Broselow tape or your favourite medical app<o:p></o:p></span></li>
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<tr><td style="text-align: center;"><a href="https://4.bp.blogspot.com/-zrH_Gpi33os/WPzqrfaU31I/AAAAAAAACLU/Fn1gdac1414nnsecH53tspMy6HAUF8vtACLcB/s1600/pedistat.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="197" src="https://4.bp.blogspot.com/-zrH_Gpi33os/WPzqrfaU31I/AAAAAAAACLU/Fn1gdac1414nnsecH53tspMy6HAUF8vtACLcB/s200/pedistat.png" width="200" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><a href="http://www.qxmd.com/apps/pedi-stat-for-iphone-android">PediStat</a> -- a commonly used pediatric reference application</td></tr>
</tbody></table>
<br />
<div class="MsoNormal">
<b><span style="color: black; font-family: "times new roman"; font-size: 14.0pt;">3. Difficult intubation seems to be rare in children, but increases in incidence in the <1 yo population.</span></b><b><span style="color: black; font-family: "times new roman"; mso-ansi-language: EN-US;"> </span></b><span style="color: black; font-family: "times new roman"; font-size: 10.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman"; font-size: 13.5pt;"><a href="https://www.ncbi.nlm.nih.gov/pubmed/22340664">This retrospective analysis of 11,219 pediatric anesthesia </a>procedures found that the overall incidence of difficult laryngoscopy to be only 1.35%. The paper highlighted some predictors of a difficult pediatric airway, which included:</span></div>
<ul type="disc">
<li><span style="font-family: "times" , "times new roman" , serif;">< 1 year old</span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Mallampati score</span><span style="font-family: "times new roman"; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman";"> (if attainable) III + IV</span><span style="font-family: "times new roman"; font-size: 13.5pt;"><o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Low BMI<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Children undergoing cardiac and oromaxillofacial surgery patients – likely due to higher proportion craniofacial dysmorphisms eg. Cleft palate, micrognathia<o:p></o:p></span></li>
</ul>
<div>
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</span></span></div>
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</div>
<div class="separator" style="clear: both; text-align: left;">
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<h2 style="clear: both; text-align: left;">
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<b><span style="font-family: "times new roman"; font-size: 18pt;">ER Pediatric Intubation Practices and Complications<o:p></o:p></span></b></div>
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<b><span style="font-family: "times new roman"; font-size: 14pt;">1. Pediatric endotracheal intubation is an uncommon procedure, but resulting desaturation and hypotension are frequent complications</span></b><b><span style="font-family: "times new roman";">. </span></b><span style="font-family: "times new roman"; font-size: 10pt;"><o:p></o:p></span></div>
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<span style="font-family: "times new roman"; font-size: 13.5pt; font-weight: normal;"><span style="color: purple;"><a href="https://www.ncbi.nlm.nih.gov/pubmed/25039321">This prospective observational study</a></span> reviews pediatric intubations in a tertiary pediatric ED. Their primary and secondary outcomes were, respectively, the rate of adverse effects during intubation and the incidence of difficult laryngoscopy and first pass success rate without desaturation and hypotension.<o:p></o:p></span></div>
<ul type="disc">
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt; font-weight: normal;">The incidence of pediatric intubations was found to be 9/10,000<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt; font-weight: normal;">79% of intubations were for medical conditions (seizure most commonly), 21% were for trauma<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt; font-weight: normal;">Median age was 3, with 25% of intubations being in the <1 population<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt; font-weight: normal;">First pass success rate was 78%<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt; font-weight: normal;">First pass rate without hypotension or hypoxia was only 49%<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt; font-weight: normal;">Difficult intubation was seen in 7% of cases, but all intubations were ultimately successful<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt;"><span style="font-weight: normal;">Ketamine was the most commonly used mono-agent and was the induction agent of choice in patients with CVS compromise</span><o:p></o:p></span></li>
</ul>
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<div class="MsoNormal">
<b><span style="font-family: "times new roman"; font-size: 14pt;">2. Desaturation and hypotension peri-intubation matter, as they are linked to poor neurologic outcomes and are predictors of airway mortality <sup>12 </sup>. </span></b><span style="font-family: "times new roman"; font-size: 13.5pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
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<span style="font-weight: normal;"><span style="font-family: "times new roman"; font-size: 13.5pt;"><span style="color: purple;"><a href="http://www.or.org/bibliography/PDF/1590079444/Fiadjoe-2016.pdf">A review of 1081 difficult airways</a></span></span><span style="font-family: "times new roman"; font-size: 13.5pt;"> found that 1% were associated with cardiac arrest, all preceded by hypoxemia. Occurrence of complications in the difficult airway was associated with: <o:p></o:p></span></span></div>
<ul type="disc">
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt; font-weight: normal;">More than two intubation attempts<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt; font-weight: normal;">Weight < 10kg<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt; font-weight: normal;">Short thyromental distance<o:p></o:p></span></li>
<li class="MsoNormal"><span style="font-family: "times new roman"; font-size: 13.5pt; font-weight: normal;">3 direct laryngoscopy attempts before switching to indirect technique</span></li>
</ul>
<ul type="disc"></ul>
<div class="MsoNormal">
<span style="font-family: "times new roman"; font-size: 14pt;">3. Direct Laryngoscopy is a reasonable first line choice, but the Pediatric Difficult Intubation (PeDI) registry data suggests we should be thinking about switching to an indirect method much sooner if we run into trouble. </span><span style="font-family: "times new roman"; font-size: 14pt;"> </span><span style="font-family: "times new roman"; font-weight: normal;"><o:p></o:p></span></div>
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<span style="font-family: "times new roman"; font-size: 13.5pt;"><span style="font-weight: normal;">In fact, first attempt success rates in the pediatric difficult airway population were found to be substantially higher in Video than in Direct Laryngoscopy (55 % vs 3 %)<sup>4</sup>. This begs the question as to whether community and ERs that see primarily adults should be stocking pediatric video laryngoscopes?</span><o:p></o:p></span></div>
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<span style="font-family: "times new roman"; font-size: 13.5pt;"><span style="font-weight: normal;">Keep in mind, though, that this is the <i>difficult airway</i> population, which we know is quite rare. <a href="https://www.ncbi.nlm.nih.gov/pubmed/24958249">A systematic review of 14 prospective RCTs </a>comparing video vs direct in the pediatric population concluded that although video improved glottis visualization, it was associated with prolonged time to intubation -- something to consider given the considerably reduced safe apnea time in children.</span></span></div>
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<b><span style="font-family: "times new roman"; font-size: 18pt;">Delayed Sequence Intubation and The Pediatric Surgical Airway<o:p></o:p></span></b></div>
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<b><span style="font-family: "times new roman"; font-size: 18pt;"><br />
</span></b></div>
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<b><span style="font-family: "times new roman"; font-size: 14pt;">Scott Weingart’s group has paved the way for future studies on Delayed Sequence Intubation (DSI)<sup>1</sup>; keep an eye out for this in the pediatric population as it’s easy to see how it might be useful in the agitated hypoxic child that needs to be intubated</span></b><span style="font-family: "times new roman";">. <o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "times new roman"; font-size: 13.5pt;"><span style="font-weight: normal;">The concept is to use ketamine as an induction agent to facilitate pre-oxygenation while keeping the patient spontaneously breathing in situations where RSI would likely lead to hypoxia. While the evidence is still in it’s infancy, <span style="color: purple;"><a href="https://www.ncbi.nlm.nih.gov/pubmed/26707248">case</a></span><span style="color: red;"> </span><a href="https://www.ncbi.nlm.nih.gov/pubmed/24712856"><span style="color: purple;">reports</span><span style="color: purple;"> </span></a><sup>2,3</sup> are surfacing of DSI being successfully used to secure the airway in agitated hypoxic and critically ill patients.</span><o:p></o:p></span></div>
<!--EndFragment--></h2>
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://3.bp.blogspot.com/-11WL0euBu2I/WP5Ky97bhKI/AAAAAAAACMA/uWbunIIWkfQp4HOX_j3ZvesHcRLHp1Y5gCLcB/s1600/dsi.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="542" src="https://3.bp.blogspot.com/-11WL0euBu2I/WP5Ky97bhKI/AAAAAAAACMA/uWbunIIWkfQp4HOX_j3ZvesHcRLHp1Y5gCLcB/s640/dsi.png" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">ASA 2013 Difficult Airway Algorithm<br />
<br />
<div style="text-align: left;">
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UnhideWhenUsed="true" QFormat="true" Name="heading 9"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 9"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 1"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 2"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 3"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 4"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 5"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 6"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 7"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 8"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 9"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footnote text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="header"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footer"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index heading"/> <w:LsdException Locked="false" Priority="35" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="caption"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of figures"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope address"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope return"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footnote reference"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation reference"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="line number"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="page number"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote reference"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of authorities"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="macro"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="toa heading"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/> <w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/> <w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/> <w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/> <w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/> <w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/> <w:LsdException Locked="false" Priority="39" Name="Table Grid"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 9"/> <w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/> <w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading"/> <w:LsdException Locked="false" Priority="61" Name="Light List"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/> <w:LsdException Locked="false" SemiHidden="true" Name="Revision"/> <w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/> <w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/> <w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/> <w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/> <w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/> <w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/> <w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/> <w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/> <w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/> <w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/> <w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/> <w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/> <w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/> <w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/> <w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/> <w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/> <w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/> <w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="52"
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<b><span style="font-family: "times new roman"; font-size: 14.0pt;">Finally, if you find yourself in the exceedingly rare but completely terrifying <i>can’t intubate, can’t ventilate</i> scenario with a pediatric patient, remember that needle cricothyrotomy is indicated in younger children<sup>14</sup>. </span></b><span style="font-family: "times new roman"; mso-ansi-language: EN-US;"><o:p></o:p></span></div>
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<li class="MsoNormal" style="mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">The literature in this area is sparse and there is no consensus on a definite age cut off for needle vs open cricothyrotomy, it will depend on how difficult landmarking is and the size of the cricothyroid membrane (CTM). <o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Consider using a Seldinger technique to transition to open once needle is secured if needle ventilation continues to be inadequate and help has not yet arrived<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; font-size: 13.5pt;">Anatomical differences making the traditional surgical airway challenging in this population include a smaller CTM, more compliant larynx and the thyroid cartilage riding under the hyoid bone.</span></li>
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<span style="font-size: 12pt;">Dr. Rebecca Brown, MD, CCFP is a 3rd year resident in the CCFP-EM program at the University of Ottawa.</span></div>
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<span style="font-size: 10pt;">Edited and Formatted by Dr. Rob Suttie, PGY2 at the University of Ottawa</span></div>
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<span style="font-family: inherit; font-size: x-small;">References</span></div>
<div class="MsoNormal">
<span style="font-family: inherit; font-size: x-small;"><o:p></o:p></span></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: inherit; font-size: x-small;"><span lang="EN-CA"><span style="mso-list: Ignore;">1.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed Sequence Intubation: A Prospective Observational Study. <i>Ann Emerg Med</i>. 2015;65:349-355. <o:p></o:p></span></span></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="font-family: inherit; font-size: x-small;"><a href="https://www.blogger.com/null" name="miescier"><!--[if !supportLists]--><span lang="EN-CA"><span style="mso-list: Ignore;">2.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Miescier MPH MJ, Bryant RJ, Nelson DS. Delayed sequence intubation with ketamine in 2 critically ill children </span></a><span style="mso-bookmark: miescier;"><span lang="EN-CA">☆</span></span><span style="mso-bookmark: miescier;"><span lang="EN-CA">. <i>Am J Emerg Med</i>. 2016;34:1190.e1-1190.e2. <o:p></o:p></span></span></span></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<a href="https://www.blogger.com/null" name="lollgen"><span style="font-family: inherit; font-size: x-small;"><!--[if !supportLists]--><span lang="EN-CA"><span style="mso-list: Ignore;">3.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Löllgen RM, Webster P, Lei E, Weatherall A. Delayed sequence intubation for management of respiratory failure in a 6-year-old child in a paediatric emergency department. <i>EMA - Emerg Med Australas</i>. 2014. <o:p></o:p></span></span></a></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<a href="https://www.blogger.com/null" name="nishisaki"><span style="font-family: inherit; font-size: x-small;"><!--[if !supportLists]--><span lang="EN-CA"><span style="mso-list: Ignore;">4.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Nishisaki A, Fiadjoe JE, McGowan Jr FX, et al. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. <i>www.thelancet.com Lancet Respir Med</i>. 2016;4:37-48. <o:p></o:p></span></span></a></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: inherit; font-size: x-small;"><span lang="EN-CA"><span style="mso-list: Ignore;">5.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Nishisaki A, Turner D a, Brown C a, Walls RM, Nadkarni VM. A National Emergency Airway Registry for children: landscape of tracheal intubation in 15 PICUs. <i>Crit Care Med</i>. 2013;41(3):874-885<o:p></o:p></span></span></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: inherit; font-size: x-small;"><span lang="EN-CA"><span style="mso-list: Ignore;">6.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Walls RM. Emergency Airway Management: A Multi-Center Report of 8937 Emergency Department Intubations. <i>J Emerg Med</i>. 2011;41(4). <o:p></o:p></span></span></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: inherit; font-size: x-small;"><span lang="EN-CA"><span style="mso-list: Ignore;">7.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Anesthesiologists A society of. Practice Guidelines for Management of the Difficult Airway. <i>Anesthesiology</i>. 2013;118(2):251-270<o:p></o:p></span></span></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: inherit; font-size: x-small;"><span lang="EN-CA"><span style="mso-list: Ignore;">8.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Choi HJ, Je SM, Kim JH, Kim E. The factors associated with successful paediatric endotracheal intubation on the first attempt in emergency departments: A 13-emergency-department registry study. <i>Resuscitation</i>. 2012;83(11):1363-1368<o:p></o:p></span></span></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: inherit; font-size: x-small;"><span lang="EN-CA"><span style="mso-list: Ignore;">9.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">CotÉ CJ, Hartnick CJ. Pediatric transtracheal and cricothyrotomy airway devices for emergency use: Which are appropriate for infants and children? <i>Paediatr Anaesth</i>. 2009;19(SUPPL. 1):66-76. <o:p></o:p></span></span></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: inherit; font-size: x-small;"><span lang="EN-CA"><span style="mso-list: Ignore;">10.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Fiadjoe JE, Stricker PA, Litman RS. Pediatric Airway Management. <i>Greg Pediatr Anesth Fifth Ed</i>. 2011;26:300-329<o:p></o:p></span></span></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: inherit; font-size: x-small;"><span lang="EN-CA"><span style="mso-list: Ignore;">11.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Gencorelli FJ, Fields RG, Litman RS. Complications during rapid sequence induction of general anesthesia in children: A benchmark study. <i>Paediatr Anaesth</i>. 2010;20(5):421-424. <o:p></o:p></span></span></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: inherit; font-size: x-small;"><span lang="EN-CA"><span style="mso-list: Ignore;">12.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Heffner AC, Swords DS, Neale MN, Jones AE. Incidence and factors associated with cardiac arrest complicating emergency airway management. <i>Resuscitation</i>. 2013; 84(11):1500-1504. <o:p></o:p></span></span></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<a href="https://www.blogger.com/null" name="heinrich"><span style="font-family: inherit; font-size: x-small;"><!--[if !supportLists]--><span lang="EN-CA"><span style="mso-list: Ignore;">13.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Heinrich S. Incidence and predictors of difficult laryngoscopy in 11.219 pediatric anesthesia procedures. 22(8). <o:p></o:p></span></span></a></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: inherit; font-size: x-small;"><span lang="EN-CA"><span style="mso-list: Ignore;">14.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Jagannathan N, Sohn L, Fiadjoe JE. Paediatric difficult airway management: what every anaesthetist should know! <i>Br J Anaesth</i>. 2016;(i) <o:p></o:p></span></span></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="font-family: inherit; font-size: x-small;"><a href="https://www.blogger.com/null" name="long"><!--[if !supportLists]--><span lang="EN-CA"><span style="mso-list: Ignore;">15.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Long E. Endotracheal intubation in the pediatric emergency department. 2014; 4(12)</span></a><span lang="EN-CA"><o:p></o:p></span></span></div>
<div style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: inherit; font-size: x-small;"><span lang="EN-CA"><span style="mso-list: Ignore;">16.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Walls, R. <i>Manual of Emergency Airway Management, 2012, 4th Edition </i>1. <span style="mso-tab-count: 1;"> </span><o:p></o:p></span></span></div>
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Name="Closing"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/> <w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/> <w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/> <w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/> <w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/> <w:LsdException Locked="false" Priority="39" Name="Table Grid"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 9"/> <w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/> <w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading"/> <w:LsdException Locked="false" Priority="61" Name="Light List"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/> <w:LsdException Locked="false" SemiHidden="true" Name="Revision"/> <w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/> <w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/> <w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/> <w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/> <w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/> <w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/> <w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/> <w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/> <w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/> <w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/> <w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/> <w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/> <w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/> <w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/> <w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/> <w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/> <w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/> <w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/> <w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/> <w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/> <w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/> <w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/> <w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 3"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 3"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 3"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 3"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 3"/> <w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 4"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 4"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 4"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 4"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 4"/> <w:LsdException Locked="false" Priority="51"
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<a href="https://www.blogger.com/null" name="sun"><span style="font-family: inherit; font-size: x-small;"><!--[if !supportLists]--><span lang="EN-CA"><span style="mso-list: Ignore;">17.<span style="font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><!--[endif]--><span lang="EN-CA">Sun Y, Lu Y, Huang Y, Jiang H. Pediatric video laryngoscope versus direct laryngoscope: a meta-analysis of randomized controlled trials. Cote C, ed. <i>Pediatr Anesth</i>. 2014;24(10):1056-1065</span></span></a><span lang="EN-CA" style="font-family: "times new roman";"><o:p></o:p></span></div>
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</style>Unknownnoreply@blogger.com2tag:blogger.com,1999:blog-1264812964585869968.post-70366954656465219792017-04-24T12:00:00.001-04:002017-04-24T12:00:33.592-04:00Effect of Noninvasive Ventilation Delivered by Helmet vs. Facemask on the Rate of Endotracheal Intubation in Patients with Acute Respiratory Distress Syndrome<h4 style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial;">
<a href="https://2.bp.blogspot.com/-tMMPFrNkASY/WP4e57bjM1I/AAAAAAAAB1E/OB6MFhAp-VkrQipx6HnJdZ0PfCH7HYSugCLcB/s1600/helmet-pic1.jpg" imageanchor="1" style="background-color: white; clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="320" src="https://2.bp.blogspot.com/-tMMPFrNkASY/WP4e57bjM1I/AAAAAAAAB1E/OB6MFhAp-VkrQipx6HnJdZ0PfCH7HYSugCLcB/s320/helmet-pic1.jpg" width="289" /></a><a href="https://2.bp.blogspot.com/-tMMPFrNkASY/WP4e57bjM1I/AAAAAAAAB1E/OB6MFhAp-VkrQipx6HnJdZ0PfCH7HYSugCLcB/s1600/helmet-pic1.jpg" imageanchor="1" style="background-color: white; clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><br /></a><a href="https://2.bp.blogspot.com/-tMMPFrNkASY/WP4e57bjM1I/AAAAAAAAB1E/OB6MFhAp-VkrQipx6HnJdZ0PfCH7HYSugCLcB/s1600/helmet-pic1.jpg" imageanchor="1" style="background-color: white; clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><br /></a><a href="https://2.bp.blogspot.com/-tMMPFrNkASY/WP4e57bjM1I/AAAAAAAAB1E/OB6MFhAp-VkrQipx6HnJdZ0PfCH7HYSugCLcB/s1600/helmet-pic1.jpg" imageanchor="1" style="background-color: white; clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><br /></a><a href="https://2.bp.blogspot.com/-tMMPFrNkASY/WP4e57bjM1I/AAAAAAAAB1E/OB6MFhAp-VkrQipx6HnJdZ0PfCH7HYSugCLcB/s1600/helmet-pic1.jpg" imageanchor="1" style="background-color: white; clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><br /></a><a href="https://2.bp.blogspot.com/-tMMPFrNkASY/WP4e57bjM1I/AAAAAAAAB1E/OB6MFhAp-VkrQipx6HnJdZ0PfCH7HYSugCLcB/s1600/helmet-pic1.jpg" imageanchor="1" style="background-color: white; clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><br /></a><a href="https://2.bp.blogspot.com/-tMMPFrNkASY/WP4e57bjM1I/AAAAAAAAB1E/OB6MFhAp-VkrQipx6HnJdZ0PfCH7HYSugCLcB/s1600/helmet-pic1.jpg" imageanchor="1" style="background-color: white; clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><br /></a></h4>
<h4>
<span style="font-family: Arial, Helvetica, sans-serif;">Summary</span></h4>
<h4 style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: red;">Methodology Score: 4/5 <br />Usefulness Score: 3.5/5</span><br /><br /><span style="font-weight: normal;">Patel BK, et al. JAMA. 2016 Jun 14;315(22):2435-41</span><br /><a href="http://jamanetwork.com/journals/jama/fullarticle/2522693" style="font-weight: normal;">Full Article</a><br /><br /><span style="font-weight: normal;">Editorial: </span><a href="http://jamanetwork.com/journals/jama/article-abstract/2522691" style="font-weight: normal;">Unmasking a Role for Noninvasive Ventilation in Early Acute Respiratory Distress Syndrome. </a><span style="font-weight: normal;">Beitler JR, et al. JAMA. 2016 Jun 14;315(22):2401-3.</span><br /><br /><span style="font-weight: normal;">This single-centre, non-blinded RCT of ICU ARDS patients, found that NIV delivered by a novel helmet, as compared to a standard NIV facemask, reduced intubations (18.2% vs. 61.5%; P <0.001) and hospital mortality (27.3% vs. 48.7%; P= 0.04). Despite its few methodological flaws, this study supports the existing literature on the advantage of oxygen delivered via helmet over facemask in avoiding intubation in ARDS, and future studies should focus on its impact in heart failure or hypercapneic respiratory failure. </span><br />By: Dr. Shannon Fernando </span></h4>
