tag:blogger.com,1999:blog-8873182011806750671.post5599683818608404343..comments2022-05-08T21:32:48.054-07:00Comments on Reviews & Opinions in Emergency Medicine: Low Risk Chest Pain and the Accelerated ProtocolsAdan Atrihamhttp://www.blogger.com/profile/07649932016422306124noreply@blogger.comBlogger3125tag:blogger.com,1999:blog-8873182011806750671.post-68891369698415259932022-05-08T21:32:48.054-07:002022-05-08T21:32:48.054-07:00buy aricep 10 mg online is in a class of drugs cal...<b><a href="https://www.dosepharmacy.com/aricep-10mg-tablet" rel="nofollow">buy aricep 10 mg online</a></b> is in a class of drugs called cholinesterase inhibitors. It improves mental function by increasing the amount of a certain naturally happening substance in the brain.Ethan Joneshttps://www.blogger.com/profile/08261068515927040953noreply@blogger.comtag:blogger.com,1999:blog-8873182011806750671.post-76497948771366700592013-11-19T15:31:19.039-08:002013-11-19T15:31:19.039-08:00Hi Rajeev!
My take on this score system business...Hi Rajeev! <br />My take on this score system business is basically a way to codify what we are already doing. If your gestalt tells you the patient in front of you does not have ACS, it is nice to have a way to codify and standardize the approach for that low risk patient who is going home. But I completely agree with you, score systems on their own don't do much, they are useful only in the right patient. I think about this in the same way as I do with the low risk pulmonary embolism patient. My pre-test prob is low, then I apply PERC and if PERC negative, I am done, pt is very low risk for PE, bye bye. If my gestalt tells me low risk for ACS, then I apply TIMI, if TIMI is 0-1, the trops are negative, the EKG is non-ischemic and pt is pain free, bye bye. <br />I guess your question is more related to the patient who you think is low risk and the TIMI is intermediate or high. I would say, don't use TIMI; get your trops, EKG, talk to your patient and engage him/her in the decision. Two years ago, David Newman in his podcast SMART-EM did a fantastic evidence based approach to the chest pain patient in the ED (http://smartem.org/podcasts/chest-pain-risk). The summary is this:<br />- Patient < 40 y/o, who is low risk by gestalt, has non-ischemic EKG, negative trops and no hypotension, his risk for AMI is 1:500.<br />- Same patient but age > 40, the risk goes to 1:250<br />- Patient with moderate risk, with 2 or more risk factors (you are concerned this could be ACS), but EKG is non-ischemic and trops are negative, the risk is 1:125.<br />So... in these group of patients in who I cannot use TIMI, I get all my other data and engage the patient in the decision of home vs admit based on the these probabilities and document the conversation. To my surprise more patients decide to go home than to be admitted, and that's OK as long as they understand that no one is 0 risk, they have good follow and they have a way back into the system if need be.<br /><br />Thanks for the comment Raj.Adan Atrihamhttps://www.blogger.com/profile/07649932016422306124noreply@blogger.comtag:blogger.com,1999:blog-8873182011806750671.post-15037918788700746922013-11-19T14:50:01.703-08:002013-11-19T14:50:01.703-08:00Hi doc .thnks for going into details of this topic...Hi doc .thnks for going into details of this topic.<br /> I agree that extreme presentations are no brainer.<br />But all these trials take and make prediction when timi score is 0.<br />STOP. <br />Lets answer the timi score NSTEMI question.<br />Did you have CP in 24 hrs ? Answer is yes<br />Age? More than 65<br />Use of aspirin ? No<br />Timi score is 3 .<br />Now what?<br /><br /> According to all these studies pt will fall in at least mod risk. When I know this pt most likely has no ACS . CP was muscular, he ran out of ASA, and he is 66.<br />I am not trying to argue or prove these studies wrong ,just thy don't help me decide who should stay.<br /> <br /> I personally talk to pt, take him into confidence, make sure he is CP FREE,pt should look good and just calculate TIMI SCORE in occipital area..<br />Edit and post if it makes sense to you.<br />Thanks<br /><br />Rajeev Singh, MDAdan Atrihamhttps://www.blogger.com/profile/07649932016422306124noreply@blogger.com