<h4 style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial;">
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><span style="font-family: Arial, Helvetica, sans-serif;">Epi lesson: </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><a href="http://emottawa.blogspot.ca/2015/06/epi-lessons-part-2-therapy-articles.html" style="font-weight: normal;">Interim Analyses and Stopping Rules</a><br /><span style="font-weight: normal;">In clinical trials, an interim analysis is one that is conducted before data collection has been completed to determine if there are safety issues or if the study should be stopped early. These interim analyses are evaluated by an independent Data Safety Monitoring Board that is at arm’s length from the investigators. The DSMB has the authority to recommend early termination if the study intervention is clearly better than control (for benefit) or if there is so little difference between groups that full enrolment will not show a difference (for futility). Statistical stopping rules should be used to adjust the interim P-values to a much severe level, e.g. <0.001 instead of <0.05 using methods described by Pocock and O'Brien & Fleming, among others. </span><br /><i>By: Dr. Ian Stiell </i></span></h4>
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</style>Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-42701034477028907272017-04-11T16:36:00.000-04:002017-04-13T11:30:30.279-04:00Focus on POCUS: Subacute, Progressive Dyspnea while Swimming<div class="MsoNormal">
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman";">A
male in his 60’s presents with progressive dyspnea on exertion x 1 month
starting while he was swimming in the ocean. He had not been
diving. He has no significant medical history and takes no
medications.</span><br />
<a name='more'></a></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman";">Two
weeks after the onset of symptoms the patient had seen his family
physician. A chest X-ray (CXR) was completed and was normal. An
outpatient stress ECHO was requested.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman";">The
patient had had two Emergency presentations:</span></div>
<ol start="1" type="1">
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">On
his first ED visit he was assessed for shortness of breath. He
was having no chest pain and vitals were within normal limits. The
following investigations were normal: CXR, CBC, electrolytes, BUN,
Creatinine, CK and TnI. The patient was discharged home pending
the outpatient stress ECHO and told to return if symptoms worsened. <o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">On
the second ED visit 6 days later, the patient complained of worsening
SOBOE, no chest pain, no PND, no orthopnea, no fever or cough, no leg pain
or edema. There were no known PE risk factors. He is a non-smoker, drinks
ETOH occasionally.<o:p></o:p></span></li>
</ol>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman";"><o:p><i>On exam:</i></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "times new roman"; font-size: 12pt;">Triage
vitals:</span><i style="font-family: "Times New Roman"; font-size: 12pt;"> </i><span style="font-family: "times new roman"; font-size: 12pt;">35.7 HR 84 BP 179/83 RR 24 O2 sat 95% r/a</span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman";">Patient
appears in no acute distress but respiratory rate is noticeably increased.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman";">CVS
normal S1/S1 no S3/S4, no murmurs, JVP not elevated<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman";">Equal
pulses bilateral<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman";">Chest
clear<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman";">No
unilateral extremity warmth, erythema or tenderness along deep venous system</span></div>
<div class="MsoNormal">
<span style="font-family: "times new roman"; font-size: 12pt;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "times new roman"; font-size: 12pt;">ECG
from 1</span><sup style="font-family: "Times New Roman";">st</sup><span style="font-family: "times new roman"; font-size: 12pt;"> ED visit, 6 days prior:</span></div>
</div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: 12pt;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-_yWpwaq1Jiw/WOU5vsom_xI/AAAAAAAACJw/Wr7ZD1FnXeIjHm6oiOUbvCApDNn_BhTzgCLcB/s1600/ECG1.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: "times" , "times new roman" , serif;"><img border="0" height="344" src="https://1.bp.blogspot.com/-_yWpwaq1Jiw/WOU5vsom_xI/AAAAAAAACJw/Wr7ZD1FnXeIjHm6oiOUbvCApDNn_BhTzgCLcB/s640/ECG1.png" width="640" /></span></a></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: 12pt;">ECG analysis: NSR. Normal axis. Narrow QRS. Few PACs. No ST
segment/T wave changes.</span></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: 12pt;"><br /></span>
<span style="font-family: "times" , "times new roman" , serif; font-size: 12pt;">ECG on the day of presentation:</span></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: 12pt;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-NihoG5C0GtI/WOU6Ahzt2CI/AAAAAAAACJ0/A22WAwgHdgwpJCaQJ2ttmm9p4SXPf8IGQCLcB/s1600/ECG2.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: "times" , "times new roman" , serif;"><img border="0" height="352" src="https://1.bp.blogspot.com/-NihoG5C0GtI/WOU6Ahzt2CI/AAAAAAAACJ0/A22WAwgHdgwpJCaQJ2ttmm9p4SXPf8IGQCLcB/s640/ECG2.png" width="640" /></span></a></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: 12pt;">ECG analysis: Borderline sinus tachycardia. Normal Axis. Narrow
QRS. New T wave inversion lead III. Q wave lead 3. No block. No other ST segment/T wave changes.</span></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif;"><b><br /></b></span>
<span style="font-family: "times" , "times new roman" , serif;"><b><br /></b></span></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif;"><b>At this point consider your differential.</b> </span></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif;"><br /></span>
<span style="font-family: "times" , "times new roman" , serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif;">It should remain broad and, really, could include most items listed for dyspnea with a normal chest XR. This includes anemia, ACS, heart failure, obstructive lung disease, metabolic abnormalities, pericardial effusion/pericarditis, neuromuscular disorders, pulmonary HTN, airway issues and medicine's greatest enigma, a pulmonary embolism. </span></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif;">A point-of-care ultrasound scan was done to help narrow the differential. </span><br />
<span style="font-family: "times" , "times new roman" , serif;"><br /></span>
<span style="font-family: "times" , "times new roman" , serif;">Below are three cardiac views. Think of what you would be looking for given the clinical scenario. </span><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://3.bp.blogspot.com/-WiN2Pe5q4Hw/WO0AW8HZarI/AAAAAAAACKE/mj2wio-d0aQHJP0QrDIYW7qLgiLRwog8QCLcB/s1600/PSL.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><span style="font-family: "times" , "times new roman" , serif;"><img border="0" height="480" src="https://3.bp.blogspot.com/-WiN2Pe5q4Hw/WO0AW8HZarI/AAAAAAAACKE/mj2wio-d0aQHJP0QrDIYW7qLgiLRwog8QCLcB/s640/PSL.gif" width="640" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "times" , "times new roman" , serif;">PSLA</span></td></tr>
</tbody></table>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://4.bp.blogspot.com/-lHEIuURka-k/WO0Ah1ec7TI/AAAAAAAACKI/SIPIyfJpj2E_X_qQnXsTsylkcOPZXGWnwCLcB/s1600/PSSA.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><span style="font-family: "times" , "times new roman" , serif;"><img border="0" height="480" src="https://4.bp.blogspot.com/-lHEIuURka-k/WO0Ah1ec7TI/AAAAAAAACKI/SIPIyfJpj2E_X_qQnXsTsylkcOPZXGWnwCLcB/s640/PSSA.gif" width="640" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "times" , "times new roman" , serif;">PSSA</span></td></tr>
</tbody></table>
</div>
<div class="MsoNormal">
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://4.bp.blogspot.com/-HNfZHwjNkWs/WO0AoH5ELAI/AAAAAAAACKM/HvJdRtlIRVwojSqj_bL7UPmL9y49m5iiQCLcB/s1600/A4C.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><span style="font-family: "times" , "times new roman" , serif;"><img border="0" height="480" src="https://4.bp.blogspot.com/-HNfZHwjNkWs/WO0AoH5ELAI/AAAAAAAACKM/HvJdRtlIRVwojSqj_bL7UPmL9y49m5iiQCLcB/s640/A4C.gif" width="640" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "times" , "times new roman" , serif;">A4C</span><br />
<span style="font-size: 12pt; text-align: left;"><br /></span>
<div style="margin: 0cm 0cm 0.0001pt; text-align: left;">
<span style="color: black;">Mostly
with intermediate point of care echocardiography, in this patient, we would be
looking for gross LV function using the "eyeball" method, presence of
a pericardial effusion and rough RV:LV size. <o:p></o:p></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
</div>
<div style="text-align: left;">
<br /></div>
<span style="color: black;"><div style="text-align: left;">
<span style="font-size: 12pt;">In these images, we can estimate that the LV function is grossly normal and
there is no pericardial effusion. Unfortunately, due to quality, we are unable
to comment on the RV:LV size ratio. However, we would be looking for a RV:LV
ratio of 0.6:1 as normal with a ratio of 1:1 as severe RV dilation. </span></div>
<div style="text-align: left;">
<span style="font-size: 12pt;"><br /></span></div>
<div style="text-align: left;">
<span style="font-size: 12pt;">We can eliminate a few diagnoses off the differential with this scan. However,
with the diagnosis of PE remaining a 2-point DVT scan was carried out:</span></div>
</span><br />
<div style="margin-bottom: .0001pt; margin: 0cm;">
<span style="color: black;"><o:p></o:p></span></div>
<div style="text-align: left;">
<div class="MsoNormal">
<span style="font-family: "times new roman"; font-size: 12pt;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "times new roman"; font-size: 12pt;">RIGHT LOWER EXTREMITY</span></div>
</div>
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<span style="font-family: "times new roman";">LEFT LOWER
EXTREMITY</span></div>
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<a href="https://2.bp.blogspot.com/-e2h6UOhWSmA/WO0Db5unE4I/AAAAAAAACKo/JxFIs7CIswoJocE7p2S8-8NT5S3t66v3wCLcB/s1600/LEV%2Bleft%2Bat%2BSFJ.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: "times" , "times new roman" , serif;"><img border="0" height="480" src="https://2.bp.blogspot.com/-e2h6UOhWSmA/WO0Db5unE4I/AAAAAAAACKo/JxFIs7CIswoJocE7p2S8-8NT5S3t66v3wCLcB/s640/LEV%2Bleft%2Bat%2BSFJ.gif" width="640" /></span></a></div>
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<a href="https://1.bp.blogspot.com/-cqQsVFxLnOU/WO0DxRuHS7I/AAAAAAAACKw/3N5muqoJK00BsG3P4ESNsMwu-8yB9MEWACEw/s1600/LEV%2Bleft%2Bat%2Btrifurcation.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: "times" , "times new roman" , serif;"><img border="0" height="480" src="https://1.bp.blogspot.com/-cqQsVFxLnOU/WO0DxRuHS7I/AAAAAAAACKw/3N5muqoJK00BsG3P4ESNsMwu-8yB9MEWACEw/s640/LEV%2Bleft%2Bat%2Btrifurcation.gif" width="640" /></span></a></div>
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<span style="font-size: small;"><span style="font-family: "times" , "times new roman" , serif;"><br /></span></span></div>
</td></tr>
</tbody></table>
<span style="font-family: "times" , "times new roman" , serif;">In each of these images it appears the vein fully collapses with compression. We can conclude that there is likely no DVT present within the limitations of the 2-point compression scan (see discussion for further details)</span><br />
<span style="font-size: 12pt;"><br /></span>
<span style="font-size: 12pt;">If we incorporate our Wells score for PE and our scan as above we can generate a diagnostic algorithm:</span></div>
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<span style="color: #1a1a1a; mso-bidi-font-family: Tahoma;"><a href="https://www.ncbi.nlm.nih.gov/pubmed/27859891">NazerianP, Volpicelli G, Gigli C et al., Diagnostic performance of Wells Score Combined with Point-of-care Lung and Venous Ultrasound in Suspected Pulmonary Embolism. Acad Emerg Med. 2017; 24(3):270-280</a></span><o:p></o:p></div>
<!--EndFragment--><!--EndFragment--></td></tr>
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<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Using this algorithm, a positive POCUS DVT scan can eliminate the need for CT, however a
negative scan should be combined with a D-dimer to guide further testing. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In our patient:</div>
<div class="MsoNormal">
<i>Wells Score:<span style="mso-spacerun: yes;"> </span>3 (PE as
likely or more likely than alternative)<o:p></o:p></i></div>
<div class="MsoNormal">
<i>D-Dimer: 6024<o:p></o:p></i></div>
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<i>Troponin: 459<o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
Due to the positive D-Dimer a CT-PE was carried out. The results are listed below:</div>
<div class="MsoNormal">
<i style="font-size: 12pt;">Large pulmonary emboli in the right pulmonary artery, right
upper, middle <span style="font-size: 12pt;">and lower lobar arteries and left lower lobar artery. There
are also </span><span style="font-size: 12pt;">smaller numerous bilateral segmental emboli. </span><b style="font-size: 12pt;">Moderate degree of right heart strain</b><span style="font-size: 12pt;">.</span></i></div>
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<i><span style="font-size: 12pt;"><br /></span></i></div>
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The patient was admitted to hospital, anti-coagulated, was discharged home
on day 2 of admission on Dalteparin. <o:p></o:p></div>
<div class="MsoNormal">
<span style="font-size: 12pt;">Radiology performed bilateral leg Dopplers were negative for
DVT.</span></div>
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<o:p></o:p></div>
<div class="MsoNormal">
<span style="font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: large;"><b>Discussion</b></span></div>
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1.<span style="mso-spacerun: yes;"> </span>Your clinical
gestalt must supercede your PoCUS result.<span style="mso-spacerun: yes;">
</span>If your scan is suboptimal then call it indeterminate and proceed to a
definitive investigation such as the CTPE study in this case.<span style="mso-spacerun: yes;"> </span><br />
<span style="font-size: 12pt;"><br /></span>
<span style="font-size: 12pt;">2.</span><span style="font-size: 12pt;"> </span><span style="font-size: 12pt;">2-Zone Lower
extremity DVT PoCUS can be very helpful when it is positive for DVT.</span><span style="font-size: 12pt;"> </span><span style="font-size: 12pt;">However one should not rely on a negative
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<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Expert Reviewer:</b><o:p></o:p></div>
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PoCUS for DVT (2-zone technique) has been shown to have a
high sensitivity and specificity, when compared to a gold-standard of radiology
performed ultrasound.<span style="mso-spacerun: yes;"> </span>Therefore, it is
reasonable to use it to exclude DVT in patients who have a low clinical
probability of DVT.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
However, the 2-zone
technique will miss clots that are isolated to the mid femoral vein (ie, above
the popliteal zone and below the sapheno-femoral junction).<span style="mso-spacerun: yes;"> </span>Fortunately, it is felt that clots isolated
to this part of the venous system are uncommon.<span style="mso-spacerun: yes;">
</span>PoCUS will also likely miss calf vein thrombosis.<span style="mso-spacerun: yes;"> </span>The management of calf vein thrombosis is an
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certainly at lower risk of fatal VTE than those with more proximal clots.<span style="mso-spacerun: yes;"> </span>In my practice, I will discharge low risk
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they have progression of swelling or pain, which might indicate extension of a
calf vein thrombosis.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
When a patient is suspected of having a pulmonary embolism,
ultrasound for DVT has utility because a positive result may obviate the need
for chest imaging.<span style="mso-spacerun: yes;"> </span>This approach is
often used in pregnant patients.<span style="mso-spacerun: yes;">
</span>However, a negative result (PoCUS or radiology performed) cannot end the
workup as many, even most, patients with PE will have a negative leg
ultrasound.<o:p></o:p></div>
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<br /></div>
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PoCUS strategies to diagnose pulmonary embolism have usually
focused on right heart dilation or strain.<span style="mso-spacerun: yes;">
</span>These findings will only be present in larger, more hemodynamically
significant PEs, therefore they lack sensitivity.<span style="mso-spacerun: yes;"> </span>Lung PoCUS for pleural based infarcts shows
promise, but this technique requires more operator skill and requires further
study.<span style="mso-spacerun: yes;"> </span></div>
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<div class="MsoNormal" style="background-color: white; color: rgba(0, 0, 0, 0.831373); font-family: Calibri; margin: 0cm;">
<span style="font-family: "arial" , "helvetica" , sans-serif; font-size: 12pt;"><span style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; color: #333333;"><span style="font-size: x-small;"><br class="Apple-interchange-newline" /></span></span></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; color: #333333;"><span style="font-size: x-small;">*Details of the case have been anonymized and altered in order to protect patient privacy</span></span></span><br />
<i style="font-family: Cambria; font-size: 12pt;"><span style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><br /></span></i>
<i style="font-family: Cambria; font-size: 12pt;"><span style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">Case by <span style="color: blue;"><a href="http://www.emottawa.ca/eng/04-resident-profile-Brown.html">Dr. Rebecca Brown, PGY3, CCFP-EM, University of
Ottawa. </a></span></span></i></div>
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<i style="font-size: 12pt;"><span style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">Expert Commentary
provided by <span style="color: blue;"><a href="http://www.emottawa.ca/eng/02-faculty-profile-Worrall.html">Dr. James Worrall, </a></span></span></i><span style="color: black; font-family: "times new roman"; font-size: 12pt;"><span style="color: blue;"><a href="http://www.emottawa.ca/eng/02-faculty-profile-Worrall.html">Associate Director EM Ultrasound, Department of EmergencyMedicine, University of Ottawa</a></span></span></div>
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<i style="font-size: 12pt;"><span style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">Edited and Formatted by <span style="color: blue;"><a href="https://twitter.com/RobSuttie">Dr. Rob Suttie,
PGY2, Emergency Medicine, University of Ottawa.</a></span></span></i></div>
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<i style="font-size: 12pt;"><span style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">For more information on
our POCUS program please see <a href="http://clinsonoottawa.blogspot.ca/"><span style="color: #2478a0; text-decoration: none;">Clinical
Sonography Ottawa. </span></a></span></i></div>
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</style>Unknownnoreply@blogger.com2tag:blogger.com,1999:blog-1264812964585869968.post-91648378769377478922017-04-03T09:00:00.000-04:002017-04-03T09:00:04.562-04:00Diagnosis of Acute Cardiogenic Pulmonary Edema (ACPE) with Point-of-Care Ultrasound<div class="separator" style="clear: both; text-align: center;">
<iframe allowfullscreen="" class="YOUTUBE-iframe-video" data-thumbnail-src="https://i.ytimg.com/vi/Fyc9CB_ncsU/0.jpg" frameborder="0" height="266" src="https://www.youtube.com/embed/Fyc9CB_ncsU?feature=player_embedded" width="320"></iframe></div>
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<span style="font-family: "times new roman"; font-size: 12pt;">Point-of-Care Ultrasonography (POCUS) is a valuable tool in the diagnostic armamentarium of the emergency physician. We have been successfully using it to the place lines, diagnose AAAs and assess the cardiac function of our dyspnea patients for awhile now. But what about the lungs? Typically air is thought of as the enemy of ultrasound, but can we successfully use it to diagnose acute respiratory conditions despite this? In this Grand Rounds review, Dr. Elizabeth Lalande goes through the use of POCUS in the diagnosis of Acute Cardiogenic Pulmonary Edema in the undifferentiated, dyspneic patient. </span></div>
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<span lang="EN-CA" style="color: black; font-family: "times new roman";"></span><br />
<a name='more'></a></div>
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<span lang="EN-CA" style="color: black; font-family: "times new roman";">The objectives are as follows:<o:p></o:p></span></div>
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<span lang="EN-CA" style="font-family: "times new roman"; font-size: 12pt;">1. </span><span lang="FR" style="color: #414040; font-family: "times new roman"; font-size: 12pt;">Definitions in lung ultrasound (US)</span></div>
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<span lang="EN-CA" style="color: black; font-family: "times new roman";">2. </span><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">The role of POCUS in diagnosing acute
cardiogenic pulmonary edema</span><span lang="EN-CA" style="color: black; font-family: "times new roman";"><o:p></o:p></span></div>
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<span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;"><span style="font-size: large;"><br /></span></span></div>
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<span style="font-size: large;"><b><span lang="EN-CA" style="color: #414040; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">Definitions</span></b><b><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR; mso-fareast-font-family: "Times New Roman";"> in Lung Ultrasound</span></b></span><b><span lang="EN-CA" style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></b></div>
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<b><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR; mso-fareast-font-family: "Times New Roman";"><br /></span></b></div>
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<span lang="EN-CA" style="color: #414040; font-family: "times new roman";"><b>B-line: </b>A</span><span style="font-family: "times new roman"; font-size: 12pt;"> discrete
laser-like, vertical, hyperechoic reverberation artifact. It arises from the
pleural line, extends to the bottom of the screen without fading, and moves
synchronously with lung sliding.</span></div>
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<br /></div>
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<span lang="EN-CA" style="color: #414040; font-family: "times new roman";">First described in <a href="https://www.ncbi.nlm.nih.gov/pubmed/6152918">1982 by Ziskin et al. and initially termed"The Comet Tail Artifact"</a></span><span lang="EN-CA" style="color: black; font-family: "times new roman";"><o:p></o:p></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-OHk2PCKP9U8/WN60fB7Bt0I/AAAAAAAACIw/uTdshZMdQpsLK8nvhpXPl2RklaEAv0SdgCEw/s1600/Screen%2BShot%2B2017-03-31%2Bat%2B3.54.55%2BPM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="112" src="https://2.bp.blogspot.com/-OHk2PCKP9U8/WN60fB7Bt0I/AAAAAAAACIw/uTdshZMdQpsLK8nvhpXPl2RklaEAv0SdgCEw/s400/Screen%2BShot%2B2017-03-31%2Bat%2B3.54.55%2BPM.png" width="400" /></a></div>
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<span style="color: #414040; font-family: "times new roman"; font-size: 12pt;"><u>Physics of the B-line:</u> Occurs when there is a change in acoustic
impedance between an object and its surroundings. The reflection of the beam
creates a phenomenon called "resonance." The US beam gets trapped
within the system and results in an endless "to-and-fro" mechanism.
This results in an endless beam as seen on the screen. </span></div>
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<td style="padding: 4.5pt 4.5pt 4.5pt 4.5pt;"><div class="separator" style="clear: both; text-align: center;">
<a href="https://3.bp.blogspot.com/-aVoMuLHUTQ8/WN62Woucd-I/AAAAAAAACI8/Cu1L4XRMXuElNlsR6rebGbOCIwqKFEalACEw/s1600/Screen%2BShot%2B2017-03-31%2Bat%2B4.02.46%2BPM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="343" src="https://3.bp.blogspot.com/-aVoMuLHUTQ8/WN62Woucd-I/AAAAAAAACI8/Cu1L4XRMXuElNlsR6rebGbOCIwqKFEalACEw/s400/Screen%2BShot%2B2017-03-31%2Bat%2B4.02.46%2BPM.png" width="400" /></a></div>
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<span lang="EN-CA" style="font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">From <a href="http://www.criticalecho.com/content/tutorial-9-lung-ultrasound">http://www.criticalecho.com/content/tutorial-9-lung-ultrasound</a><o:p></o:p></span></div>
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<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="mso-cellspacing: 0cm; mso-padding-alt: 4.5pt 4.5pt 4.5pt 4.5pt; mso-yfti-tbllook: 1184;"><tbody>
<tr style="mso-yfti-irow: 1; mso-yfti-lastrow: yes;"><td style="padding: 3.0pt 4.5pt 4.5pt 4.5pt;"><div class="MsoNormal" style="margin-top: 18.0pt;">
<u><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">Positive
zone for B-lines: </span></u><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">A positive zone is determined when there
are at least 3 B-lines in one interc</span><span lang="EN-CA" style="color: #414040; font-family: "times new roman";">ostal space that can be seen at any moment
during a respiratory cycle.<o:p></o:p></span></div>
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<span lang="EN-CA" style="color: #414040; font-family: "times new roman";"></span></div>
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable"><tbody>
<tr><td style="padding: 3pt 4.5pt 4.5pt;"><div class="separator" style="clear: both; text-align: center;">
<a href="https://4.bp.blogspot.com/-pMi1K6XcDQk/WN66ApCtxWI/AAAAAAAACJI/kk4iJC6Qruk-6z0-4GZ9oMK-PMKLzuCDgCEw/s1600/Picture2.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="326" src="https://4.bp.blogspot.com/-pMi1K6XcDQk/WN66ApCtxWI/AAAAAAAACJI/kk4iJC6Qruk-6z0-4GZ9oMK-PMKLzuCDgCEw/s400/Picture2.png" width="400" /></a></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><br class="Apple-interchange-newline" /><span style="font-size: x-small;">Multiple B-lines in one intercostal space. From Lichtenstein DA et al. The Comet-tail artifact: An Ultrasound Sign of Alevolar-Interstitial Syndrome. Am J Respir Crit Care Med 1997; 156: 1640-1646</span></span></div>
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<b><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">Alveolo-interstitial
syndrome (AIS):</span></b><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;"> </span><span style="color: #414040; font-family: "times new roman"; font-size: 12pt;">This syndrome is defined
by a B-profile, as described by <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734893/">Lichtenstein DA and Mezière GA in their 2008 study: "Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure, The BLUE protocol"</a> published in </span><i style="color: #414040; font-family: "Times New Roman"; font-size: 12pt;">Chest </i><span style="color: #414040; font-family: "times new roman"; font-size: 12pt;">(2). The B-profile will have two separate, positive zones for B-lines, as
previously defined, bilaterally.</span></div>
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<td style="padding: 4.5pt 4.5pt 4.5pt 4.5pt;"><div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-dEPjqIYvjGA/WN68D5rBX0I/AAAAAAAACJU/455wyIXV7oMOn_iOK7TPPdQDVL3RAjXJgCEw/s1600/Picture1.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="315" src="https://2.bp.blogspot.com/-dEPjqIYvjGA/WN68D5rBX0I/AAAAAAAACJU/455wyIXV7oMOn_iOK7TPPdQDVL3RAjXJgCEw/s640/Picture1.png" width="640" /></a></div>
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<td style="padding: 3.0pt 4.5pt 4.5pt 4.5pt;"><div align="center" class="MsoNormal" style="margin-top: 18.0pt; text-align: center;">
<span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;"><span style="font-size: x-small;">Lung US profiles. From Lichtenstein DA and Mezière GA, Relevance of Lung
Ultrasound in the Diagnosis of Acute Respiratory Failure, The BLUE protocol.
(2)</span></span><span lang="EN-CA" style="color: #414040; font-family: "times new roman";"><o:p></o:p></span></div>
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<span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;"><br /></span></div>
<div class="MsoNormal" style="mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; mso-outline-level: 2;">
<b><span lang="EN-CA" style="font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><span style="font-size: large;">Role of POCUS in Diagnosing ACPE</span><o:p></o:p></span></b></div>
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<span lang="EN-CA" style="color: #414040; font-family: "times new roman";">The </span><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">sensitivity of POCUS for AIS is around</span><span lang="EN-CA" style="color: #414040; font-family: "times new roman";"> 97%</span><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;"> with a specificity of</span><span lang="EN-CA" style="color: #414040; font-family: "times new roman";"> 95%. Considering that previous
studies </span><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">looking at</span><span lang="EN-CA" style="color: #414040; font-family: "times new roman";"> the test characteristics
of CXR, which is used on a daily basis for this purpose, </span><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">showed a sensitivity ranging from 50 to 70%</span><span lang="EN-CA" style="color: #414040; font-family: "times new roman";"> for </span><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">AIS as interpreted by a Cardiologist, these figures are quite impressive.
<o:p></o:p></span></div>
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<span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">The differential
diagnosis for AIS, however, includes a variety of lung conditions not just
ACPE but also acute respiratory distress syndrome, interstitial pneumonia
and </span><span lang="EN-CA" style="color: #414040; font-family: "times new roman";">diffuse parenchymal lung disease</span><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">, as
described by the <i><a href="https://link.springer.com/article/10.1007%2Fs00134-012-2513-4">International evidence-based recommendations for Point-of-Care lung ultrasound</a></i>, published in 2012 (3). So the clinical
context of the scan is as important as the scan itself. <o:p></o:p></span></div>
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<span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">In terms of technique
to elicit the B-profile, the best method was described by </span><span lang="IT" style="color: #414040; font-family: "times new roman"; mso-ansi-language: IT;">Volpicelli et al. in 2006. They describe</span><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">d an
8 zones technique, 4 zones </span><span lang="EN-CA" style="color: #414040; font-family: "times new roman";">on each side of the thorax</span><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">, as shown below:</span><span lang="EN-CA" style="color: #414040; font-family: "times new roman";"><o:p></o:p></span></div>
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<span lang="FR" style="font-family: "times new roman"; mso-ansi-language: FR; mso-fareast-font-family: "Times New Roman";"><span style="font-size: x-small;">The 8 zones technique, described by Volpicelli in 2006 (4)</span></span><span lang="EN-CA" style="font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span lang="EN-CA" style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">The next question after
a scanning protocol is determined is, can we accurately use POCUS to diagnose
ACPE in the ED?</span><span lang="EN-CA" style="font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span lang="EN-CA" style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">Fortunately, there are
two major literature sources that can answer that for us:<o:p></o:p></span></div>
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<i><span lang="EN-CA" style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">1. </span></i><i><span lang="EN-CA" style="color: #414040; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><a href="http://onlinelibrary.wiley.com/doi/10.1111/acem.12435/abstract;jsessionid=9F660EAD1806F59BE69CB776D0647AB1.f04t02">Al Deeb M and coll., Point-of-care ultrasonography for theDiagnosis of Acute Caridogenic Pulmonary Edema in Patients Presenting with AcuteDyspnea: A systematic Review and Meta-Analysis.</a> (5)</span></i><span lang="EN-CA" style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span lang="EN-CA" style="color: #414040; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><br />
</span><span lang="FR" style="color: black; font-family: "times new roman"; mso-ansi-language: FR; mso-fareast-font-family: "Times New Roman";">These patients all presented
with acute dyspnea and a suspicion of ACPE, which is pretty similar to our
population in the ED. There was no restriction on the protocol, machine or
operator performing the scan used as long as they used B-lines to make the
diagnosis and the physicians performing the scan was a non-radiologist at the
bedside. </span><span lang="EN-CA" style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><span lang="FR" style="color: black; font-family: "times new roman"; mso-ansi-language: FR; mso-fareast-font-family: "Times New Roman";">The
primary outcome</span></b><span lang="FR" style="color: black; font-family: "times new roman"; mso-ansi-language: FR; mso-fareast-font-family: "Times New Roman";"> was
the c</span><span lang="EN-CA" style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">linical diagnosis of ACPE using POCUS with
B-lines</span><span lang="FR" style="color: black; font-family: "times new roman"; mso-ansi-language: FR; mso-fareast-font-family: "Times New Roman";"> and the reference
standard was final diagnosis at clinical follow-up. <b>The pooled
sensitivity was 94% and specificity was 93%.</b> They did another analysis
without 3 of the studies that could alter the estimates and found similar
results. This study showed us that lung US has great test characteristics to
diagnosis ACPE.</span><span lang="EN-CA" style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<i><span lang="FR" style="color: black; font-family: "times new roman"; mso-ansi-language: FR; mso-fareast-font-family: "Times New Roman";">2. </span></i><i><span lang="EN-CA" style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><a href="http://onlinelibrary.wiley.com/doi/10.1111/acem.12878/abstract">Martindale JL and coll., Diagnosing Acute Heart Failure in theEmergency Department a Systematic Review and Meta-Analysis.</a> (6)</span></i><span lang="EN-CA" style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR; mso-fareast-font-family: "Times New Roman";">This
review looked at the operating test characteristics of the different modalities
used by emergency physicians (EPs) for the diagnosis of ACPE among patients
presenting to the ED with dyspnea. They included the performance of lung US in
the diagnostic work-up. Studies eligible focused on the diagnosis of acute
heart failure in the ED population. </span><span lang="EN-CA" style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR; mso-fareast-font-family: "Times New Roman";">Their
search for lung US studies was not limited to a specific protocol but they
narrowed their inclusion </span><span lang="EN-CA" style="color: #414040; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">of</span><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR; mso-fareast-font-family: "Times New Roman";"> studies investigating lung US and
echocardiography to those that had <b>EPs both performing and interpreting
the lung US</b>. </span><span lang="EN-CA" style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR; mso-fareast-font-family: "Times New Roman";">Eight
studies were included in the final analysis for lung US. Their results: </span><span lang="EN-CA" style="color: #414040; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">a pooled </span><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR; mso-fareast-font-family: "Times New Roman";">sensitivity
of</span><span lang="EN-CA" style="color: #414040; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"> <b>85% and </b></span><b><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR; mso-fareast-font-family: "Times New Roman";">specificity of</span></b><b><span lang="EN-CA" style="color: #414040; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"> 92% with a +LR of 7.4 and a negative one of 0.16 for lung
US</span></b><span lang="EN-CA" style="color: #414040; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">.</span><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR; mso-fareast-font-family: "Times New Roman";"> Once
again, this study has demonstrated that lung US is a great diagnostic tool for
us when looking for ACPE in the acute, undifferentiated dysnpneic
patient. </span><span lang="EN-CA" style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><span lang="EN-CA" style="color: #414040; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><br />
How about integrating cardiac views as well? </span></b><b><span lang="EN-CA" style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></b></div>
<div class="MsoNormal">
<span lang="EN-CA" style="color: #414040; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">ACPE comes from a sick
heart. It is certainly useful to visualize the left ventricular systolic
function to assess if it goes in hand with the diagnosis of ACPE. If the echo
views show a depressed systolic left ventricular function, then it really helps
confirm the diagnosis. </span><span lang="EN-CA" style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b style="font-size: 12pt;"><span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">Conclusions:</span></b></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 19.65pt; margin-right: 0cm; margin-top: 18.0pt; text-indent: -19.65pt;">
<span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">1. Lung US is a great tool to diagnose ACPE, with excellent test
characteristics.</span><span lang="EN-CA" style="color: #414040; font-family: "times new roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 19.65pt; margin-right: 0cm; margin-top: 18.0pt; text-indent: -19.65pt;">
<span lang="FR" style="color: #414040; font-family: "times new roman"; mso-ansi-language: FR;">2. An eight zone protocol can be used at the bedside to look for the
B-profile in your patients with undifferentiated dyspnea. Remember a B-profile
consists of at least 3 B-lines in one intercostal space. </span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 19.65pt; margin-right: 0cm; margin-top: 18.0pt; text-indent: -19.65pt;">
<span style="color: #414040; font-family: "times new roman"; font-size: 12pt; text-indent: -19.65pt;">3. Don’t forget to look at the heart as well, to increase your post-test
probability of finding the right diagnosis for your patient!</span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 19.65pt; margin-right: 0cm; margin-top: 18.0pt; text-indent: -19.65pt;">
<span style="color: #414040; font-family: "times new roman";">---- Dr. Elizabeth Lalande, MD, FRCPC is an Emergency Medicine POCUS Fellow at the University of Ottawa. She also works as a staff physician at The Ottawa Hospital. </span></div>
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<span style="font-size: x-small;">Edited and Formatted by Dr. R Suttie, PGY2, Emergency Medicine. </span></div>
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References:</div>
<div class="corpspetit" style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; margin-right: 0cm; margin-top: 18.0pt;">
<span lang="FR" style="color: #414040; font-size: 10.0pt;">1.<span style="font-stretch: normal; font-variant-caps: normal; font-variant-ligatures: normal;"> Lichtenstein DA<span class="apple-converted-space"> </span><i>and coll</i>.,<span class="apple-converted-space"> </span></span><span style="color: #414040; font-size: 10.0pt;">The Comet-tail Artifact</span><span lang="FR" style="color: #414040; font-size: 10.0pt;">:</span><span class="apple-converted-space"><span style="color: #414040; font-size: 10.0pt;"> </span></span><span style="color: #414040; font-size: 10.0pt;">An Ultrasound Sign of
Alveolar-Interstitial Syndrome</span><span lang="FR" style="color: #414040; font-size: 10.0pt;">.<span class="apple-converted-space"> </span><i>Am
J Respir Crit Care Med</i><span class="apple-converted-space"> </span>1997;156:1640–1646.<u1:p></u1:p></span><span style="color: #414040; font-size: 30.0pt;"><o:p></o:p></span></span></div>
<div class="corpspetit" style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; margin-right: 0cm; margin-top: 18.0pt;">
<span lang="FR" style="color: #414040; font-size: 10.0pt;">2.<span style="font-stretch: normal; font-variant-caps: normal; font-variant-ligatures: normal;"> Lichtenstein DA and Mezière
GA,<span class="apple-converted-space"> </span></span><span style="color: #414040; font-size: 10.0pt;">Relevance of Lung Ultrasound in the
Diagnosis of Acute Respiratory Failure* The BLUE Protocol</span><span lang="FR" style="color: #414040; font-size: 10.0pt;">.<span class="apple-converted-space"> </span><i>CHEST</i><span class="apple-converted-space"> </span>2008;134:117–125.</span></span></div>
<div class="corpspetit" style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; margin-right: 0cm; margin-top: 18.0pt;">
<span style="font-size: 10pt;">3.</span><span style="font-size: 10pt; font-stretch: normal;"> Volpicelli G<span class="apple-converted-space"> </span><i>and coll</i>., International
evidence-based recommendations for point-of-care lung ultrasound.<span class="apple-converted-space"> </span></span><i style="font-size: 10pt;"><span style="font-size: 10pt;">Intensive Care Med</span></i><span class="apple-converted-space" style="font-size: 10pt;"><span lang="FR" style="font-size: 10pt;"> </span></span><span lang="FR" style="font-size: 10pt;">2012;38:577–591.</span></div>
<div class="corpspetit" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; margin-right: 0cm; margin-top: 18.0pt; orphans: 2; text-align: start; widows: 2; word-spacing: 0px;">
<span lang="FR" style="color: #414040; font-size: 10.0pt;">4.<span style="font-stretch: normal; font-variant-caps: normal; font-variant-ligatures: normal;"> Volpicelli G and coll.,<span class="apple-converted-space"> </span></span><span style="color: #414040; font-size: 10.0pt;">Bedside lung ultrasound in the assessment of
alveolar-interstitial syndrome.<span class="apple-converted-space"> </span></span><i><span lang="FR" style="color: #414040; font-size: 10.0pt;">AJEM</span></i><span class="apple-converted-space"><span lang="FR" style="color: #414040; font-size: 10.0pt;"> </span></span><span lang="FR" style="color: #414040; font-size: 10.0pt;">2006; 24(6):689-96.<u1:p></u1:p></span><span style="color: #414040; font-size: 30.0pt;"><o:p></o:p></span></span></div>
<div class="corpspetit" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; margin-right: 0cm; margin-top: 18.0pt; orphans: 2; text-align: start; widows: 2; word-spacing: 0px;">
<span lang="FR" style="color: #414040; font-size: 10.0pt;">5.<span style="font-stretch: normal; font-variant-caps: normal; font-variant-ligatures: normal;"> Al Deeb M and coll., Point-of-care ultrasonography for
the Diagnosis of Acute Cariogenic Pulmonary Edema in Patients Presenting with
Acute Dyspnea: A systematic Review and Meta-Analysis.<span class="apple-converted-space"> </span><i>Acad Emer Med<span class="apple-converted-space"> </span></i>2014;21:844–852.<u1:p></u1:p></span><span style="color: #414040; font-size: 30.0pt;"><o:p></o:p></span></span></div>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="35" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="1" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
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<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
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<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
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<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
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<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
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<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
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<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
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<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
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<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
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<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
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<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
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<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
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<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
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</style>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-49421477009585632412017-03-13T14:07:00.001-04:002017-03-29T18:38:01.234-04:00Clindamycin versus trimethoprim-sulfamethoxazole for uncomplicated skin infections<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-9V7jfaaV5UU/WMbeg8pc6PI/AAAAAAAABzk/Ib18di5YnCIgbTvuCyi-1N0NWMpX1_yTACLcB/s1600/Cellulitis_Left_Leg.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="241" src="https://2.bp.blogspot.com/-9V7jfaaV5UU/WMbeg8pc6PI/AAAAAAAABzk/Ib18di5YnCIgbTvuCyi-1N0NWMpX1_yTACLcB/s320/Cellulitis_Left_Leg.JPG" width="320" /></a></div>
<h4 style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">Journal Club Summary</span></span></h4>
<div class="Title9" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span lang="EN-US"><b><span lang="EN-US" style="color: red;"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">Methodology Score: 4/5 </span></span></b></span></div>
<div class="Title9" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span lang="EN-US"><b><span lang="EN-US" style="color: red;"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">Usefulness Score: 2/5</span></span></b></span></div>
<div class="Title9" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span lang="EN-US"><b><span lang="EN-US" style="color: red;"><span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></span></b></span></div>
<div class="Title9" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><span lang="EN-US">Miller LG</span><span lang="EN-US">, et al.</span></span></div>
<div class="details" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><span class="jrnl"><span lang="EN-US">N Engl J Med</span></span><span lang="EN-US" style="color: black;">.<span class="apple-converted-space"> </span><span style="mso-bidi-font-weight: bold;">2015</span><span class="apple-converted-space"> </span>Mar
19;372(12):1093-103.<o:p></o:p></span></span></div>
<div class="desc" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1403789">Full Article</a></span></div>
<div class="desc" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-size: large;"></span><br />
<a name='more'></a><span style="font-size: large;"><br /></span></div>
<h1 style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">Editorial: Choosing an antibiotic for skin infections.<o:p></o:p></span></span></h1>
<div class="MsoNormal" style="background: white;">
<span lang="EN-US" style="color: black;"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">Wessels
MR<o:p></o:p></span></span></div>
<div class="MsoNormal" style="background: white;">
<span lang="EN-US" style="color: black;"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">N
Engl J Med.<span class="apple-converted-space"> </span><span class="highlight">2015</span><span class="apple-converted-space"> </span>Mar
19;372(12):1164-5.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;"><a href="http://www.nejm.org/doi/full/10.1056/NEJMe1500331">http://www.nejm.org/doi/full/10.1056/NEJMe1500331</a><span style="color: red;"><o:p></o:p></span></span></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US" style="color: black;"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">This multicenter,
prospective, randomized, double-blind trial compared the treatment of uncomplicated
skin infections with clindamycin versus TMP-SMX. Designed as a superiority
trial, cure rates did not differ significantly, and neither intervention was found
to be superior. The study enrolled healthy patients only, with rigorous
exclusion criteria, which does not reflect our patient population. In addition,
77% of all patients with <i>S. aureus</i> were MRSA (32% of the study patients
grew MRSA), a much higher rate than within our center. <o:p></o:p></span></span></div>
<div class="MsoNormal" style="background: white;">
<b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span style="font-family: "times" , "times new roman" , serif; font-size: large;"><span lang="EN-CA" style="mso-ansi-language: EN-CA;">By: </span><span lang="EN-US" style="mso-bidi-font-style: italic;">Dr. Jillian Ritsma<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span></i></b></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<br /></div>
<h4 style="mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-CA"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">Epi lesson:
</span></span></h4>
<div class="MsoNormalCxSpMiddle" style="margin-bottom: 10.0pt; mso-add-space: auto;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><b><u><span lang="EN-US"><a href="http://emottawa.blogspot.ca/2015/06/epi-lessons-part-2-therapy-articles.html">Allocation Concealment vs. Blinding</a></span></u></b><span lang="EN-US"> </span></span></div>
<div class="MsoNormalCxSpMiddle" style="margin-bottom: 10.0pt; mso-add-space: auto;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">These clinical trial
terms have different meanings but are often confused. <b>Concealment</b> refers
to the process<b><i> </i></b>whereby the treatment allocation is made unknown
or concealed <b>prior to patient randomization</b>. This helps prevent
selection bias by ensuring that health providers and research staff are not
tempted to include or exclude cases according to their views on the allocated
treatment. <b>Blinding </b>refers to the methods employed <b>after
randomization</b> to ensure that patients, health care providers, and research
staff cannot determine whether the patient is receiving the study or the
control treatment. This reduces ascertainment bias (the likelihood of
differential assessment of outcome).</span></div>
<div class="MsoNormalCxSpMiddle" style="margin-bottom: 10.0pt; mso-add-space: auto;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><b><i><span lang="EN-CA">By: </span></i></b><b><i><span lang="EN-US">Dr. Venkatesh Thiruganasambandamoorthy</span></i></b></span></div>
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Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-48362244677209432552017-03-09T09:00:00.000-05:002017-03-29T18:39:13.351-04:00Focus on POCUS: Palpitations and Dyspnea Post-AVR<div class="MsoNormal" style="margin-bottom: 10.0pt;">
<span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">This case is brought to you by <a href="http://www.emottawa.ca/eng/04-resident-profile-Ohle.html">Dr. Robert Ohle</a>, PGY5 in emergency
medicine, who assessed the patient and captured all of the ultrasound images!<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 10.0pt;">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><b><span style="color: black; font-family: "times new roman";">Case Vignette:</span></b><span style="color: black; font-family: "times new roman";"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="margin-bottom: 10.0pt;">
<span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">A female in her 20's presents to the emergency department 15 days
after major cardiac surgery to repair a congenital aortic valve defect. Her
chief complaint is palpitations and shortness of breath, which have been
constant and ongoing for the last 4 days. She has no PND or orthopnea, no calf
swelling, or history of DVT/PE. She has no past medical history other than the
aortic valve defect and is on no medications.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 10.0pt;">
<span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">Her exam shows a well looking young female in no acute distress.
Her vitals are BP 110/40, HR 110, afebrile, O2 99% on room air, RR 18. Her
sternotomy incision site looks healthy. Her lungs are clear and there is a loud
cardiac murmur, but both the senior resident and staff are unable to tell if it
is systolic or diastolic because of the patient’s tachycardia. There are no
signs of DVT.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 10.0pt;">
<span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">Routine bloodwork including cardiac enzymes, chest x-ray, and ECG
are all normal other than sinus tachycardia. A comprehensive echocardiogram
performed day 2 post-operatively was normal with only trace aortic
regurgitation.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 10.0pt;">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><b><span style="color: black; font-family: "times new roman";">At this point, what are the top 4 things you can
think of that might be going wrong with this patient?</span></b><span style="color: black; font-family: "times new roman";"><o:p></o:p></span></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><b><span style="color: black; font-family: "times new roman";"></span></b></span><br />
<a name='more'></a></div>
<ul style="margin-top: 0cm;" type="disc">
<li class="MsoNormal" style="color: black; margin-bottom: 10.0pt; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: "arial" , "helvetica" , sans-serif; mso-fareast-font-family: "Times New Roman";">Some kind of problem with the
aortic valve repair, such as new <b>aortic regurgitation (AR)</b> should
be a concern. The patient has no reports of fever, but <b>endocarditis</b> should
always be considered in a post-operative valve repair. The widened pulse
pressure was also noticed by the physician, which could indicate aortic
regurgitation.<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; margin-bottom: 10.0pt; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: "arial" , "helvetica" , sans-serif; mso-fareast-font-family: "Times New Roman";">As with any post-operative
patient, <b>pulmonary embolism</b> should be on the list. This
patient’s Wells Score is at least 3 (post-operative +1.5, HR over 100
+1.5), and could be as high as 6 if you think PE is the most likely
diagnosis. The physician thought the presence of the loud murmur made PE
less likely.<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; margin-bottom: 10.0pt; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><b><span style="font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">Pericardial effusion and
impending tamponade</span></b><span style="font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";"> is a possibility if there
has been slow postoperative bleeding into the pericardial sac.<o:p></o:p></span></span></li>
<li class="MsoNormal" style="color: black; margin-bottom: 10.0pt; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><b><span style="font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">CHF </span></b><span style="font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">is
less likely given the clear lungs and absent PND/orthopnea.<o:p></o:p></span></span></li>
</ul>
<div class="MsoNormal" style="margin-bottom: 10.0pt;">
<b><span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">A focused echocardiogram was performed to try to
differentiate between these causes. These are the images obtained by Dr. Ohle:</span></b></div>
<div class="MsoNormal" style="margin-bottom: 10.0pt;">
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-G2PrGUxubQE/WL64fBS_etI/AAAAAAAABzA/KThY3JR-0-kTMx9QmKeRCc4Z8ZaCAFEYQCLcB/s1600/giphy%2B%25282%2529.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><img border="0" height="480" src="https://1.bp.blogspot.com/-G2PrGUxubQE/WL64fBS_etI/AAAAAAAABzA/KThY3JR-0-kTMx9QmKeRCc4Z8ZaCAFEYQCLcB/s640/giphy%2B%25282%2529.gif" width="640" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: small;"><b>Parasternal long axis view</b></span></td></tr>
</tbody></table>
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<div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><img border="0" height="480" src="https://3.bp.blogspot.com/-a9H0l8UfZ-A/WLrcCrADmoI/AAAAAAAACAM/ueNYDKdxlbozg-Ho3p4ZitAdhjA92vwlACLcB/s640/PSSA.gif" style="margin-left: auto; margin-right: auto;" width="640" /></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: small;"><b>Parasternal Short Axis View at the level of the aortic valve</b></span></td></tr>
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><img border="0" height="480" src="https://3.bp.blogspot.com/-QQYJpcFYS_U/WLrcdMlLkLI/AAAAAAAACAQ/mEIaI6vTr58icRsoVsWs_vQd7ARU-TwHwCLcB/s640/A4C.gif" style="margin-left: auto; margin-right: auto;" width="640" /></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="text-align: start;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: small;"><b>Apical 4 Chamber View</b></span></span></td></tr>
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<b><span style="color: black; font-family: "arial" , "helvetica" , sans-serif;"><br /></span></b>
<b><span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">After reviewing the images, take a second to
consider your differential diagnosis now. As always, we ask ourselves the
following questions after performing the cardiac ultrasound:</span></b></div>
<div class="MsoNormal" style="margin-left: 36.0pt; text-indent: -18.0pt;">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><b><span style="color: black; font-family: "times new roman";">1.</span></b><span style="color: black; font-family: "times new roman";"> <b>Is
the LV function hyperdynamic, normal, decreased, or severely decreased?</b><o:p></o:p></span></span></div>
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<span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">Based on the parasternal long axis view, the LV walls are coming
together at least 30% in systole, so the LV function appears normal. Also the
mitral valve is almost making contact with the septum, which also confirms
normal LV function.</span></div>
<div class="MsoNormal" style="margin-left: 36.0pt; text-indent: -18.0pt;">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><b><span style="color: black; font-family: "times new roman";">2.</span></b><span style="color: black; font-family: "times new roman";"> <b>Are
there signs of RV dilatation or strain?</b><o:p></o:p></span></span></div>
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<span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">Based on the A4C view, the RV appears smaller than the LV and
appears to be contacting well, so there are no echo signs of RV strain.</span></div>
<div class="MsoNormal" style="margin-left: 36.0pt; text-indent: -18.0pt;">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><b><span style="color: black; font-family: "times new roman";">3.</span></b><span style="color: black; font-family: "times new roman";"> <b>Is
there a pericardial effusion?</b><o:p></o:p></span></span></div>
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<span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">A subxyphoid view is usually the most sensitive for looking for an
effusion, but based on the views obtained there’s no effusion seen.<o:p></o:p></span></div>
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<div class="MsoNormal" style="margin-bottom: 10.0pt;">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><b><span style="color: black; font-family: "times new roman";">Then, Dr. Ohle gets fancy and tries using
doppler ultrasound. What does this view show?</span></b><span style="color: black; font-family: "times new roman";"><o:p></o:p></span></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-gyepylWTVO4/WLreLPRZYXI/AAAAAAAACAc/qaol5JaefuMnJYEgBgE2A3n5tBcEQIihACLcB/s1600/PLS%2Bdoppler.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><img border="0" height="480" src="https://1.bp.blogspot.com/-gyepylWTVO4/WLreLPRZYXI/AAAAAAAACAc/qaol5JaefuMnJYEgBgE2A3n5tBcEQIihACLcB/s640/PLS%2Bdoppler.gif" width="640" /></span></a></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 0cm; mso-add-space: auto;">
<span style="font-family: "arial" , "helvetica" , sans-serif; font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-bottom: 10.0pt;">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="color: black;">The
doppler ultrasound over the aortic valve demonstrates a <u>significant
amount of aortic regurgitation</u>. Usually, blood flow moving AWAY from the
ultrasound probe should appear </span><span style="color: #0070c0;">BLUE</span><span style="color: black;">, whereas blood flow moving TOWARDS the ultrasound probe
should appear </span><span style="color: red;">RED/YELLOW.</span><span style="color: black;"><u1:p></u1:p><o:p></o:p></span></span></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 10.0pt; orphans: 2; text-align: start; widows: 2; word-spacing: 0px;">
<span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">What we see here is a combination
of a blue jet streaming backwards through the aortic valve, with a red/yellow
jet that appears seemingly in the middle of the blue jet. This is an ultrasound
artifact called <b>aliasing</b>, which means that very rapid, turbulent
blood flow in the middle of the aortic regurgitation jet is exceeding the scale
the machine is currently set to, meaning it’s travelling greater than 64
cm/second AWAY from the probe. This cine clip could have been made better if
the scale had been increased on the machine, which would have made the
regurgitant jet appear entirely in blue.<o:p></o:p></span></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 10.0pt; orphans: 2; text-align: start; widows: 2; word-spacing: 0px;">
<span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">Even if you’re not interested or
experienced in recognizing aortic regurgitation or aliasing, we can at least
say there’s no sign of decreased LV or RV function and no pericardial effusion,
which eliminates tamponade from our differential and although it doesn’t
eliminate PE or CHF as possibilities, they seem less likely now.<o:p></o:p></span></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-bottom: 10.0pt; orphans: 2; text-align: start; widows: 2; word-spacing: 0px;">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><b><span style="color: black;"><br /></span></b></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><b><span style="color: black;">What qualifies as significant
aortic regurgitation (AR)?</span></b><span style="color: black;"><u1:p></u1:p><o:p></o:p></span></span></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; orphans: 2; text-align: start; widows: 2; word-spacing: 0px;">
<span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">Another important pearl is how to
differentiate insignificant AR from significant AR. As emergency physicians, we
don’t really care about any valvular lesion that is “trace” or “1+ severity” on
a cardiology performed echo. What we want to be able to recognize is the
severe, 3+ or 4+ valvular lesions which may affect our management.</span></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; orphans: 2; text-align: start; widows: 2; word-spacing: 0px;">
<span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">While truly quantifying AR is hard,
in general <u>if you can see the regurgitant jet takes up >65% of the
LV outflow tract, that’s likely to be a significant problem.</u></span></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; orphans: 2; text-align: start; widows: 2; word-spacing: 0px;">
<span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">Also don’t forget the basics, like
just looking at the valve leaflets and qualitatively deciding whether it looks
like they’re coming together properly in diastole. If you happen to see a big
floppy vegetation sitting on the valve, that’s obviously really useful too.<o:p></o:p></span></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; orphans: 2; text-align: start; widows: 2; word-spacing: 0px;">
<span style="color: black; font-family: "arial" , "helvetica" , sans-serif;"><br /></span></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; orphans: 2; text-align: start; widows: 2; word-spacing: 0px;">
<b><span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">Outcome:<o:p></o:p></span></b></div>
<div class="MsoNormal">
<span style="font-family: "arial" , "helvetica" , sans-serif;">With the major change from the
post-operative echo which showed just trace aortic regurgitation, and the
bedside echo suggesting there was now severe aortic regurgitation, cardiac
surgery was consulted. A comprehensive echo performed shortly after showed 4+
aortic regurgitation likely from a torn suture causing a torn valve, and the
patient went on to have a repeat repair procedure.</span></div>
<div class="MsoNormal">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span></div>
<div class="MsoNormal" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; orphans: 2; text-align: start; widows: 2; word-spacing: 0px;">
<b><span style="color: black; font-family: "arial" , "helvetica" , sans-serif;">Summary of Main Pearls from the
Case:</span></b></div>
<ul style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; margin-top: 0cm; orphans: 2; text-align: start; widows: 2; word-spacing: 0px;" type="disc">
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: "arial" , "helvetica" , sans-serif; mso-fareast-font-family: "Times New Roman";">Even without a detailed
knowledge of valvular assessment, qualitative assessment of LV and RV
function is still useful in narrowing the differential diagnosis in a
patient with suspected valve dysfunction.<o:p></o:p></span></li>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><u1:p></u1:p>
</span>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: "arial" , "helvetica" , sans-serif; mso-fareast-font-family: "Times New Roman";">Hemodynamically
significant aortic regurgitation will usually have a jet that fills
>65% of the LVOT.<o:p></o:p></span></li>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><u1:p></u1:p>
</span>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: "arial" , "helvetica" , sans-serif; mso-fareast-font-family: "Times New Roman";">Aliasing is an important
artifact to recognize when using colour doppler and may require you to
increase the scale on the machine.<o:p></o:p></span></li>
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<div class="MsoNormal">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="color: black; mso-fareast-font-family: "Times New Roman";">Thanks the Dr. Ohle for the great case and saving the images!<br style="mso-special-character: line-break;" />
<!--[if !supportLineBreakNewLine]--><br style="mso-special-character: line-break;" />
<!--[endif]--></span><span style="mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></span></div>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/>
<w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/>
<w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 9"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><u1:p></u1:p>
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<span style="color: black; font-family: "arial" , "helvetica" , sans-serif;"><i>Expert Commentary provided by Dr.
Brandon Ritcey, FRCPC Assistant Fellowship Director of EM POCUS at the University
of Ottawa<o:p></o:p></i></span></div>
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<span style="color: black; font-family: "arial" , "helvetica" , sans-serif;"><i>Edited by Dr. Paul Pageau, CCFP-EM, Assistant Professor, Program Director for Ultrasonography at the University of Ottawa</i></span></div>
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<i><span style="font-family: "arial" , "helvetica" , sans-serif;">Edited and Formatted by Dr. Rob Suttie, PGY2, Emergency Medicine at the University of Ottawa.</span></i></div>
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<i><span style="font-family: "arial" , "helvetica" , sans-serif;">For more informtation on our POCUS program please see <a href="http://clinsonoottawa.blogspot.ca/">Clinical Sonography Ottawa. </a></span></i></div>
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margin-bottom:10.0pt;}
@page WordSection1
{size:612.0pt 792.0pt;
margin:72.0pt 72.0pt 72.0pt 72.0pt;
mso-header-margin:36.0pt;
mso-footer-margin:36.0pt;
mso-paper-source:0;}
div.WordSection1
{page:WordSection1;}
-->
</style>
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-priority:99;
mso-style-parent:"";
mso-padding-alt:0cm 5.4pt 0cm 5.4pt;
mso-para-margin-top:0cm;
mso-para-margin-right:0cm;
mso-para-margin-bottom:10.0pt;
mso-para-margin-left:0cm;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:Calibri;
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<!--EndFragment--></div>
<style>
<!--
/* Font Definitions */
@font-face
{font-family:"Cambria Math";
panose-1:2 4 5 3 5 4 6 3 2 4;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:-536870145 1107305727 0 0 415 0;}
@font-face
{font-family:Calibri;
panose-1:2 15 5 2 2 2 4 3 2 4;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:-536870145 1073786111 1 0 415 0;}
/* Style Definitions */
p.MsoNormal, li.MsoNormal, div.MsoNormal
{mso-style-unhide:no;
mso-style-qformat:yes;
mso-style-parent:"";
margin-top:0cm;
margin-right:0cm;
margin-bottom:10.0pt;
margin-left:0cm;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:Calibri;
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:Calibri;
mso-fareast-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
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{mso-style-type:export-only;
mso-default-props:yes;
font-size:11.0pt;
mso-ansi-font-size:11.0pt;
mso-bidi-font-size:11.0pt;
font-family:Calibri;
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:Calibri;
mso-fareast-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
.MsoPapDefault
{mso-style-type:export-only;
margin-bottom:10.0pt;}
@page WordSection1
{size:612.0pt 792.0pt;
margin:72.0pt 72.0pt 72.0pt 72.0pt;
mso-header-margin:36.0pt;
mso-footer-margin:36.0pt;
mso-paper-source:0;}
div.WordSection1
{page:WordSection1;}
-->
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<!--
/* Font Definitions */
@font-face
{font-family:"Cambria Math";
panose-1:2 4 5 3 5 4 6 3 2 4;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:-536870145 1107305727 0 0 415 0;}
@font-face
{font-family:Calibri;
panose-1:2 15 5 2 2 2 4 3 2 4;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:-536870145 1073786111 1 0 415 0;}
/* Style Definitions */
p.MsoNormal, li.MsoNormal, div.MsoNormal
{mso-style-unhide:no;
mso-style-qformat:yes;
mso-style-parent:"";
margin-top:0cm;
margin-right:0cm;
margin-bottom:10.0pt;
margin-left:0cm;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:Calibri;
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:Calibri;
mso-fareast-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
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{mso-style-type:export-only;
mso-default-props:yes;
font-size:11.0pt;
mso-ansi-font-size:11.0pt;
mso-bidi-font-size:11.0pt;
font-family:Calibri;
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:Calibri;
mso-fareast-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
.MsoPapDefault
{mso-style-type:export-only;
margin-bottom:10.0pt;}
@page WordSection1
{size:612.0pt 792.0pt;
margin:72.0pt 72.0pt 72.0pt 72.0pt;
mso-header-margin:36.0pt;
mso-footer-margin:36.0pt;
mso-paper-source:0;}
div.WordSection1
{page:WordSection1;}
-->
</style><style>
<!--
/* Font Definitions */
@font-face
{font-family:"Courier New";
panose-1:2 7 3 9 2 2 5 2 4 4;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:-536859905 -1073711037 9 0 511 0;}
@font-face
{font-family:Wingdings;
panose-1:5 0 0 0 0 0 0 0 0 0;
mso-font-charset:2;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:0 268435456 0 0 -2147483648 0;}
@font-face
{font-family:"Cambria Math";
panose-1:2 4 5 3 5 4 6 3 2 4;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:-536870145 1107305727 0 0 415 0;}
@font-face
{font-family:Calibri;
panose-1:2 15 5 2 2 2 4 3 2 4;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:-536870145 1073786111 1 0 415 0;}
/* Style Definitions */
p.MsoNormal, li.MsoNormal, div.MsoNormal
{mso-style-unhide:no;
mso-style-qformat:yes;
mso-style-parent:"";
margin:0cm;
margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:Calibri;
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:Calibri;
mso-fareast-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
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{mso-style-type:export-only;
mso-default-props:yes;
font-family:Calibri;
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:Calibri;
mso-fareast-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
@page WordSection1
{size:612.0pt 792.0pt;
margin:72.0pt 72.0pt 72.0pt 72.0pt;
mso-header-margin:35.4pt;
mso-footer-margin:35.4pt;
mso-paper-source:0;}
div.WordSection1
{page:WordSection1;}
/* List Definitions */
@list l0
{mso-list-id:658920119;
mso-list-template-ids:343843628;}
@list l0:level1
{mso-level-number-format:bullet;
mso-level-text:;
mso-level-tab-stop:36.0pt;
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text-indent:-18.0pt;
mso-ansi-font-size:10.0pt;
font-family:Symbol;}
@list l0:level2
{mso-level-number-format:bullet;
mso-level-text:o;
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mso-level-number-position:left;
text-indent:-18.0pt;
mso-ansi-font-size:10.0pt;
font-family:"Courier New";
mso-bidi-font-family:"Times New Roman";}
@list l0:level3
{mso-level-number-format:bullet;
mso-level-text:;
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mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l0:level4
{mso-level-number-format:bullet;
mso-level-text:;
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text-indent:-18.0pt;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l0:level5
{mso-level-number-format:bullet;
mso-level-text:;
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mso-level-number-position:left;
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mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l0:level6
{mso-level-number-format:bullet;
mso-level-text:;
mso-level-tab-stop:216.0pt;
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text-indent:-18.0pt;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l0:level7
{mso-level-number-format:bullet;
mso-level-text:;
mso-level-tab-stop:252.0pt;
mso-level-number-position:left;
text-indent:-18.0pt;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l0:level8
{mso-level-number-format:bullet;
mso-level-text:;
mso-level-tab-stop:288.0pt;
mso-level-number-position:left;
text-indent:-18.0pt;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l0:level9
{mso-level-number-format:bullet;
mso-level-text:;
mso-level-tab-stop:324.0pt;
mso-level-number-position:left;
text-indent:-18.0pt;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
ol
{margin-bottom:0cm;}
ul
{margin-bottom:0cm;}
-->
</style><style>
<!--
/* Font Definitions */
@font-face
{font-family:"Cambria Math";
panose-1:2 4 5 3 5 4 6 3 2 4;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:-536870145 1107305727 0 0 415 0;}
@font-face
{font-family:Calibri;
panose-1:2 15 5 2 2 2 4 3 2 4;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:-536870145 1073786111 1 0 415 0;}
/* Style Definitions */
p.MsoNormal, li.MsoNormal, div.MsoNormal
{mso-style-unhide:no;
mso-style-qformat:yes;
mso-style-parent:"";
margin-top:0cm;
margin-right:0cm;
margin-bottom:10.0pt;
margin-left:0cm;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:Calibri;
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:Calibri;
mso-fareast-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
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{mso-style-type:export-only;
mso-default-props:yes;
font-size:11.0pt;
mso-ansi-font-size:11.0pt;
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font-family:Calibri;
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:Calibri;
mso-fareast-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
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{mso-style-type:export-only;
margin-bottom:10.0pt;}
@page WordSection1
{size:612.0pt 792.0pt;
margin:72.0pt 72.0pt 72.0pt 72.0pt;
mso-header-margin:36.0pt;
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div.WordSection1
{page:WordSection1;}
-->
</style><style>
<!--
/* Font Definitions */
@font-face
{font-family:"Courier New";
panose-1:2 7 3 9 2 2 5 2 4 4;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:-536859905 -1073711037 9 0 511 0;}
@font-face
{font-family:Wingdings;
panose-1:5 0 0 0 0 0 0 0 0 0;
mso-font-charset:2;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:0 268435456 0 0 -2147483648 0;}
@font-face
{font-family:"Cambria Math";
panose-1:2 4 5 3 5 4 6 3 2 4;
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mso-font-signature:-536870145 1107305727 0 0 415 0;}
@font-face
{font-family:Calibri;
panose-1:2 15 5 2 2 2 4 3 2 4;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:-536870145 1073786111 1 0 415 0;}
/* Style Definitions */
p.MsoNormal, li.MsoNormal, div.MsoNormal
{mso-style-unhide:no;
mso-style-qformat:yes;
mso-style-parent:"";
margin-top:0cm;
margin-right:0cm;
margin-bottom:10.0pt;
margin-left:0cm;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:Calibri;
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:Calibri;
mso-fareast-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
p.MsoListParagraph, li.MsoListParagraph, div.MsoListParagraph
{mso-style-priority:34;
mso-style-unhide:no;
mso-style-qformat:yes;
margin-top:0cm;
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margin-left:36.0pt;
mso-add-space:auto;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:Calibri;
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mso-fareast-font-family:Calibri;
mso-fareast-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
p.MsoListParagraphCxSpFirst, li.MsoListParagraphCxSpFirst, div.MsoListParagraphCxSpFirst
{mso-style-priority:34;
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mso-style-type:export-only;
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margin-bottom:0cm;
margin-left:36.0pt;
margin-bottom:.0001pt;
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mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:Calibri;
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mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:Calibri;
mso-fareast-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
p.MsoListParagraphCxSpMiddle, li.MsoListParagraphCxSpMiddle, div.MsoListParagraphCxSpMiddle
{mso-style-priority:34;
mso-style-unhide:no;
mso-style-qformat:yes;
mso-style-type:export-only;
margin-top:0cm;
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margin-left:36.0pt;
margin-bottom:.0001pt;
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font-family:Calibri;
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mso-fareast-font-family:Calibri;
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mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
p.MsoListParagraphCxSpLast, li.MsoListParagraphCxSpLast, div.MsoListParagraphCxSpLast
{mso-style-priority:34;
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mso-style-qformat:yes;
mso-style-type:export-only;
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margin-bottom:10.0pt;
margin-left:36.0pt;
mso-add-space:auto;
mso-pagination:widow-orphan;
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font-family:Calibri;
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mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:Calibri;
mso-fareast-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
.MsoChpDefault
{mso-style-type:export-only;
mso-default-props:yes;
font-size:11.0pt;
mso-ansi-font-size:11.0pt;
mso-bidi-font-size:11.0pt;
font-family:Calibri;
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:Calibri;
mso-fareast-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
.MsoPapDefault
{mso-style-type:export-only;
margin-bottom:10.0pt;}
@page WordSection1
{size:612.0pt 792.0pt;
margin:72.0pt 72.0pt 72.0pt 72.0pt;
mso-header-margin:36.0pt;
mso-footer-margin:36.0pt;
mso-paper-source:0;}
div.WordSection1
{page:WordSection1;}
/* List Definitions */
@list l0
{mso-list-id:547883338;
mso-list-type:hybrid;
mso-list-template-ids:1013729066 67698689 67698691 67698693 67698689 67698691 67698693 67698689 67698691 67698693;}
@list l0:level1
{mso-level-number-format:bullet;
mso-level-text:;
mso-level-tab-stop:none;
mso-level-number-position:left;
text-indent:-18.0pt;
font-family:Symbol;}
@list l0:level2
{mso-level-number-format:bullet;
mso-level-text:o;
mso-level-tab-stop:none;
mso-level-number-position:left;
text-indent:-18.0pt;
font-family:"Courier New";}
@list l0:level3
{mso-level-number-format:bullet;
mso-level-text:;
mso-level-tab-stop:none;
mso-level-number-position:left;
text-indent:-18.0pt;
font-family:Wingdings;}
@list l0:level4
{mso-level-number-format:bullet;
mso-level-text:;
mso-level-tab-stop:none;
mso-level-number-position:left;
text-indent:-18.0pt;
font-family:Symbol;}
@list l0:level5
{mso-level-number-format:bullet;
mso-level-text:o;
mso-level-tab-stop:none;
mso-level-number-position:left;
text-indent:-18.0pt;
font-family:"Courier New";}
@list l0:level6
{mso-level-number-format:bullet;
mso-level-text:;
mso-level-tab-stop:none;
mso-level-number-position:left;
text-indent:-18.0pt;
font-family:Wingdings;}
@list l0:level7
{mso-level-number-format:bullet;
mso-level-text:;
mso-level-tab-stop:none;
mso-level-number-position:left;
text-indent:-18.0pt;
font-family:Symbol;}
@list l0:level8
{mso-level-number-format:bullet;
mso-level-text:o;
mso-level-tab-stop:none;
mso-level-number-position:left;
text-indent:-18.0pt;
font-family:"Courier New";}
@list l0:level9
{mso-level-number-format:bullet;
mso-level-text:;
mso-level-tab-stop:none;
mso-level-number-position:left;
text-indent:-18.0pt;
font-family:Wingdings;}
ol
{margin-bottom:0cm;}
ul
{margin-bottom:0cm;}
-->
</style><style>
<!--
/* Font Definitions */
@font-face
{font-family:"Cambria Math";
panose-1:2 4 5 3 5 4 6 3 2 4;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:-536870145 1107305727 0 0 415 0;}
@font-face
{font-family:Calibri;
panose-1:2 15 5 2 2 2 4 3 2 4;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:-536870145 1073786111 1 0 415 0;}
/* Style Definitions */
p.MsoNormal, li.MsoNormal, div.MsoNormal
{mso-style-unhide:no;
mso-style-qformat:yes;
mso-style-parent:"";
margin:0cm;
margin-bottom:.0001pt;
mso-pagination:widow-orphan;
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</style>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-31360777149766628372017-03-06T09:00:00.000-05:002017-03-29T18:40:34.165-04:00Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine - The POKER Study: A Randomized Double-Blind Clinical Trial<h4 style="mso-layout-grid-align: none; text-autospace: none;">
<a href="https://2.bp.blogspot.com/-A3owcsJzrc8/WLrwY1T2uBI/AAAAAAAAByg/aGh57aO2bUoX-QJn4lOCZkSxFk6mQawCgCLcB/s1600/Anesthesiologist.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="292" src="https://2.bp.blogspot.com/-A3owcsJzrc8/WLrwY1T2uBI/AAAAAAAAByg/aGh57aO2bUoX-QJn4lOCZkSxFk6mQawCgCLcB/s320/Anesthesiologist.jpg" width="320" /></a><b>Journal Club Summary</b></h4>
<div class="MsoNormal">
<span lang="EN-US"><b><span lang="EN-US" style="color: red;">Methodology Score: 4/5</span></b></span><br />
<b><span lang="EN-US" style="color: red;">Usefulness Score: 3.5/5</span></b><br />
<b><span lang="EN-US" style="color: red;"><br /></span></b></div>
<div class="MsoNormal">
<span lang="EN-US">Ferguson I, et al.</span><br />
<span class="jrnl"><span lang="EN-US" style="background: white; color: black;">Ann Emerg Med</span></span><span lang="EN-US" style="background: white; color: black;">. 2016 Nov;68(5):574-582.</span><br />
<a href="http://www.sciencedirect.com/science/article/pii/S0196064416302049">Abstract Link</a><br />
<br />
<a name='more'></a><br /></div>
<div class="MsoNormal">
<span lang="EN-CA" style="color: black; mso-ansi-language: EN-CA;">This
was a large multicenter double-blind RCT to compare ketafol in a 1:1 ratio to
propofol failed to find </span><span lang="EN-US" style="color: black;">a 10%
absolute reduction in adverse respiratory events but did find significantly
more transient hypotension in the propofol group. We felt that while both
medications appear to be safe, JC attendees questioned desaturation (SpO2 ≤93%)
as one of the composite outcomes as majority only required oxygen and airway
repositioning. The study was not powered to detect differences in the more
serious respiratory events (laryngospasm, aspiration or airway obstruction). </span><span lang="EN-US" style="color: black; font-family: "tahoma"; font-size: 10.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-right: -36.0pt;">
<b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span lang="EN-US">By: </span></i></b><b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span lang="EN-CA" style="mso-ansi-language: EN-CA;">Dr. </span><span lang="EN-US" style="mso-bidi-font-style: italic;">Talia Burwash-Brennan</span></i></b><span style="font-size: 12pt;"> </span></div>
<div class="MsoPlainText">
<span lang="EN-US" style="font-family: "times new roman"; font-size: 12.0pt;"><o:p><br /></o:p></span></div>
<h4 style="mso-layout-grid-align: none; text-autospace: none;">
<b><i style="mso-bidi-font-style: normal;"><span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-fareast-language: EN-CA;">Epi lesson </span></i></b></h4>
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<b><u><span lang="EN-US"><a href="http://emottawa.blogspot.ca/2015/06/epi-lessons-part-2-therapy-articles.html">Modified
Intention-to-treat (M-ITT) Analyses</a></span></u></b><br />
Intention-to-treat (ITT) analyses are widely recommended as the
preferred approach to the analysis of most clinical trials. The basic
intention-to-treat principle is that participants in trials should be analysed
in the groups to which they were randomized, regardless of whether they
received or adhered to the allocated intervention, crossed over to other
treatments, or were withdrawn from the study. Post-randomization exclusions may
be acceptable when patients are inappropriately randomized into a clinical
trial or when pre-randomization information on patients' eligibility status is
not available at the time of randomization. Such an approach is known as
“modified intention-to-treat” analysis and must be pre-specified in the
protocol. M-ITT is most likely to be seen in RCTs of critical situations, e.g.
cardiac arrest.</div>
<div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-US"><b><i>Dr. Venkatesh Thiruganasambandamoorthy</i></b></span></div>
Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-71580578161767233162017-03-02T10:00:00.000-05:002017-04-07T12:02:33.297-04:00SIRS? No SIRS? Understanding Sepsis in the Emergency Department after Sepsis-3. <div style="text-align: center;">
<iframe allowfullscreen="" frameborder="0" height="270" src="https://www.youtube.com/embed/nMuusCSSNqc" width="480"></iframe><br /></div>
<div class="MsoNormal">
<div style="text-align: center;">
<span style="font-family: "times" , "times new roman" , serif;"><span lang="EN-CA" style="font-family: "times new roman";">Use of the term “sepsis” continues to be controversial. We understand that patients with infection can manifest an immune-mediated systemic response, and are at risk of deterioration, organ dysfunction, and death. At what point in that cascade the patient is termed “septic” remains the centre of ongoing debate. In 2016, under the coordination of Drs. Mervyn Singer and Cliff Deutschman, a task force of experts in sepsis research were assembled to create <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4968574/">The Third International Consensus Definitions and Clinical Criteria of Sepsis and Septic Shock (Sepsis-3)</a> </span><!--[if supportFields]><span lang=EN-CA
style='font-family:"Times New Roman"'><span style='mso-element:field-begin'></span><span
style='mso-spacerun:yes'> </span>ADDIN EN.CITE <span style='mso-element:field-begin'></span><span
style='mso-spacerun:yes'> </span>ADDIN EN.CITE.DATA <![if gte mso 9]><xml> 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</xml><![endif]><span style='mso-element:field-end'></span><span
style='mso-element:field-separator'></span></span><![endif]--><span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;">[1]</span><!--[if gte mso 9]><xml> 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</xml><![endif]--></span><!--[if supportFields]><span lang=EN-CA
style='font-family:"Times New Roman"'><span style='mso-element:field-end'></span></span><![endif]--><span lang="EN-CA" style="font-family: "times new roman";">. Prior to this, the most recent set of definitions were released in <a href="http://www.esicm.org/upload/file4.pdf">2001</a> </span><!--[if supportFields]><span
lang=EN-CA style='font-family:"Times New Roman"'><span style='mso-element:field-begin'></span><span
style='mso-spacerun:yes'> </span>ADDIN EN.CITE <EndNote><Cite><Author>Levy</Author><Year>2003</Year><RecNum>26</RecNum><DisplayText>[2]</DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="ea5zf99fm0z05aedttjxwvrjez50fxf9fdzd" timestamp="1476043800">26</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Levy, M. M.</author><author>Fink, M. P.</author><author>Marshall, J. C.</author><author>Abraham, E.</author><author>Angus, D.</author><author>Cook, D.</author><author>Cohen, J.</author><author>Opal, S. M.</author><author>Vincent, J. L.</author><author>Ramsay, G.</author><author>Sccm/Esicm/Accp/Ats/Sis,</author></authors></contributors><auth-address>Rhode Island Hospital, Brown University School of Medicine, 593 Eddy Street, Providence, RI 02903, USA.</auth-address><titles><title>2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference</title><secondary-title>Crit Care Med</secondary-title></titles><periodical><full-title>Crit Care Med</full-title></periodical><pages>1250-6</pages><volume>31</volume><number>4</number><keywords><keyword>Humans</keyword><keyword>Multiple Organ Failure/complications/diagnosis</keyword><keyword>Sepsis/complications/*diagnosis</keyword><keyword>Shock, Septic/diagnosis</keyword><keyword>Systemic Inflammatory Response Syndrome/*diagnosis</keyword><keyword>*Terminology as Topic</keyword></keywords><dates><year>2003</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>0090-3493 (Print)&#xD;0090-3493 (Linking)</isbn><accession-num>12682500</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/12682500</url></related-urls></urls><electronic-resource-num>10.1097/01.CCM.0000050454.01978.3B</electronic-resource-num></record></Cite></EndNote><span
style='mso-element:field-separator'></span></span><![endif]--><span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;">[2]</span></span><!--[if supportFields]><span
lang=EN-CA style='font-family:"Times New Roman"'><span style='mso-element:field-end'></span></span><![endif]--><span lang="EN-CA" style="font-family: "times new roman";">, and our understanding of sepsis has since changed. Thus, the definition of sepsis required an update. These definitions have been a source of major disagreement, but their major tenets must be known and understood by Emergency Department (ED) physicians, in order to apply them correctly. <o:p></o:p></span></span></div>
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<a name='more'></a><u><span style="font-family: "times" , "times new roman" , serif;"><b>Screening vs Risk-Stratification Tool</b></span></u></div>
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<span lang="EN-CA" style="font-family: "times" , "times new roman" , serif;">Keep in mind that there is a difference between a <u>screening</u> tool and a <u>risk-stratification</u> tool. A screening tool aims to <i style="mso-bidi-font-style: normal;">identify</i> patients with a particular disease (ex: infection) from a larger pool of patients (ex: all patients in the ED). Once those patients with the disease are identified, a risk-stratification tool can be applied to individuals in this selected population in order to determine their likelihood of meeting a particular outcome (ex: death or ICU admission). This will become more important later on.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-CA" style="font-family: "times" , "times new roman" , serif;"><u>SIRS and Sepsis-3</u></span></b></h4>
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<span style="font-weight: normal;"><span style="font-family: "times" , "times new roman" , serif;"><span lang="EN-CA" style="font-size: 12pt;">An important thing to realize about Sepsis-3 is that no Emergency Medicine physicians were a part of the assembled task force. However, ED physicians are intimately involved in the diagnosis, early management and risk-stratification of patients with presumed sepsis. The large majority of patients ultimately admitted to the ICU with sepsis or septic shock initially present to the ED, and most of these patients are identified (screened for) using the Systemic Inflammatory Response Syndrome (SIRS) criteria </span><span lang="EN-CA" style="font-size: 12pt;">[3]</span><span lang="EN-CA" style="font-size: 12pt;">. “Sepsis” had therefore been defined as presence of 2 or more of the SIRS criteria, coupled with suspected infection </span><span lang="EN-CA" style="font-size: 12pt;">[4]</span><span lang="EN-CA" style="font-size: 12pt;">. However, the SIRS criteria were criticized for being too non-specific, and were seen in many patients who did not have infection </span><span lang="EN-CA" style="font-size: 12pt;">[5]</span><span lang="EN-CA" style="font-size: 12pt;">. Further to this, Kaukonen and colleagues </span><span lang="EN-CA" style="font-size: 12pt;">[6]</span><span lang="EN-CA" style="font-size: 12pt;"> demonstrated that 1/8 of patients admitted to the ICU with severe sepsis or septic shock did not meet the SIRS criteria, and that presence of the SIRS criteria was not associated with increased mortality. Thus, both the specificity <i>and</i> the sensitivity of the SIRS criteria in detecting sepsis were questioned.</span></span></span></h4>
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<tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-KWeGeq31TrM/WKnquxK8zfI/AAAAAAAAB-4/sfCoqyu2FTA3L5famtaGi-Wg_M5LXP-MACLcB/s1600/Picture1.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><span style="font-family: "times" , "times new roman" , serif;"><img border="0" height="254" src="https://1.bp.blogspot.com/-KWeGeq31TrM/WKnquxK8zfI/AAAAAAAAB-4/sfCoqyu2FTA3L5famtaGi-Wg_M5LXP-MACLcB/s640/Picture1.png" width="640" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "times" , "times new roman" , serif;">SIRS Criteria <u>></u> 2 or more </span></td></tr>
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Based on this, the Sepsis-3 task force chose to remove SIRS from the definition of sepsis. Instead, they chose to focus the definition on the <b style="mso-bidi-font-weight: normal;">3 things </b>we seem to know about sepsis with some degree of confidence: A) It starts with infection; B) It involves a complex immune-mediated host response; and C) It results in multi-system organ dysfunction. Therefore, the definition of sepsis was changed to:<o:p></o:p></span></div>
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<i style="mso-bidi-font-style: normal;"><span lang="EN-CA" style="font-family: "times" , "times new roman" , serif;">“Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection.”<o:p></o:p></span></i></div>
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<span lang="EN-CA" style="font-family: "times" , "times new roman" , serif;">This definition raises some important questions. How do you define “organ dysfunction”? What is a “dysregulated” host response? For that matter, what is a “regulated” host response? These questions are not answered in Sepsis-3. <o:p></o:p></span></div>
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<span style="font-family: "times" , "times new roman" , serif;"><span lang="EN-CA" style="font-family: "times new roman";">After the task force had created their definition, they sought to create clinical criteria that could be used to <u>diagnose</u> a patient with sepsis. To do this, they chose to use the Sequential (Sepsis-related) Organ Failure Assessment (SOFA) score, which has been well-demonstrated to be associated with mortality in ICU patients with sepsis </span><!--[if supportFields]><span
lang=EN-CA style='font-family:"Times New Roman"'><span style='mso-element:field-begin'></span><span
style='mso-spacerun:yes'> </span>ADDIN EN.CITE <span style='mso-element:field-begin'></span><span
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style='mso-element:field-separator'></span></span><![endif]--><span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;">[7]</span><!--[if gte mso 9]><xml> <w:data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w:data> </xml><![endif]--></span><!--[if supportFields]><span lang=EN-CA
style='font-family:"Times New Roman"'><span style='mso-element:field-end'></span></span><![endif]--><span lang="EN-CA" style="font-family: "times new roman";">. The SOFA score also grades severity of illness on the basis of organ dysfunction – one of the major tenets of the new definition. <o:p></o:p></span></span></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif;"><br />
</span></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif;"><span lang="EN-CA" style="font-family: "times new roman";">Now, according to Sepsis-3, in order to diagnose a patient with sepsis, there must be <b style="mso-bidi-font-weight: normal;">suspected infection and an acute increase in the SOFA score by two or more points</b> </span><!--[if supportFields]><span
lang=EN-CA style='font-family:"Times New Roman"'><span style='mso-element:field-begin'></span><span
style='mso-spacerun:yes'> </span>ADDIN EN.CITE <span style='mso-element:field-begin'></span><span
style='mso-spacerun:yes'> </span>ADDIN EN.CITE.DATA <![if gte mso 9]><xml> 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</xml><![endif]><span style='mso-element:field-end'></span><span
style='mso-element:field-separator'></span></span><![endif]--><span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;">[1]</span><!--[if gte mso 9]><xml> 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style='font-family:"Times New Roman"'><span style='mso-element:field-end'></span></span><![endif]--><span lang="EN-CA" style="font-family: "times new roman";">.</span></span><br />
<span lang="EN-CA" style="font-family: "times" , "times new roman" , serif;"><br />
</span></div>
<div class="MsoNormal">
<h4>
<b style="mso-bidi-font-weight: normal;"><span lang="EN-CA" style="font-family: "times" , "times new roman" , serif;"><u>At The Bedside: qSOFA</u></span></b></h4>
</div>
<div class="MsoNormal">
<span lang="EN-CA" style="font-family: "times" , "times new roman" , serif;">Looking at the SOFA score, one can see that it is not the easiest score to apply in the ED setting. It involves variables not routinely measured in the ED (when was the last time you calculated a PaO<sub>2</sub>/FiO<sub>2</sub> ratio in the ED?). <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif;"><br />
</span></div>
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Name="List Continue 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/> <w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/> <w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/> <w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/> <w:LsdException Locked="false" Priority="39" Name="Table Grid"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 9"/> <w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/> <w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading"/> <w:LsdException Locked="false" Priority="61" Name="Light List"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/> <w:LsdException Locked="false" SemiHidden="true" Name="Revision"/> <w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/> <w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/> <w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/> <w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/> <w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/> <w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/> <w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/> <w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/> <w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/> <w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/> <w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/> <w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/> <w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/> <w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/> <w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/> <w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/> <w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/> <w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/> <w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/> <w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/> <w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/> <w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/> <w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 3"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 3"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 3"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 3"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 3"/> <w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 4"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 4"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 4"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 4"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 4"/> <w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 5"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 5"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 5"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 5"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 5"/> <w:LsdException Locked="false" Priority="51"
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</xml><![endif]--></span><!--[if supportFields]><span lang=EN-CA
style='font-size:12.0pt;font-family:"Times New Roman";mso-fareast-font-family:
Calibri;mso-fareast-theme-font:minor-latin;mso-ansi-language:EN-CA;mso-fareast-language:
EN-US;mso-bidi-language:AR-SA'><span style='mso-element:field-end'></span></span><![endif]--><span lang="EN-CA" style="font-size: 12pt;">. The qSOFA score consists of three criteria: Hypotension (SBP </span><span lang="EN-CA" style="font-size: 12.0pt;"> ≤</span><span lang="EN-CA" style="font-size: 12pt;"> 100mHg), altered mental status (GCS ≤ 13) and tachypnea (respiratory rate ≥ 22). Presence of 2 or more of these criteria was associated with significantly increased risk of death or ICU admission ≥ 72 hours.</span></span><br />
<span style="font-family: "times" , "times new roman" , serif;"><span lang="EN-CA" style="font-size: 12.0pt;"><span lang="EN-CA" style="font-size: 12pt;"><br />
</span></span> </span><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://3.bp.blogspot.com/-p0CooVWnhs8/WKnrHHSFgfI/AAAAAAAAB-8/2QJg1qo3t1UP499sjKtljytqfnvWJCUYACLcB/s1600/qSOFA.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><span style="font-family: "times" , "times new roman" , serif;"><img border="0" height="329" src="https://3.bp.blogspot.com/-p0CooVWnhs8/WKnrHHSFgfI/AAAAAAAAB-8/2QJg1qo3t1UP499sjKtljytqfnvWJCUYACLcB/s640/qSOFA.png" width="640" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "times" , "times new roman" , serif;">Image from R.E.B.E.L. EM - http://rebelem.com/sepsis-3-0/</span></td></tr>
</tbody></table>
<span style="font-family: "times" , "times new roman" , serif;"><span lang="EN-CA" style="font-size: 12.0pt;"><span lang="EN-CA" style="font-size: 12pt;"> </span><!--EndFragment--></span><span lang="EN-CA" style="font-size: 12pt;">An important thing to realize about the qSOFA score before you apply it is that <b>qSOFA was designed as a risk-stratification tool, NOT a screening tool</b>. That is, it was designed to maximize specificity, not sensitivity. So the presence of 2 or more of the criteria is an ominous sign. However, absence of the qSOFA criteria should not reassure you. Since SIRS was removed from the definition by the Sepsis-3 task force, there is a temptation to use qSOFA in its place. However, SIRS is a screening tool, while qSOFA is a risk-stratification tool. They are not interchangeable </span><span lang="EN-CA" style="font-size: 12pt;">[5]</span><span lang="EN-CA" style="font-size: 12pt;">. Further to that, according to the Sepsis-3 investigators, qSOFA does not replace the SOFA criteria in the diagnosis of sepsis either </span><span lang="EN-CA" style="font-size: 12pt;">[1]</span><span lang="EN-CA" style="font-size: 12pt;">. Finally, it is important to know that the qSOFA score has never been prospectively applied in the ED (but stay tuned…).</span></span><br />
<span style="font-family: "times" , "times new roman" , serif;"><span lang="EN-CA" style="font-size: 12pt;"><br />
</span> </span><br />
<div class="MsoNormal">
<h4>
<b><span lang="EN-CA" style="font-family: "times" , "times new roman" , serif;"><u>The Sickest of the Sick: Septic Shock</u></span></b></h4>
</div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif;"><span lang="EN-CA" style="font-family: "times new roman";">The last goal of the Sepsis-3 investigators was to identify patients at the highest risk of death, which they defined as “Septic Shock” </span><!--[if supportFields]><span
lang=EN-CA style='font-family:"Times New Roman"'><span style='mso-element:field-begin'></span><span
style='mso-spacerun:yes'> </span>ADDIN EN.CITE <span style='mso-element:field-begin'></span><span
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style='font-family:"Times New Roman"'><span style='mso-element:field-end'></span></span><![endif]--><span lang="EN-CA" style="font-family: "times new roman";">. In the 2001 definitions, septic shock was defined as sepsis (i.e. presence of the SIRS criteria and suspected infection) coupled with hypotension (systolic blood pressure ≤ 90 mmHg). With SIRS being discarded from their definition of sepsis, the Sepsis-3 task force had to create new criteria for defining septic shock. Based on their data sets, these investigators defined septic shock <b>as initiation of vasopressors required to maintain a MAP ≥ 65mmHg <u>AND</u> serum lactate > 2.0 mmol/L, following “adequate fluid resuscitation”</b>. The concept of “adequate fluid resuscitation” was not defined. These patients were at highest risk of mortality from infection.</span></span></div>
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<a href="https://2.bp.blogspot.com/-ame93OGbTQM/WKnrOGOCX2I/AAAAAAAAB_A/gIMWCICjEvEL8QKHog_MhW69Mq6PRndjACLcB/s1600/dvbaewr.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: "times" , "times new roman" , serif;"><img border="0" height="376" src="https://2.bp.blogspot.com/-ame93OGbTQM/WKnrOGOCX2I/AAAAAAAAB_A/gIMWCICjEvEL8QKHog_MhW69Mq6PRndjACLcB/s640/dvbaewr.png" width="640" /></span></a></div>
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<span style="font-family: "times" , "times new roman" , serif;"><span lang="EN-CA" style="font-size: 12pt;">The inclusion of lactate in this definition was novel, but done on the basis of good evidence. In the ED, we know the initial lactate level has good prognostic utility in identifying patients at highest risk of in-hospital mortality </span><span lang="EN-CA" style="font-size: 12pt;">[10]</span><span lang="EN-CA" style="font-size: 12pt;">. Importantly<b>, an initial lactate level ≥ 4.0 mmol/L is highly specific (although poorly sensitive) for in-hospital mortality </b>in patients with suspected infection </span><span lang="EN-CA" style="font-size: 12pt;">[10, 11]</span><span lang="EN-CA" style="font-size: 12pt;">. Furthermore, lactate clearance has been demonstrated to have some association with resuscitation and improved outcomes </span><span lang="EN-CA" style="font-size: 12pt;">[12-14]</span><span lang="EN-CA" style="font-size: 12pt;">.</span></span><br />
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<b><span lang="EN-CA" style="font-family: "times" , "times new roman" , serif;"><u>Sepsis-3: The Take Home Messages</u></span></b></h4>
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<span style="font-family: "times" , "times new roman" , serif;"><span lang="EN-CA" style="font-family: "times new roman";">A lot has been made of the Sepsis-3 definitions and clinical criteria </span><!--[if supportFields]><span
lang=EN-CA style='font-family:"Times New Roman"'><span style='mso-element:field-begin'></span><span
style='mso-spacerun:yes'> </span>ADDIN EN.CITE <span style='mso-element:field-begin'></span><span
style='mso-spacerun:yes'> </span>ADDIN EN.CITE.DATA <![if gte mso 9]><xml> 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style='font-family:"Times New Roman"'><span style='mso-element:field-end'></span></span><![endif]--><span lang="EN-CA" style="font-family: "times new roman";">. Whether they represent a step forward in our understanding of this disease process is a matter of ongoing debate. Whether they will stand the test of prospective validation is simply a matter of time. <o:p></o:p></span></span></div>
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<span lang="EN-CA" style="font-family: "times" , "times new roman" , serif;">What can be said with confidence is that these new definitions do not reflect the practice of Emergency Medicine. “Sepsis” was previously defined as an inflammatory response (SIRS) in a patient with infection, but it has been changed to reflect a significantly greater degree of illness, namely organ dysfunction. Basing the diagnosis on the SOFA score makes it much harder for an ED physician to diagnose a patient with “sepsis”. Similarly, qSOFA may be a valuable tool for risk-stratification, but does not provide the ED physician with a screening tool for identifying low-risk patients suitable for discharge home. <o:p></o:p></span></div>
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<span lang="EN-CA" style="font-family: "times" , "times new roman" , serif;">Ultimately, this just may be an issue of semantics. As stated, we know that patients with infection are at risk of complex systemic response, organ failure and death. At what point the patient is labeled as “sepsis” is probably less important than identifying those patients at risk of deterioration. And given the role of the ED physician in initiating treatment and determining disposition, that may be where we should focus our energy.</span><br />
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<b><u><span style="font-family: "times" , "times new roman" , serif;">Take home messages:</span></u></b></h4>
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<ul>
<li><span style="font-family: "times" , "times new roman" , serif;">We still need a screening tool to identify patients with infection. This is not addressed in Sepsis-3. While these investigators chose to remove the SIRS criteria from the definition of sepsis, it may not make sense to remove them from our ED screening (at least for now). We know that utilization of the SIRS criteria for ED screening and early initiation of treatment has been associated with improved patient outcomes <span lang="EN-CA" style="font-size: 12pt; text-indent: -18pt;">[18]</span><span lang="EN-CA" style="font-size: 12pt; text-indent: -18pt;">.</span></span></li>
<li><span style="font-family: "times" , "times new roman" , serif;">“Sepsis” is diagnosed by Sepsis-3 as suspected infection coupled with an acute increase in the SOFA score of 2 or more. However, the cumbersome nature of the SOFA score makes it difficult to apply in the ED.</span></li>
<li><span lang="EN-CA" style="font-family: "times" , "times new roman" , serif; font-size: 12pt; text-indent: -18pt;">The qSOFA score was designed for easy application at the bedside, but it was created as a risk-stratification tool, NOT a screening tool. A qSOFA ≥ 2 should concern you, but a qSOFA < 2 should not reassure you. Do not use it as a substitute for SIRS.</span></li>
<li><span style="font-family: "times" , "times new roman" , serif;">Septic Shock is now defined as initiation of vasopressors to maintain a MAP ≥ 65mmHg, coupled with a lactate > 2.0 mmol/L following “adequate fluid resuscitation”. These patients are at highest risk of death.</span></li>
<li><span style="font-family: "times" , "times new roman" , serif;"><span lang="EN-CA" style="font-size: 12pt;">Keep an eye on your initial lactate. A lactate ≥ 4.0 mmol/L has a specificity of 92% for in-hospital mortality in patients with infection </span><span lang="EN-CA" style="font-size: 12pt;">[10]</span><span lang="EN-CA" style="font-size: 12pt;">.</span></span></li>
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Name="List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/> <w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/> <w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/> <w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/> <w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/> <w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/> <w:LsdException Locked="false" Priority="39" Name="Table Grid"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 9"/> <w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/> <w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading"/> <w:LsdException Locked="false" Priority="61" Name="Light List"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/> <w:LsdException Locked="false" SemiHidden="true" Name="Revision"/> <w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/> <w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/> <w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/> <w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/> <w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/> <w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/> <w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/> <w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/> <w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/> <w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/> <w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/> <w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/> <w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/> <w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/> <w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/> <w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/> <w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/> <w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/> <w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/> <w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/> <w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/> <w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/> <w:LsdException Locked="false" Priority="51"
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<span lang="EN-CA" style="font-family: "times new roman";"><i><span lang="EN-CA" style="font-family: "times" , "times new roman" , serif;"><br />
</span></i></span></div>
<span style="font-family: "times" , "times new roman" , serif;"><span lang="EN-CA" style="font-family: "times new roman";"><span style="font-family: "times" , "times new roman" , serif;"> </span></span> </span><br />
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<span lang="EN-CA" style="font-family: "times new roman";"><span lang="EN-CA" style="font-family: "times" , "times new roman" , serif;">Dr. Shannon Fernando is a 3<sup>rd</sup> year Emergency Medicine resident at the University of Ottawa. He has a particular interest in critical care, resuscitation, airway management, and point-of-care ultrasound. His research focuses on the use of predictive modeling techniques to identify and risk-stratify Emergency Department patients with critical illness. He will be pursuing his fellowship training in Critical Care Medicine at the University of Ottawa in July 2017. </span></span><span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">Edited By Dr. R Suttie, PGY2 Emergency Medicine</span></div>
<span lang="EN-CA" style="font-family: "times new roman";"> </span> <br />
<div class="MsoNormal" style="text-align: center;">
<br /></div>
<span lang="EN-CA" style="font-family: "times new roman";"> </span> <br />
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style='mso-element:field-begin'></span><span
style='mso-spacerun:yes'> </span>ADDIN EN.REFLIST <span style='mso-element:
field-separator'></span></span><![endif]--><span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">1.<span style="mso-tab-count: 1;"> </span>Singer M, Deutschman CS, Seymour CW<i style="mso-bidi-font-style: normal;"> et al</i>. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). <i style="mso-bidi-font-style: normal;">JAMA</i> 2016;315:801-810.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">2.<span style="mso-tab-count: 1;"> </span>Levy MM, Fink MP, Marshall JC<i style="mso-bidi-font-style: normal;"> et al</i>. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. <i style="mso-bidi-font-style: normal;">Crit Care Med</i> 2003;31:1250-1256.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">3.<span style="mso-tab-count: 1;"> </span>Keegan J, Wira CR, 3rd. Early identification and management of patients with severe sepsis and septic shock in the emergency department. <i style="mso-bidi-font-style: normal;">Emerg Med Clin North Am</i> 2014;32:759-776.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">4.<span style="mso-tab-count: 1;"> </span>Bone RC, Balk RA, Cerra FB<i style="mso-bidi-font-style: normal;"> et al</i>. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. <i style="mso-bidi-font-style: normal;">Chest</i> 1992;101:1644-1655.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">5.<span style="mso-tab-count: 1;"> </span>Vincent JL, Martin GS, Levy MM. qSOFA does not replace SIRS in the definition of sepsis. <i style="mso-bidi-font-style: normal;">Crit Care</i> 2016;20:210.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">6.<span style="mso-tab-count: 1;"> </span>Kaukonen KM, Bailey M, Pilcher D<i style="mso-bidi-font-style: normal;"> et al</i>. Systemic inflammatory response syndrome criteria in defining severe sepsis. <i style="mso-bidi-font-style: normal;">N Engl J Med</i> 2015;372:1629-1638.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">7.<span style="mso-tab-count: 1;"> </span>Vincent JL, de Mendonca A, Cantraine F<i style="mso-bidi-font-style: normal;"> et al</i>. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on "sepsis-related problems" of the European Society of Intensive Care Medicine. <i style="mso-bidi-font-style: normal;">Crit Care Med</i> 1998;26:1793-1800.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">8.<span style="mso-tab-count: 1;"> </span>Seymour CW, Liu VX, Iwashyna TJ<i style="mso-bidi-font-style: normal;"> et al</i>. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). <i style="mso-bidi-font-style: normal;">JAMA</i> 2016;315:762-774.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">9.<span style="mso-tab-count: 1;"> </span>Shankar-Hari M, Phillips GS, Levy ML<i style="mso-bidi-font-style: normal;"> et al</i>. Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). <i style="mso-bidi-font-style: normal;">JAMA</i> 2016;315:775-787.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">10.<span style="mso-tab-count: 1;"> </span>Shapiro NI, Howell MD, Talmor D<i style="mso-bidi-font-style: normal;"> et al</i>. Serum lactate as a predictor of mortality in emergency department patients with infection. <i style="mso-bidi-font-style: normal;">Ann Emerg Med</i> 2005;45:524-528.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">11.<span style="mso-tab-count: 1;"> </span>Mikkelsen ME, Miltiades AN, Gaieski DF<i style="mso-bidi-font-style: normal;"> et al</i>. Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. <i style="mso-bidi-font-style: normal;">Crit Care Med</i> 2009;37:1670-1677.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">12.<span style="mso-tab-count: 1;"> </span>Jones AE, Shapiro NI, Trzeciak S<i style="mso-bidi-font-style: normal;"> et al</i>. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. <i style="mso-bidi-font-style: normal;">JAMA</i> 2010;303:739-746.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">13.<span style="mso-tab-count: 1;"> </span>Arnold RC, Shapiro NI, Jones AE<i style="mso-bidi-font-style: normal;"> et al</i>. Multicenter Study of Early Lactate Clearance as a Determinant of Survival in Patients with Presumed Sepsis. <i style="mso-bidi-font-style: normal;">Shock</i> 2009;32:35-39.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">14.<span style="mso-tab-count: 1;"> </span>Nguyen HB, Rivers EP, Knoblich BP<i style="mso-bidi-font-style: normal;"> et al</i>. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock*. <i style="mso-bidi-font-style: normal;">Crit Care Med</i> 2004;32:1637-1642.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">15.<span style="mso-tab-count: 1;"> </span>Marshall JC. Sepsis-3: What is the Meaning of a Definition? <i style="mso-bidi-font-style: normal;">Crit Care Med</i> 2016;44:1459-1460.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">16.<span style="mso-tab-count: 1;"> </span>Deutschman CS. Imprecise Medicine: The Limitations of Sepsis-3. <i style="mso-bidi-font-style: normal;">Crit Care Med</i> 2016;44:857-858.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">17.<span style="mso-tab-count: 1;"> </span>Simpson SQ. New Sepsis Criteria: A Change We Should Not Make. <i style="mso-bidi-font-style: normal;">Chest</i> 2016;149:1117-1118.<o:p></o:p></span></span></span></div>
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Name="List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/> <w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/> <w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/> <w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/> <w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/> <w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/> <w:LsdException Locked="false" Priority="39" Name="Table Grid"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 9"/> <w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/> <w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading"/> <w:LsdException Locked="false" Priority="61" Name="Light List"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/> <w:LsdException Locked="false" SemiHidden="true" Name="Revision"/> <w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/> <w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/> <w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/> <w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/> <w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/> <w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/> <w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/> <w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/> <w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/> <w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/> <w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/> <w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/> <w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/> <w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/> <w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/> <w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/> <w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/> <w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/> <w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/> <w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/> <w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/> <w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/> <w:LsdException Locked="false" Priority="51"
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<span lang="EN-CA" style="font-family: "times new roman";"><span style="mso-no-proof: yes;"><span style="font-family: "times" , "times new roman" , serif; font-size: x-small;">18.<span style="mso-tab-count: 1;"> </span>McColl T, Gatien M, Calder L<i style="mso-bidi-font-style: normal;"> et al</i>. Implementation of an Emergency Department Sepsis Bundle and System Redesign: A Process Improvement Initiative. <i style="mso-bidi-font-style: normal;">CJEM</i> 2016:1-10.<o:p></o:p></span></span></span></div>
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</style>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-70103762043823218072017-02-27T17:37:00.001-05:002017-02-27T17:37:59.703-05:00Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis: The HYPRESS Randomized Clinical Trial<h4 style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: Times, Times New Roman, serif;">Journal Club Summary</span></h4>
<div>
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div>
<b><span lang="EN-US" style="color: red;"><span style="font-family: Times, Times New Roman, serif;">Methodology Score: 3/5 </span></span></b></div>
<div>
<b><span lang="EN-US" style="color: red;"><span style="font-family: Times, Times New Roman, serif;">Usefulness Score: 2.5/5</span></span></b></div>
<div class="desc" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span lang="EN-US" style="color: black; mso-bidi-font-weight: bold;"><span style="font-family: Times, Times New Roman, serif; font-size: small;"><br /></span></span></div>
<div class="desc" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: Times, Times New Roman, serif; font-size: small;"><span lang="EN-US" style="color: black; mso-bidi-font-weight: bold;">Keh</span><span class="apple-converted-space"><span lang="EN-US" style="color: black;"> </span></span><span lang="EN-US" style="color: black;">D, et al. <o:p></o:p></span></span></div>
<div class="details" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: Times, Times New Roman, serif; font-size: small;"><span class="jrnl"><span lang="EN-US" style="color: black;">JAMA</span></span><span lang="EN-US" style="color: black;">.<span class="apple-converted-space"> </span><span style="mso-bidi-font-weight: bold;">2016</span><span class="apple-converted-space"> </span>Nov
1;316(17):1775-1785<o:p></o:p></span></span></div>
<div class="MsoNormal" style="background: white;">
<span style="font-family: Times, Times New Roman, serif; font-size: small;"><a href="http://jamanetwork.com/journals/jama/article-abstract/2565176">Abstract Link</a></span></div>
<div class="MsoNormal" style="background: white;">
<span style="background-color: transparent; font-family: Times, "Times New Roman", serif; font-size: small;">In this multicenter placebo-controlled double-blind RCT, the authors concluded that in adults with severe sepsis, hydrocortisone IV infusion does not prevent progression of severe sepsis to septic shock. While this study was well done overall, the group had concerns about the removal of patients with adverse events from the modified intention-to-treat analysis, the lack of reporting of time to antibiotics, powering the study to detect a very high (15%) difference between groups. This not being an ED study the results are not applicable to our population.</span></div>
<div class="MsoNormal" style="background: white; font-size: medium;">
<b style="background-color: transparent; font-family: Times, "Times New Roman", serif;"><i><span lang="EN-US">By: Dr. Stephanie Barnes</span></i></b></div>
<div class="MsoNormal" style="background: white; font-size: medium;">
<b style="background-color: transparent; font-family: Times, "Times New Roman", serif;"><i><span lang="EN-US"><br /></span></i></b></div>
<div class="MsoNormal" style="background: white;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-bidi-font-style: italic;"><span style="font-family: Times, Times New Roman, serif; font-size: small;">EDITORIAL:</span></span></b></div>
<div class="MsoNormal" style="background: white;">
<span style="font-family: Times, "Times New Roman", serif; font-size: small;">Yende
S,</span><sup style="font-family: Times, "Times New Roman", serif;"> </sup><span style="font-family: Times, "Times New Roman", serif; font-size: small;">et al.</span></div>
<div class="MsoNormal" style="background: white;">
<span style="font-family: Times, "Times New Roman", serif; font-size: small;">Evaluating Glucocorticoids for Sepsis: Time to Change
Course. </span></div>
<div class="MsoNormal" style="background: white;">
<span style="font-family: Times, "Times New Roman", serif; font-size: small;">JAMA.</span><span class="apple-converted-space" style="font-family: Times, "Times New Roman", serif; font-size: small;"> </span><span class="highlight" style="font-family: Times, "Times New Roman", serif; font-size: small;">2016</span><span class="apple-converted-space" style="font-family: Times, "Times New Roman", serif; font-size: small;"> </span><span style="font-family: Times, "Times New Roman", serif; font-size: small;">Nov 1;316(17):1769-1771.</span></div>
<div class="MsoNormal" style="background: white;">
<a href="http://jamanetwork.com/journals/jama/article-abstract/2565175" style="background-color: transparent; font-family: Times, "Times New Roman", serif; font-size: medium;">http://jamanetwork.com/journals/jama/article-abstract/2565175</a><b style="background-color: transparent; font-size: 12pt;"><span lang="EN-CA"><o:p><span style="font-family: Times, Times New Roman, serif; font-size: small;"> </span></o:p></span></b></div>
<h4 style="mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-CA"><span style="font-family: Times, Times New Roman, serif;"><br /></span></span></h4>
<h4 style="mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-CA"><span style="font-family: Times, Times New Roman, serif;">Epi lesson</span></span></h4>
<div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span lang="EN-US"><span style="font-family: Times, Times New Roman, serif; font-size: small;"><a href="http://emottawa.blogspot.ca/2015/06/epi-lessons-part-2-therapy-articles.html"><u>Randomization by Pocock minimization algorithm</u></a> <u>February
2017<o:p></o:p></u></span></span></i></b></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-US"><span style="font-family: Times, Times New Roman, serif; font-size: small;">A random allocation of patients to treatment-control group (by
sealed envelopes etc.) generally leads to balanced groups but can lead to
differences in the groups on some aspects (more males or obese patients in one
arm than the other). If important factors of identified (e.g. sex, obesity)
then the patients could be stratified based on sex and BMI. Using block
randomization a list is created for a block of x patients to be equally
assigned to the study arms based on the important factors identified. If there
a large number of important factors, then the block randomization becomes
extremely complex. Pocock and Simon adaptive stratified sampling algorithm can
be used to calculate the imbalance between the groups based on each factor and
add an additional random element to assignment of the next patient.</span></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<b style="font-family: Times, "Times New Roman", serif; font-size: medium;"><i><span lang="EN-CA">By: </span></i></b><b style="font-family: Times, "Times New Roman", serif; font-size: medium;"><i><span lang="EN-US">Dr. Venkatesh Thiruganasambandamoorthy</span></i></b></div>
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</style>Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-48586109205392394442017-02-23T09:00:00.000-05:002017-03-31T15:36:28.499-04:00REBOA: Resuscitative Endovascular Balloon Occlusion of the Aorta <div class="separator" style="clear: both; text-align: center;">
<iframe allowfullscreen="" class="YOUTUBE-iframe-video" data-thumbnail-src="https://i.ytimg.com/vi/ggbSbhfV7CU/0.jpg" frameborder="0" height="266" src="https://www.youtube.com/embed/ggbSbhfV7CU?feature=player_embedded" width="320"></iframe></div>
<br />
<div class="MsoNormal">
<span style="color: black; font-family: "times new roman";">The use of <b>Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) </b>has become a topic of considerable interest as of late, primarily to treat non-compressible truncal hemorrhage (NCTH). However, it is beginning to expand into other causes of <u>non-compressible</u> bleeding. </span></div>
<div class="MsoNormal" style="text-align: justify;">
<h4>
<b><u><span style="color: black; font-family: "times new roman";">Why do we care?</span></u></b></h4>
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<span style="color: black; font-family: "times new roman";">Bleeding is the 2<sup>nd</sup> leading cause of traumatic death behind only traumatic brain injury (TBI). Additionally, it is the number one cause of preventable death in trauma, causing 85% of all preventable trauma deaths. Furthermore, 35% of all pre-hospital deaths and over 40% of deaths within the first 24 hours following trauma are attributed to bleeding (<a href="https://www.ncbi.nlm.nih.gov/pubmed/16763478"><span style="color: blue;">Kauvar, Lefering, & Wade, 2006</span></a>). One article states that there are around 60 000 civilian deaths per year in the US secondary to traumatic bleeding (<a href="https://www.ncbi.nlm.nih.gov/pubmed/7869433"><span style="color: blue;">Sauaia et al., 1995</span></a>).</span></div>
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<b><u><span style="color: black; font-family: "times new roman";">Is this REBOA thing new?!</span></u></b></h4>
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<span style="color: black; font-family: "times new roman";">Nope. <o:p></o:p></span></div>
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<span style="color: black; font-family: "times new roman";">The concept and use of REBOA has been around since at least 1954, when Lieutenant Colonel Carl Hughes of the US military published an article describing one injury in which REBOA was used to treat NCTH and two other battlefield injuries in which REBOA could potentially have been used to stem the bleeding (<a href="https://www.ncbi.nlm.nih.gov/pubmed/13178946"><span style="color: blue;">Hughes, 1954</span></a>).</span></div>
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<span style="font-family: "times new roman"; font-size: 12pt;">The next published data following this initial report was in 1986 and 1989 (</span><a href="https://www.ncbi.nlm.nih.gov/pubmed/2661845" style="font-family: "Times New Roman"; font-size: 12pt;"><span style="color: blue;">Gupta et al., 1989</span></a><span style="font-family: "times new roman"; font-size: 12pt;">; </span><a href="https://www.ncbi.nlm.nih.gov/pubmed/3777619" style="font-family: "Times New Roman"; font-size: 12pt;"><span style="color: blue;">Low, Longmore, Rubinstein,Flores, & Wolvek, 1986</span></a><span style="font-family: "times new roman"; font-size: 12pt;">) showing the use intra-aortic balloon occlusion in traumatic injuries actually leading to some individuals surviving. However, with no randomization obviously it was not possible to determine if this was due to use of REBOA, extent of injuries or something else entirely. Interestingly, following these publications the study and use of REBOA for trauma seemed to fall off the map entirely….until recently.</span></div>
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<b style="font-size: 12pt;"><u><span style="font-family: "times new roman";">How do <i>I </i>put in a REBOA?</span></u></b></h4>
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<span style="font-family: "times new roman"; font-size: 12pt;">REBOA consists of non-rigid catheter with a balloon on the end inflated with a radiopaque substance such as saline. One example includes the </span><u style="font-family: "Times New Roman"; font-size: 12pt;">CODA balloon catheter</u><span style="font-family: "times new roman"; font-size: 12pt;"> pictured here: </span></div>
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://2.bp.blogspot.com/-_2jqeUrvNUk/WIofHZW440I/AAAAAAAAB8w/gMPHp0FykKc0xKqUX5XEUBItHFBfEMK2ACLcB/s1600/Screen%2BShot%2B2017-01-26%2Bat%2B11.05.51%2BAM.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="299" src="https://2.bp.blogspot.com/-_2jqeUrvNUk/WIofHZW440I/AAAAAAAAB8w/gMPHp0FykKc0xKqUX5XEUBItHFBfEMK2ACLcB/s640/Screen%2BShot%2B2017-01-26%2Bat%2B11.05.51%2BAM.png" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">CODA Balloon Catheter</td></tr>
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<span style="font-family: "times new roman"; font-size: 12pt; text-align: justify;">In order to place this catheter, a minimum 12 F introducer sheath (but more commonly a 14 or 16F sheath) is placed in the common femoral artery, followed by insertion of a long, stiff wire (eg. </span><a href="https://www.cookmedical.com/products/6bdfd1b8-480e-496c-89da-a4a760439bb7/" style="font-family: "Times New Roman"; font-size: 12pt; text-align: justify;"><span style="color: blue;">150 cm Amplatz</span></a><a href="https://www.cookmedical.com/products/6bdfd1b8-480e-496c-89da-a4a760439bb7/" style="font-family: "Times New Roman"; font-size: 12pt; text-align: justify;"><span style="color: blue;"> extra stiff wire</span></a><span style="font-family: "times new roman"; font-size: 12pt; text-align: justify;">) with the balloon catheter inserted over the wire to the desired location within the aorta, estimated by external landmarks and measurements.</span></div>
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<span style="font-family: "times new roman"; font-size: 12pt; text-align: justify;">The two main landing zones for REBOA placement are in zone I (intra-thoracic) for intra-abdominal bleeding, or zone III (intra-abdominal distal to renal arteries) for pelvic bleeding. </span></div>
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<tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-tS9lNA7M7Gg/WIofiN5xDZI/AAAAAAAAB80/jqvC6O2_B_Ak22pGtAjX_YC9FXEDGLVaACLcB/s1600/Picture1.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="640" src="https://1.bp.blogspot.com/-tS9lNA7M7Gg/WIofiN5xDZI/AAAAAAAAB80/jqvC6O2_B_Ak22pGtAjX_YC9FXEDGLVaACLcB/s640/Picture1.png" width="499" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">REBOA in Zone I</td></tr>
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<span style="font-family: "times new roman"; font-size: 12pt; text-align: justify;">Classically, placement was confirmed via x-ray/fluoroscopy, however more recent data shows either ultrasound confirmation or simply clinical assessment may be accurate.</span></div>
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<span style="font-family: "times new roman"; font-size: 12pt; text-align: justify;">Advances in equipment have seen intuitive and important improvements on the intra-aortic balloon design. One example of this (NB: I receive no funding/support from any company) is the </span><a href="http://prytimemedical.com/" style="font-family: "Times New Roman"; font-size: 12pt; text-align: justify;"><span style="color: blue;">Pryor Medical “Prytime”ER-REBOA catheter</span></a><span style="font-family: "times new roman"; font-size: 12pt; text-align: justify;"> (seen here; images from product brochure). </span></div>
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<tr><td style="text-align: center;"><img border="0" height="262" src="https://3.bp.blogspot.com/-utoQU_YQs-Y/WIogTJnp3OI/AAAAAAAAB88/LeeTzp4u2pwCH2F9AO4zkWg-e8IbJayuwCLcB/s640/Screen%2BShot%2B2017-01-26%2Bat%2B11.13.11%2BAM.png" style="margin-left: auto; margin-right: auto;" width="640" /></td></tr>
<tr><td class="tr-caption" style="text-align: center;">PRYOR MEDICAL Prytyme ER-REBOA Catheter</td></tr>
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Changes to the new design include, but are not limited to: <o:p></o:p></span></div>
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<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">Requires only a 7F introducer sheath eliminating the need for arterial repair on removal<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">A protective “p-tip” to avoid vascular injury on insertion<o:p></o:p></span></li>
<li class="MsoNormal" style="color: black; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">External landmarks for more accurate placement without additional equipment and a proximal arterial line port in order to accurately measure blood pressure following balloon inflation.</span></li>
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<span style="color: black; font-family: "times new roman"; mso-fareast-font-family: "Times New Roman";">One would expect these design improvements to not only improve provider placement and use of the balloon, but potentially improve patient outcomes, however <u>this has yet to be proven in the literature.</u></span><br />
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<b><u><span style="color: black; font-family: "times new roman";">Does REBOA work?</span></u></b></h4>
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<span style="color: black; font-family: "times new roman";">In theory it should however there are currently no RCTs to prove this. One must also consider the alternatives when deciding to implement new technologies despite the lack of research-based evidence. In this instance, that alternative would be a resuscitative thoracotomy (RT) followed by cross-clamping of the descending thoracic aorta. What we do have in the literature, is evidence that using this technique is <u>quite poor</u> for patient outcomes in the bleeding patient. Mattox et al (1979) showed a 0% survival rate in 51 patients with intra-abdominal bleeding who received a RT & aortic cross-clamping, regardless of a penetrating or blunt mechanism. More recently, multiple lines of evidence – mainly from Baltimore, Houston, LA and Denver in the US – have demonstrated (albeit non-prospectively) that REBOA may in fact improve outcomes in traumatic bleeding.</span></div>
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<span style="font-family: "times new roman"; font-size: 12pt;">Dr. Megan Brenner and colleagues (</span><a href="https://www.ncbi.nlm.nih.gov/pubmed/24089121" style="font-family: "Times New Roman"; font-size: 12pt;"><span style="color: blue;">Brenner et al., 2013</span></a><span style="font-family: "times new roman"; font-size: 12pt;">) published a case-series of 6 patients receiving REBOA in either Shock Trauma in Baltimore or Herman Memorial in Houston, in which 4 patients survived to discharge (see below; image from publication). </span></div>
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<span style="font-family: "times new roman"; font-size: 12pt; text-align: justify;">Subsequently, </span><a href="http://www.jem-journal.com/article/S0736-4679(15)01292-5/abstract" style="font-family: "Times New Roman"; font-size: 12pt; text-align: justify;"><span style="color: blue;">Moore et al</span></a><span style="font-family: "times new roman"; font-size: 12pt; text-align: justify;">. published a study based on trauma registry data of REBOA (n=24) vs RT (n=72) in which 62.5% of REBOA patients died vs 90.3% of RT (see table below from published manuscript)</span></div>
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<a href="https://2.bp.blogspot.com/-FrqUAErct3E/WKndZkW25oI/AAAAAAAAB-Q/rnPXc24xP_knMTuujLAibKabKZ_3zNGSACLcB/s1600/Screen%2BShot%2B2017-02-19%2Bat%2B12.58.59%2BPM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: "times" , "times new roman" , serif; font-size: small;"><img border="0" height="336" src="https://2.bp.blogspot.com/-FrqUAErct3E/WKndZkW25oI/AAAAAAAAB-Q/rnPXc24xP_knMTuujLAibKabKZ_3zNGSACLcB/s640/Screen%2BShot%2B2017-02-19%2Bat%2B12.58.59%2BPM.png" width="640" /></span></a></div>
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<span style="font-family: "times new roman"; font-size: 12pt;">Additionally, as presented by Dr. Gareth Grier at the scientific meeting of AGN in Graz, Austria in April 2016, the prehospital HEMS service in London has placed 5 prehospital REBOA catheters and an additional 4 on arrival to hospital, and have had no deaths due to bleeding, further demonstrating the efficacy of REBOA.</span><br />
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<b style="font-size: 12pt;"><u><span style="font-family: "times new roman";">Who gets REBOA?</span></u></b></h4>
As with many invasive procedures in critically ill patients (eg. ECMO), the million dollar question really is who gets REBOA. Trauma centres in both Denver (from manuscript; below) and Baltimore (below; widely available on internet) have proposed various algorithms in order to determine who gets REBOA in the trauma bay, and where REBOA should be placed (ie. Zone I vs Zone III)</div>
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<a href="https://2.bp.blogspot.com/-FfqDHN7jHzU/WKndzDDoLPI/AAAAAAAAB-c/osYUtSyecoAuUlhiOrNCDWzojgvPMvx0QCLcB/s1600/Screen%2BShot%2B2017-02-19%2Bat%2B12.59.17%2BPM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: "times" , "times new roman" , serif; font-size: small;"><img border="0" height="566" src="https://2.bp.blogspot.com/-FfqDHN7jHzU/WKndzDDoLPI/AAAAAAAAB-c/osYUtSyecoAuUlhiOrNCDWzojgvPMvx0QCLcB/s640/Screen%2BShot%2B2017-02-19%2Bat%2B12.59.17%2BPM.png" width="640" /></span></a></div>
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<b><u><span style="color: black; font-family: "times new roman";">It’s not all roses…</span></u></b></h4>
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<span style="font-family: "times new roman"; font-size: 12pt;">Of vital importance is to recognize that REBOA is </span><b style="font-family: "Times New Roman"; font-size: 12pt;">not a cure for anything! </b><span style="font-family: "times new roman"; font-size: 12pt;">Like ECMO, it is simply</span><b style="font-family: "Times New Roman"; font-size: 12pt;"> a bridge</b><span style="font-family: "times new roman"; font-size: 12pt;"> in an effort to keep patients alive in order to get them to definitive treatment for their primary problem – OR vs angio in the case of traumatic bleeding. </span></div>
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<span style="font-family: "times new roman"; font-size: 12pt;">Using a swine model, </span><a href="https://www.ncbi.nlm.nih.gov/pubmed/24836421" style="font-family: "Times New Roman"; font-size: 12pt;"><span style="color: blue;">Morrison and his colleagues (2014)</span></a><span style="font-family: "times new roman"; font-size: 12pt;"> demonstrated significant physiologic derangements that worsened with duration of REBOA balloon inflation at 30, 60 and 90 minutes, including; </span></div>
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<span style="font-size: 12pt;"> Additionally, use of REBOA has been reported to cause significant a</span><u style="font-family: "Times New Roman"; font-size: 12pt;">rterial injury and/or dissection, complete bowel ischemia and necrosis, distal limb necrotic ulcers and lower body ischemia. </u></div>
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<span style="font-family: "times new roman"; font-size: 12pt;">One Japanese study reported a </span><b style="font-family: "Times New Roman"; font-size: 12pt;">21.4%</b><span style="font-family: "times new roman"; font-size: 12pt;"> amputation rate (3/14 survivors out of 24 total cases; </span><a href="http://journals.lww.com/jtrauma/Abstract/2015/05000/Evaluation_of_the_safety_and_feasibility_of.1.aspx" style="font-family: "Times New Roman"; font-size: 12pt;"><span style="color: blue;">Saito et al., 2015</span></a><span style="font-family: "times new roman"; font-size: 12pt;">), demonstrating the potential for quite significant adverse events from REBOA. Contradicting this however, is data reported by Moore et al. at the Military Health Research Symposium in 2016, where they show </span><b style="font-family: "Times New Roman"; font-size: 12pt;">no amputations</b><span style="font-family: "times new roman"; font-size: 12pt;"> in 21 survivors out of 33 cases, however 62% required a primary common femoral artery repair, and additional 8 patients required a thrombectomy, dissection flap repair or angioplasty due to REBOA usage.</span></div>
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<span style="font-family: "times new roman"; font-size: 12pt;">Of additional consideration is the maintenance of competency in terms of insertion of a REBOA catheter, nursing care following insertion and most importantly a system in place to get patients to definitive care in a timely manner following REBOA insertion.</span></div>
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<b style="font-size: 12pt;"><u><span style="font-family: "times new roman";">The future of REBOA</span></u></b></h4>
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<span style="font-family: "times new roman"; font-size: 12pt;">Although the utility of REBOA in traumatic bleeding is promising, more research is indeed required to demonstrate the efficacy and safety of this modality. The American Association for the Surgery of Trauma (AAST) has created a registry in order to collect as much data from as many different sources as possible once a REBOA catheter is utilized for traumatic bleeding (</span><a href="https://www.ncbi.nlm.nih.gov/labs/articles/27050883/" style="font-family: "Times New Roman"; font-size: 12pt;"><span style="color: blue;">DuBose et al., 2016</span></a><span style="font-family: "times new roman"; font-size: 12pt;">). </span></div>
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<span style="font-family: "times new roman"; font-size: 12pt;">As well, promising research is demonstrating the use of partial (p-REBOA) and intermittent (i-REBOA) as modalities to extend the safety profile of aortic occlusion if prolonged resuscitation or transfer is required (</span><a href="http://tsaco.bmj.com/content/tsaco/1/1/e000028.full.pdf" style="font-family: "Times New Roman"; font-size: 12pt;"><span style="color: blue;">Davidson et al. 2016</span></a><span style="font-family: "times new roman"; font-size: 12pt;">; </span><a href="http://mobile.journals.lww.com/jtrauma/Citation/2016/11002/Partial_resuscitative_balloon_occlusion_of_the.14.aspx" style="font-family: "Times New Roman"; font-size: 12pt;"><span style="color: blue;">Johnson, Neff, Williams, &DuBose, 2016</span></a><span style="font-family: "times new roman"; font-size: 12pt;">; </span><a href="https://www.ncbi.nlm.nih.gov/pubmed/27070441" style="font-family: "Times New Roman"; font-size: 12pt;"><span style="color: blue;">Williams et al., 2016</span></a><span style="font-family: "times new roman"; font-size: 12pt;">).</span></div>
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<span style="font-family: "times new roman"; font-size: 12pt;">Case reports have also begun popping up regarding the use in non-traumatic bleeding requiring urgent resuscitation, including; post-partum hemorrhage (</span><a href="https://www.ncbi.nlm.nih.gov/pubmed/24300388" style="font-family: "Times New Roman"; font-size: 12pt;"><span style="color: blue;">Yamashita et al., 2016</span></a><span style="font-family: "times new roman"; font-size: 12pt;">), non-variceal upper GI bleeding (</span><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4875689/" style="font-family: "Times New Roman"; font-size: 12pt;"><span style="color: blue;">Sano et al., 2016</span></a><span style="font-family: "times new roman"; font-size: 12pt;">), ectopic pregnancy rupture (</span><a href="http://www.ajemjournal.com/article/S0735-6757(16)00106-6/abstract" style="font-family: "Times New Roman"; font-size: 12pt;"><span style="color: blue;">Okumura, Tsurukiri, Oomura, Tanaka, & Oomura,2016</span></a><span style="font-family: "times new roman"; font-size: 12pt;">) among others.</span></div>
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<b style="font-size: 12pt;"><u><span style="font-family: "times new roman";">Summing it all up</span></u></b></div>
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<span style="font-family: "times new roman"; font-size: 12pt;">REBOA has proven itself to likely be a true player in the management of NCTH in trauma with the potential for use in other pathologies requiring urgent hemorrhage control. It has shown itself to seemingly be at least as effective as resuscitative thoracotomy (perhaps better?) and certainly creates much less of a secondary iatrogenic injury. Burgeoning advances in catheter technology, increasing utilization in major international trauma centres and considerations of altering balloon inflation characteristics all lend themselves to an exciting time in the treatment of one of the most lethal problems we face as physicians, with the real potential to vastly improve patient outcomes.</span></div>
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<span style="background-color: white; color: #333333; font-family: "times" , "times new roman" , serif; text-align: center;"><span style="font-size: small;">Dr. Noam Katz is a 5th year Emergency Medicine Resident in the FRCPC program. He has a special interest in acute care medicine and resuscitation.</span></span></div>
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<span style="background-color: white; color: #333333; font-family: times, "times new roman", serif; font-size: xx-small; text-align: center;">Edited by Dr. Robert Suttie, PGY2 Emergency Medicine</span></div>
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<!--[if supportFields]><span
style='mso-element:field-begin;mso-field-lock:yes'></span>ADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY <span style='mso-element:field-separator'></span><![endif]--><span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">1. Brenner, M. L., Moore, L. J., DuBose, J. J., Tyson, G. H., McNutt, M. K., Albarado, R. P., Rasmussen, T. E. (2013). A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. <i>The Journal of Trauma and Acute Care Surgery</i>, <i>75</i>(3), 506–11. http://doi.org/10.1097/TA.0b013e31829e5416</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">2. Davidson, A. J., Russo, R. M., DuBose, J. J., Roberts, J., Jurkovich, G. J., & Galante, J. M. (2016). Potential benefit of early operative utilization of low profile, partial resuscitative endovascular balloon occlusion of the aorta (P-REBOA) in major traumatic hemorrhage. <i>Trauma Surgery & Acute Care Open</i>, <i>1</i>(1), e000028. http://doi.org/10.1136/tsaco-2016-000028</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">3. DuBose, J. J., Scalea, T. M., Brenner, M., Skiada, D., Inaba, K., Cannon, J., … Poulin, N. (2016). The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry. <i>Journal of Trauma and Acute Care Surgery</i>, <i>81</i>(3), 409–419. http://doi.org/10.1097/TA.0000000000001079</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">4. GUPTA, B. K., KHANEJA, S. C., FLORES, L., EASTLICK, L., LONGMORE, W., & SHAFTAN, G. W. (1989). The Role of Intra-aortic Balloon Occlusion in Penetrating Abdominal Trauma. <i>The Journal of Trauma: Injury, Infection, and Critical Care</i>. http://doi.org/10.1097/00005373-198906000-00026</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">5. Hughes, C. (1954). Use of an Intra-Aortic Balloon Catheter Tamponade for Controlling Intra-Abdominal Hemorrhage in Man. <i>Surgery</i>, <i>36</i>(1), 65–8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/13178946</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">6. Johnson, M. A., Neff, L. P., Williams, T. K., & DuBose, J. J. (2016). Partial Resuscitative Balloon Occlusion of the AORTA (P-REBOA). <i>Journal of Trauma and Acute Care Surgery</i>, 1. http://doi.org/10.1097/TA.0000000000001146</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">7. Kauvar, D. S., Lefering, R., & Wade, C. E. (2006). Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. <i>The Journal of Trauma</i>, <i>60</i>(6 Suppl), S3-11. http://doi.org/10.1097/01.ta.0000199961.02677.19</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">8. Low, R. B., Longmore, W., Rubinstein, R., Flores, L., & Wolvek, S. (1986). Preliminary report on the use of the percluder® occluding aortic balloon in human beings. <i>Annals of Emergency Medicine</i>, <i>15</i>(12), 1466–1469. http://doi.org/10.1016/S0196-0644(86)80945-3</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">9. Moore, L. J., Brenner, M., Kozar, R. A., Pasley, J., Wade, C. E., Baraniuk, M. S., … Houston, T. (2014). Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. <i>J Trauma Acute Care Surg</i>, <i>79</i>(4), 523–532. http://doi.org/10.1097/TA.0000000000000809</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">10. Morrison, J. J., Ross, J. D., Markov, N. P., Scott, D. J., Spencer, J. R., & Rasmussen, T. E. (2014). The inflammatory sequelae of aortic balloon occlusion in hemorrhagic shock. <i>Journal of Surgical Research</i>, <i>191</i>(2), 423–431. http://doi.org/10.1016/j.jss.2014.04.012</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">11. Okumura, E., Tsurukiri, J., Oomura, T., Tanaka, Y., & Oomura, R. (2016). Partial resuscitative endovascular balloon occlusion of the aorta as a hemorrhagic shock adjunct for ectopic pregnancy. <i>The American Journal of Emergency Medicine</i>, <i>34</i>(9), 1917.e1-1917.e2. http://doi.org/10.1016/j.ajem.2016.02.026</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">12. Saito, N., Matsumoto, H., Yagi, T., Hara, Y., Hayashida, K., Motomura, T., … Wagatsuma, Y. (2015). Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta. <i>J Trauma Acute Care Surg</i>, <i>78</i>(5), 897–904. http://doi.org/10.1097/TA.0000000000000614</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">13. Sano, H., Tsurukiri, J., Hoshiai, A., Oomura, T., Tanaka, Y., & Ohta, S. (2016). Resuscitative endovascular balloon occlusion of the aorta for uncontrollable nonvariceal upper gastrointestinal bleeding. <i>World Journal of Emergency Surgery</i>. http://doi.org/10.1186/s13017-016-0076-3</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">14. Sauaia, A., Moore, F. A., Moore, E. E., Moser, K. S., Brennan, R., Read, R. A., & Pons, P. T. (1995). Epidemiology of Trauma Deaths. <i>The Journal of Trauma: Injury, Infection, and Critical Care</i>, <i>38</i>(2), 185–193. http://doi.org/10.1097/00005373-199502000-00006</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: xx-small;">15. Williams, T. K., Neff, L. P., Johnson, M. A., Ferencz, S.-A., Davidson, A. J., Russo, R. M., & Rasmussen, T. E. (2016). Extending resuscitative endovascular balloon occlusion of the aorta. <i>Journal of Trauma and Acute Care Surgery</i>, <i>81</i>(2), 294–301. http://doi.org/10.1097/TA.0000000000001075</span></div>
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<span style="font-family: "times" , "times new roman" , serif;"><span style="font-size: xx-small;">16. Yamashita, Y., Kawashima, A., Hasegawa, J., Oba, T., Nakamura, M., Yamashita, T., … Sekizawa, A. (2016). Intra-aortic balloon occlusion without fluoroscopy for life-threating post-partum hemorrhage. <i>Case Reports in Perinatal Medicine</i>, <i>5</i>(1), 19–22. http://doi.org/10.1515/crpm-2015-0050</span><span style="font-size: small;"><o:p></o:p></span></span></div>
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</style>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-45035242481868826822017-02-21T09:00:00.000-05:002017-02-27T21:49:09.721-05:00Focus on POCUS: Pleuritic Chest Pain with Tachycardia - Pericarditis or PE?<h4>
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Case Description</span></h4>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">A young, previously healthy male in his 30s
presents to the ED from his family physicians office with chest pain and an
abnormal ECG. He has a 3-4 day history of non-radiating upper back pain and
sensation of chest tightness that is pleuritic in nature and worse when supine.
In addition there is a history of fever, chills, myalgias and night sweats. He
has no recent travel history. He denies any SOB, cough, orthopnea, PND or
syncope. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">There is no IV drug use, immunocompromise
or diabetes. He has no previous cardiac history other than a possible history
of pericarditis a year ago. There is no personal history of PE/DVT.<o:p></o:p></span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">On initial presentation the patient was
febrile at 38.1C and tachycardic in the 120s. His blood pressure was normal at
114/79. Respiratory rate and oxygen saturation were normal on room air. <o:p></o:p></span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">His cardiovascular exam was normal, other
than an S3. There was no pericardial rub. Respiratory exam was unremarkable. <o:p></o:p></span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">Laboratory investigations were
unremarkable, including an undetectable troponin level.<o:p></o:p></span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">His ECG was below:<o:p></o:p></span></span><br />
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<a href="https://3.bp.blogspot.com/-3LiSxOJ-EK0/WKqeeoVsbCI/AAAAAAAABxM/Vo8I3m02jfotrxkHAVEa-PvrEPbq1s1oACLcB/s1600/Screen%2BShot%2B2017-02-20%2Bat%2B2.44.11%2BAM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="414" src="https://3.bp.blogspot.com/-3LiSxOJ-EK0/WKqeeoVsbCI/AAAAAAAABxM/Vo8I3m02jfotrxkHAVEa-PvrEPbq1s1oACLcB/s640/Screen%2BShot%2B2017-02-20%2Bat%2B2.44.11%2BAM.png" width="640" /></a></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">What is your differential diagnosis?</span></div>
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<a href="https://2.bp.blogspot.com/-X6taZgWQSgk/WKCQ7L5jTqI/AAAAAAAABuw/V23GlwOokLEllSt1JZhAI9xKYljYYbJWwCLcB/s1600/download%2B%25285%2529.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: "times" , "times new roman" , serif; font-size: large;"><img border="0" height="270" src="https://2.bp.blogspot.com/-X6taZgWQSgk/WKCQ7L5jTqI/AAAAAAAABuw/V23GlwOokLEllSt1JZhAI9xKYljYYbJWwCLcB/s400/download%2B%25285%2529.jpeg" width="400" /></span></a></div>
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<br /></div>
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<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">The top two differential diagnoses at this
point were pericarditis vs. pulmonary embolism (which can be a noninfectious
cause of fever).<o:p></o:p></span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;"><span style="font-size: large;">What is your next step? CXR? CT-PE? POCUS?</span></span></div>
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<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">In this case the next step was POCUS. Take a look at the clips below. </span></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Subxiphoid</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span><iframe allowfullscreen="" class="YOUTUBE-iframe-video" data-thumbnail-src="https://i.ytimg.com/vi/--aOYeoBjNk/0.jpg" frameborder="0" height="266" src="https://www.youtube.com/embed/--aOYeoBjNk?feature=player_embedded" width="320"></iframe></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Parasternal Long</span></div>
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<iframe allowfullscreen="" class="YOUTUBE-iframe-video" data-thumbnail-src="https://i.ytimg.com/vi/JSerdSochJ4/0.jpg" frameborder="0" height="266" src="https://www.youtube.com/embed/JSerdSochJ4?feature=player_embedded" width="320"></iframe></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Apical 4-Chamber</span></div>
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<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Discussion</span></h4>
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<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">A clinically significant pericardial
effusion was found which is more consistent with a diagnosis of pericarditis.
This finding prompted the ED physician to contact the cardiology team for an
admission to observe the effusion.</span></span></div>
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<br /></div>
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<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;">A comprehensive echocardiogram completed next day
showed a moderate size pericardial effusion with RA and LA collapse and a
non-collapsable IVC dilation that suggested a hemodynamic effect. The LV
systolic function was interpreted as borderline reduced.<o:p></o:p></span></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Conclusion</span></h4>
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">POCUS helped to focus in on the diagnosis
and avoided the significant radiation dose of a CT-PE for this patient! It also
helped risk stratify as the effusion (along with the persistent
tachycardia) prompted a call to cardiology and subsequent admission.</span><br />
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<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></span></div>
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<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></span></div>
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<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;"><i><u>Expert Comment</u> - Dr. Michael Woo</i></span></span></div>
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<span lang="EN-US"><span style="font-family: "times" , "times new roman" , serif; font-size: large;"><i><span style="background-color: white; color: #212121;">Be cautious when </span><span class="gmail_msg" style="background-color: white;">commenting on the size of an effusion when only looking at the subxiphoid view. Yes, subxiphoid is the best to identify effusion, however the operator can make it look much larger than it seems and also demonstrate some sonographic RV collapse as well, which can be very misleading. S</span><span class="gmail_msg" style="background-color: white;">ubxiphoid can be very helpful in identify presence or absence of PCE but should be careful when talking about the size of effusion unless in conjunction with other echo views (PSL, A4C, PSS). </span></i></span></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">*Details of the case have been anonymized and altered in order to protect patient privacy*</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Case by: </span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Dr. Julia Traer PGY-3 - University of Ottawa</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Expert Reviewers:</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Dr. Paul Pageau - Ultrasonography Program Director</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Dr. Michael Woo - EMUS Fellowship Director</span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">For more information on our POCUS program please see <a href="http://clinsonoottawa.blogspot.ca/">Clinical Sonography Ottawa</a></span></div>
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</style>Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-65479864961316702252017-02-13T09:00:00.000-05:002017-02-13T09:32:48.954-05:00The Top 10 Most Important Articles of 2016 (and some from 2015)<div class="page" title="Page 1">
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<h4>
This is a summary of a talk given by Drs. Krishan Yadav and Maggie Kisilewicz at the <a href="http://www.emottawa.ca/eng/60-nccem.html">National Capital Conference in Emergency Medicine</a>. Below are brief summaries and a bottom line, but of course you'll have to read the literature yourself to make your own decisions!</h4>
<h4>
</h4>
<h4>
1) Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage ATACH-2 </h4>
Qureshi et al. N Engl J Med 2016; 375: 1033 – 1043.<br />
<a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1603460"> DOI: 10.1056/NEJMoa1603460.</a> <br />
<br />
• RCT to assess if aggressive SBP reduction within 4.5 hours of spontaneous intracranial hemorrhage results in decreased death or disability at 3 months. <br />
• Main Finding: No difference in death or disability at 3 months for Intensive BP (110 – 139 mmHg) vs. Standard BP (140 – 179 mmHg) group. <br />
o Caution: this trial really compared SBP targets of 129 mmHg vs. 141 mmHg (see Figure 1)</div>
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<i><br /> • Bottom Line: BP reduction to 140 mmHg is safe. Aim for a SBP target of 160 mmHg in </i></div>
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<i>spontaneous ICH – if the patient continues to deteriorate, revise target to 140 mmHg.</i><br />
<h4>
<br />2) <a href="http://emottawa.blogspot.ca/2015/12/an-age-adjusted-d-dimer-threshold-for.html?q=d-dimer">An Age-Adjusted D-dimer Threshold of Emergency Department patients with Suspected Pulmonary Embolus: Accuracy and Clinical Implications. </a></h4>
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Sharp et al. Ann Emerg Med. 2016 Feb;67(2):249-57. </div>
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<a href="http://www.annemergmed.com/article/S0196-0644(15)00616-2/abstract">DOI: 10.1016/j.annemergmed.2015.07.026</a><br />
<br />
• Retrospective chart review to assess the sensitivity and specificity of using an age-adjusted D-dimer threshold to aid in diagnosing PE in patients 50 years or older.<br />
• Main Finding: In older adults, the age-adjusted D-dimer threshold is more accurate. It is more specific (64% versus 54%) but less sensitive (93% versus 98%) than the standard threshold of 500 ng/dL resulting in less low value imaging.</div>
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<br />
<i>• Bottom Line: Start using age adjusted D-dimer to evaluate older adults suspected of PE.</i><br />
<br />
<h4>
3) Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia. </h4>
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Driver et al. Ann Emerg Med. 2016 December; 68(6): 697-705.<br />
<a href="http://www.annemergmed.com/article/S0196-0644(16)30162-7/abstract">DOI: http://dx.doi.org/10.1016/j.annemergmed.2016.04.057.</a></div>
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<br />
• Retrospective cohort study to determine if ED patients with moderate to severe hyperglycemia suffer adverse outcomes at 7 days (return to ED, admission, DKA, or HHS)<br />
• Main Finding: could not find any association between discharge glucose level or treating hyperglycemia (IVF +/- insulin) and 7-day adverse events<br />
o Caution: consider correcting hyperglycemia in the patient being discharged with an infection<br />
<br />
<i>• Bottom Line: in uncomplicated hyperglycemia (no DKA/HHS or infection), do not administer IVF or insulin to lower blood glucose to an arbitrary ‘safe’ level. Instead, focus on ensuring appropriate follow-up for long-term glycemic control.</i><br />
<br />
<h4>
4) Air Versus Oxygen in ST-Segment–Elevation Myocardial Infarction. </h4>
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Stub D. et al. Circulation. 2015 Jun16;131(24):2143-50. </div>
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<a href="http://circ.ahajournals.org/content/early/2015/05/22/CIRCULATIONAHA.114.014494">DOI: 0.1161/CIRCULATIONAHA.114.014494.</a><br />
<br />
• Multicenter RCT to determine if administering air or supplemental oxygen to normoxic STEMI patients undergoing PCI affected infarct size as assessed by cardiac enzyme rise and by cardiac MRI 6 months post infarct.<br />
• Main Finding: Supplemental oxygen resulted in statistically higher peak creatinine kinase but not troponin-I. After 6 months, patients receiving supplemental oxygen had larger areas of infarct on cMRI. There was statistical increase in the rates of re-infarction and arrhythmias in patients receiving oxygen, however the study was not powered for these clinical end-points.<br />
<i><br /> • Bottom Line: Supplemental oxygen administered to normoxic STEMI patients has not shown to be beneficial and may, in fact, increase myocardial injury</i><br />
<br />
<h4>
5) Randomized Clinical Trial of Observation versus Antibiotic Treatment for a First Episode of CT Proven Uncomplicated Acute Diverticulitis (DIABOLO). </h4>
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Daniels et al. Br J Surg 2016; 104: 52 – 61.<br />
<a href="http://onlinelibrary.wiley.com/doi/10.1002/bjs.10309/abstract">DOI: 10.1002/bjs.10309.</a><br />
<br />
• Multicenter RCT to determine if antibiotics versus observation leads to decreased time to recovery during 6 months of follow-up.<br />
• Main Finding: antibiotics did not improve time to recovery for first-episode uncomplicated diverticulitis. In addition, there was no benefit for multiple secondary outcomes (readmission rates, development of complicated diverticulitis, need for surgery)<br />
o Caution: 8% of trial participants had an abscess < 5 cm; these patients should still get antibiotics<br />
<i><br />• Bottom Line: Use shared decision making with carefully selected patients (can get GP follow-up, tolerating PO intake, no fever) regarding outpatient antibiotics for uncomplicated diverticulitis.</i><br />
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<h4>
6) Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. </h4>
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Patel et al. JAMA Intern Med. 2016 Jul 1;176(7):981-8. </div>
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<a href="http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2527389">DOI:10.1001/jamainternmed.2016.1509.</a><br />
<br />
• Retrospective cohort looking at whether hospital referral is safer than routine outpatient management for ambulatory patients with asymptomatic hypertension (>180/100).<br />
• Main Finding: In this study of 58 535 patients, emergency department visits for hypertensive urgency were associated with higher rates of hospital admission but not major cardiac events when compared with patients who were sent home. The rate of major adverse cardiac events was less than 1% in all patients. Two-thirds of patients still had uncontrolled hypertension at 6 months.<br />
<br />
<i>• Bottom Line: ED visits for hypertensive urgency are associated with more resource utilization but not better CV outcomes. </i><br />
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<h4>
7) <a href="http://emottawa.blogspot.ca/2016/10/immediate-total-body-ct-scanning-versus.html?q=d-dimer">Immediate Total-Body CT Scanning Versus Conventional Imaging and Selective CT Scanning in Patients with Severe Trauma (REACT-2): A Randomized Controlled Trial. </a></h4>
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Sierink et al. Lancet 2016; 388(10045): 673 – 683. </div>
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<a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30932-1/abstract">DOI: 10.1016/S0140-6736(16)30932-1</a>. <br />
<br />
• Published data to date suggests pan-can is associated with improved survival – but all studies have been retrospective. This is the first RCT to determine if pan-scan for trauma is associated with decreased in-hospital mortality. <br />
• Main Finding: No difference between pan-scan versus selective-scan groups for in-hospital mortality. <br />
o Caution: 46% of patients in selective-scan group ended up with the equivalent of a pan-scan during hospital stay <br />
<br />
<i>• Bottom Line: There is still no consensus on which trauma patients actually benefit from a pan-scan.</i><br />
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<h4>
8) Immediate Discharge and Home Treatment With Rivaroxaban of Low Risk Venous Thromboembolism Diagnosed in Two U.S. Emergency Departments: A One-year Preplanned Analysis. </h4>
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Beam et al. Acad Emerg Med. 2015 Jul;22(7):788-95. </div>
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<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5034796/">DOI: 10.1111/acem.12711. </a><br />
<br />
• In this prospective observational study, 106 low-risk PE and DVT patients were started on rivaroxaban and sent home directly from the ED. Outpatient clinic follow up occurred within 36h of discharge. Outcomes included VTE recurrence, bleeding complications and medication compliance over a 6 month period. Patient and physician satisfaction was not measured. <br />
• Main Findings: No patients developed recurrent or new VTE while on treatment and there were no major bleeding events. Overall patient compliance was 92%. <br />
<br />
<i>• Bottom Line: Selected low-risk patients diagnosed with VTE can be safely started on DOAC therapy and discharged from the ED to close outpatient follow up. </i><br />
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<h4>
9) <a href="http://emottawa.blogspot.ca/2015/05/a-randomized-trial-of-intraarterial.html?q=d-dimer">A randomized trial of intraarterial treatment for acute ischemic stroke. </a></h4>
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Berhamer et al. N Engl J Med. 2015 Jan 1;372(1):11-20. </div>
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<a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1411587#t=article">DOI: 10.1056/NEJMoa1411587. </a><br />
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• In this pragmatic, multicenter RCT, 500 patients with disabling ischemic stroke localized to the anterior circulation artery were randomized to intra-arterial treatment plus usual care or usual care alone. <br />
• Main Finding: Absolute difference of 13.5 percentage points in good neurologic outcome (modified Rankin Score 0 – 2) favouring the intervention group. This corresponds to an NNT = 8. No increase in mortality or symptomatic ICH was seen. <br />
<br />
<i>• Bottom Line: Intra-arterial therapy within 6 hours of symptom onset improved functional independence at 90days.</i><br />
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<h4>
10) <a href="http://emottawa.blogspot.ca/2016/12/prevalence-of-pulmonary-embolism-among.html?q=d-dimer">Prevalence of Pulmonary Embolism Among Patients Hospitalized for Syncope (PESIT). </a></h4>
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Prandoni et al. N Engl J Med 2016; 375: 1542 – 1531.<br />
<a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1602172#t=article">DOI: 10.1056/NEJMoa1602172.</a><br />
<br />
• Cross-sectional multicenter study to determine the prevalence of pulmonary embolism (PE) among patients hospitalized for syncope.<br />
• Main Finding: overall prevalence for PE = 17.3% (“approximately 1 in 6 patients hospitalized for syncope had a PE”)<br />
o Caution: cause and effect not established. This does not mean 1 in 6 patients had syncope because of a PE.<br />
<br />
<i>• Bottom Line: Do not change current clinical practice. Patients with syncope should be worked up for PE when it is felt to be clinically warranted.</i><br />
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</style>Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-11367624146419929642017-02-06T14:24:00.000-05:002017-02-06T14:24:07.922-05:00Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial<h3 style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<a href="https://4.bp.blogspot.com/-qyJVG-n8nQg/WJDrUQ6lIWI/AAAAAAAABtw/yMnpWS5vMqcy7uTNY3APOawbihp-02dQQCLcB/s1600/download%2B%25284%2529.jpeg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://4.bp.blogspot.com/-qyJVG-n8nQg/WJDrUQ6lIWI/AAAAAAAABtw/yMnpWS5vMqcy7uTNY3APOawbihp-02dQQCLcB/s1600/download%2B%25284%2529.jpeg" /></a><span lang="EN-US">Journal Club Summary</span></h3>
<div>
<span lang="EN-US"><br /></span></div>
<div class="Title8" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<b><span lang="EN-US" style="color: red;">Methodology Score: 2.5/5 </span></b></div>
<div class="Title8" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<b><span lang="EN-US" style="color: red;">Usefulness Score: 3/5</span></b></div>
<div class="desc" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span lang="EN-US" style="color: black; mso-bidi-font-weight: bold;"><br /></span></div>
<div class="desc" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span lang="EN-US" style="color: black; mso-bidi-font-weight: bold;">Motov S</span><span lang="EN-US" style="color: black;">, et al. <o:p></o:p></span></div>
<div class="details" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span class="jrnl"><span lang="EN-US" style="color: black;">Ann Emerg Med</span></span><span lang="EN-US" style="color: black;">. 2016 Dec 14. pii: S0196-0644(16)31244-6.<span class="apple-converted-space"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<a href="https://www.ncbi.nlm.nih.gov/pubmed/27993418">Abstract Link</a></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">This randomized, double-blind study of the
analgesic efficacy of ketorolac at three different doses (10mg, 15mg, 30mg) in
240 ED patients with acute pain, demonstrated no difference in verbal numeric
rating scores of pain at 30 minutes. The results suggest an analgesic
ceiling of ketorolac dosing at 10mg IV but significant methodological flaws
preclude definitive conclusions (heterogeneous patient population, use of a
continuous rather than binary outcome, not stratifying by pain severity or
condition). </span></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span lang="EN-CA" style="mso-ansi-language: EN-CA;">By: </span><span lang="EN-US" style="mso-bidi-font-style: italic;">Dr. Peter
Reardon <span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span></span></i></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-style: italic;"><o:p></o:p></span></b></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<br /></div>
<h3 style="mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-CA">Epi lesson</span></h3>
<div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<b><u><span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-fareast-language: EN-CA;"><a href="http://emottawa.blogspot.ca/2015/06/epi-lessons-part-2-therapy-articles.html">Use of Continuous Data as Primary Outcome</a></span></u></b><i><span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-bidi-font-weight: bold; mso-fareast-language: EN-CA;"><br />
</span></i><span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-bidi-font-weight: bold; mso-fareast-language: EN-CA;">Beware of studies that compare the
effectiveness of interventions by using continuous data outcomes, such as pain
scales (1-100), oxygen saturation values, and minutes to pain relief. These
kinds of data can produce statistically significant differences between groups
with relatively small sample sizes but often give you little information about
clinical importance. Far better and almost always the norm are outcome measures
given as proportions or percentages, such as % of patients who achieve: 20
points improvement in pain, an oxygen saturation of 90%, pain relief in less
than 2 hours, or<i> </i><span style="mso-bidi-font-style: italic;">survival.</span></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-bidi-font-weight: bold; mso-fareast-language: EN-CA;"><span style="mso-bidi-font-style: italic;"><b><i>By: Dr. Ian Stiell</i></b></span></span></div>
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</style>Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-60051709526379151482017-01-30T11:17:00.001-05:002017-01-30T11:17:40.756-05:00Restrictive versus liberal blood transfusion for acute upper gastrointestinal bleeding (TRIGGER): a pragmatic, open-label, cluster randomized feasibility trial <h3 style="background: white;">
<a href="https://1.bp.blogspot.com/-XuIPso-9ae4/WI9mW3zsaLI/AAAAAAAABtY/47dI7z-fTqMNOy85wXw_HR7iWMj-HiEXgCLcB/s1600/Deep_gastric_ulcer.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="309" src="https://1.bp.blogspot.com/-XuIPso-9ae4/WI9mW3zsaLI/AAAAAAAABtY/47dI7z-fTqMNOy85wXw_HR7iWMj-HiEXgCLcB/s320/Deep_gastric_ulcer.png" width="320" /></a>Journal Club Summary</h3>
<div class="MsoNormal" style="background: white;">
<span lang="EN-US" style="mso-bidi-font-style: italic;"><b><span lang="EN-US" style="color: red;">Methodology Score: 3/5 </span></b></span></div>
<div class="MsoNormal" style="background: white;">
<span lang="EN-US" style="mso-bidi-font-style: italic;"><b><span lang="EN-US" style="color: red;">Usefulness Score: 2/5</span></b></span></div>
<div class="MsoNormal" style="background: white;">
<span lang="EN-US" style="mso-bidi-font-style: italic;"><br /></span></div>
<div class="MsoNormal" style="background: white;">
<span lang="EN-US" style="mso-bidi-font-style: italic;">Jairath V, et al. <o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="background: white; color: black;">Lancet.<span class="apple-converted-space"> </span>2015 Jul 11;386(9989):137-44<o:p></o:p></span></div>
<div class="MsoNormal" style="background: white;">
<a href="http://www.sciencedirect.com/science/article/pii/S0140673614619991">Abstract Link</a></div>
<div class="MsoNormal" style="background: white;">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US" style="color: black;">This open label,
cluster randomized feasibility trial based in six university hospitals in the
United Kingdom including 936 patients demonstrated no difference in measured
clinical outcomes between the liberal and restrictive blood transfusion groups
for acute upper gastrointestinal bleeds. Although this was a feasibility trial
and many limitations of the study were identified (balance between clusters, adherence
to protocol, contamination, loss to follow-up), it was felt even a large
non-inferiority trial is unlikely to find a difference in patient outcomes with
the two transfusion regimens. <o:p></o:p></span></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span lang="EN-US">By: </span></i></b><b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span lang="EN-CA" style="mso-ansi-language: EN-CA;">Dr. </span><span lang="EN-US" style="mso-bidi-font-style: italic;">Shannon McCarter</span></i></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-CA" style="mso-ansi-language: EN-CA;"><o:p></o:p></span></b></div>
<div class="MsoPlainText">
<br /></div>
<h3 style="mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-CA">Epi lesson</span></h3>
<div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<b><u><span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-fareast-language: EN-CA;"><a href="http://emottawa.blogspot.ca/2015/06/epi-lessons-part-2-therapy-articles.html">Cluster
Randomized Controlled Trials</a></span></u></b><span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-bidi-font-weight: bold; mso-fareast-language: EN-CA;"><a href="http://emottawa.blogspot.ca/2015/06/epi-lessons-part-2-therapy-articles.html"> </a> <br />
A cluster randomized trial is a trial in which individuals are randomized in
groups (i.e. the group is randomized, not the individual); for example, all
patients treated By: a particular EMS service or at a particular hospital.
Reasons for performing cluster randomized trials vary. Sometimes the
intervention can only be administered to the group, for example an addition to
the water supply; sometimes the motivation is to avoid contamination amongst
health care providers; sometimes the design is simply more convenient or
economical. Such trials are often appropriate when the intervention is a
psychomotor task (e.g. CPR) but not when the intervention is a drug. Specific
sample size and data analytic approaches are required. </span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<b><i><span lang="EN-CA">By: </span></i></b><b><i><span lang="EN-US">Dr. Ian Stiell </span></i></b></div>
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</style>Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0tag:blogger.com,1999:blog-1264812964585869968.post-34802183692423884912017-01-23T17:15:00.000-05:002017-01-23T17:15:02.836-05:00Bedside Diagnosis of the 'Red Eye': A Systematic Review<h3 style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<a href="https://2.bp.blogspot.com/-ljEkzIFnQok/WIaALVY5ojI/AAAAAAAABs4/fmpm-4xq41YyfnQcOrTCVBPQiS4StAGrwCLcB/s1600/Vernal.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="225" src="https://2.bp.blogspot.com/-ljEkzIFnQok/WIaALVY5ojI/AAAAAAAABs4/fmpm-4xq41YyfnQcOrTCVBPQiS4StAGrwCLcB/s320/Vernal.jpg" width="320" /></a><span style="font-family: Arial, Helvetica, sans-serif; font-size: small;">Summary</span></h3>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="Title8" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<b><span lang="EN-US" style="color: red;"><span style="font-family: Arial, Helvetica, sans-serif; font-size: small;">Methodology Score: 2/5 </span></span></b></div>
<div class="Title8" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<b><span lang="EN-US" style="color: red;"><span style="font-family: Arial, Helvetica, sans-serif; font-size: small;">Usefulness Score: 2/5</span></span></b></div>
<div class="Title8" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><br /></span></div>
<div class="desc" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span lang="EN-US" style="color: black; mso-bidi-font-weight: bold;">Narayana S</span><span lang="EN-US" style="color: black;">, et al. <o:p></o:p></span></span></div>
<div class="details" style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="jrnl"><span lang="EN-US" style="color: black;">Am J Med</span></span><span lang="EN-US" style="color: black;">. 2015 Nov;128(11):1220-1224.e1.<o:p></o:p></span></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><a href="http://www.sciencedirect.com/science/article/pii/S000293431500577X">Abstract Link</a></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span lang="EN-US">This review study looked at the diagnostic
accuracy of physical exam findings for serious causes of red eye and bacterial
conjunctivitis; for red eye photophobia (direct, indirect and near synkinesis)
and anisocoria had the highest LR, while for bacterial conjunctivitis complete
redness of conjunctival membrane, observed purulent discharge and bilateral
morning matting of the eyes had the highest LRs. Overall the group felt
this review paper was not helpful as it was not thorough enough in its
literature search and many of the exam findings had insignificant LRs.</span><span lang="EN-US"> </span></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span lang="EN-US">By: <span style="mso-bidi-font-style: italic;">Dr. Julia Traer </span></span></i></b><span lang="EN-US"><o:p></o:p></span></span></div>
<div class="MsoNormal">
<br /></div>
<h3 style="mso-layout-grid-align: none; text-autospace: none;">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><b><span lang="EN-CA">Epi lesson</span></b></span></h3>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><a href="http://emottawa.blogspot.ca/2015/06/epi-lessons-part-1-diagnosis-articles.html">Likelihood Ratios</a></span></div>
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<span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-bidi-font-weight: bold; mso-fareast-font-family: "MS 明朝"; mso-fareast-language: EN-CA; mso-fareast-theme-font: minor-fareast;"><span style="font-family: Arial, Helvetica, sans-serif; font-size: small;">For
diagnostic tests, LR+ increases the post-test probability of a diagnosis and
LR- decreases the post-test probability. LR values generally have this impact:
a) large and conclusive (LR+ >10, LR- <0.1), b) moderate (LR+ 5 to10, LR-
0.1 to 0.2), c) small but important (LR+ 2 to 5, LR- 0.2 to 0.5), d)
unimportant (LR+ 1 to 2, LR- 0.5 to 1). In emergency medicine, we are generally
most interested in ruling out serious conditions and look for tests with very
high sensitivity and very low LR-.<o:p></o:p></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><b><i style="mso-bidi-font-style: normal;"><span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-fareast-font-family: "MS 明朝"; mso-fareast-language: EN-CA; mso-fareast-theme-font: minor-fareast;">By: </span></i></b><b><i><span lang="EN-US">Dr. Ian Stiell </span></i></b></span><span lang="EN-CA" style="mso-ansi-language: EN-CA; mso-bidi-font-weight: bold; mso-fareast-font-family: "MS 明朝"; mso-fareast-language: EN-CA; mso-fareast-theme-font: minor-fareast;"><o:p></o:p></span></div>
Hans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.com0