>In Case you Missed It – Spring 2014

Dr Paul Atkinson’s quarterly look back at the recent literature of note.

A non-random selection of papers you may or may not have seen:

Penetrating abdominal trauma

Modern management of penetrating abdominal trauma in hemodynamically stable patients is progressing further away from ‘no questions asked’ laparotomy. Selective non-operative management of penetrating abdominal injury is gaining acceptance and is now even being used in some cases of ballistic trauma. A review in Trauma (2013;15:289) describes and evaluates the evidence underpinning this changing practice. Interestingly, the authors conclude that the failure of non-operative management following stab wounds or gunshot wounds is invariably apparent within 24 h.

Glucagon (Gluca-Gone) and Esophageal Obstruction

Although many patients will eventually resolve their food bolus obstructions spontaneously, they will still need a non-emergent EGD. Likewise, patients who don’t clear them need intervention and, at some point, an EGD. Why not make that point right now? Diagnostic or therapeutic, an urgent/emergent EGD is the most effective treatment. Are other treatments as effective as EGD for these obstructions? Leopard et al. published a systematic review of this topic (Ann R Coll Surg Engl. 2011;93:441-444.) Hyoscine butylbromide was determined to be ineffective. Gas producers (eg, carbonated beverages) worked in 70 percent of cases, but glucagon was no better than placebo (one randomized, controlled trial and two other studies). However, EGD was effective in 93 percent to 100 percent of patients and found pathology in 55 percent to 90 percent of those cases.

A shocking ProCESS

So after all that training, it appears that treatment of sepsis does not require a mandatory central line, unless needed for administering intravenous fluids. In a multicenter trial conducted in the tertiary care setting, the ProCESS Investigators found that early goal-directed therapy (EGDT) protocol-based resuscitation of patients with septic shock in the emergency department did not improve outcomes. The EGDT protocol was based on Rivers’ 6-hour protocol of (EGDT), in which intravenous fluids, vasopressors, inotropes, and blood transfusions were adjusted to reach central hemodynamic targets. The other groups received protocol-based standard therapy that did not require the placement of a central venous catheter, administration of inotropes, or blood transfusions; or usual care. (N Engl J Med. 2014 Mar 18. PMID: 24635773). There were no significant differences in 90-day mortality, 1-year mortality, or the need for organ support. Make sure usual care reflects the principles of early antibiotics and appropriate fluid resuscitation though!

Tattoos in OSCES

Researchers in Belfast have developed a novel way of simulating dermatological conditions for use in objective structured clinical examinations. They have used low cost, durable temporary transfer tattoos applied to standardized patients and achieved impressive scores in terms of realism (Clin Teach 2013;10:251–7).

Ney – Does central venous pressure (CVP) predict fluid responsiveness? A systematic review of the literature and the tale of seven mares!

So you thought CVP was a good marker of fluid status in patients right? This systematic review of the literature was performed to determine the relationship between CVP and blood volume, the ability of CVP to predict fluid responsiveness, and the ability of the change in CVP (DeltaCVP) to predict fluid responsiveness. The review demonstrated a very poor relationship (56% accuracy, similar to a coin flip) between CVP and blood volume as well as the inability of CVP/DeltaCVP to predict the hemodynamic response to a fluid challenge. So, another reason not to routinely insert a central line; CVP should not be used to make clinical decisions regarding fluid management (Chest. 2008;134(1):172-8.). What about the horses? The only evidence supporting CVP was in 7 standing mares who were subjected to hemorrhage!

Playground bumps

Playground related injuries are common in children, particularly during the summer months. A prospective study from Singapore (J Pediatr Orthop 2013;33:221–6) aimed to correlate various risk factors with severity of fractures. Interestingly, it found that the height of equipment and other playground factors were not linked to the severity of injury. Factors which were important included the level of supervision and the child’s body mass index. (So keep an eye on your kid’s diet and activities!)

Treating nausea and vomiting in kids with head injury

This study examined the effects of ondansetron use in a retrospective cohort of 28,271 children presenting to two tertiary care pediatric EDs from 2003 through 2010 with mild head trauma (Am J Emerg Med 31(1):166, 2013). Rates of missed diagnoses were 0% in children treated with ondansetron vs. 0.04% in those not so treated (one of these seven required operative intervention). Among children with head trauma who are discharged home after a negative CT scan, treatment with ondansetron in the ED was associated with a decrease in return ED visits.

Keep moving

A systematic review in the BMJ (2013;347:f5555) examined the evidence from 60 randomized controlled trials in order to answer the question of whether exercise improves function and reduces pain in osteoarthritis of the knee and hip. The study concludes that there is a significant benefit of exercise in patients with osteoarthritis, and that an approach combining exercises to increase strength, flexibility and aerobic capacity is likely to be most effective in the management of lower limb osteoarthritis.

Ottawa headache rules

A large multi-centre cohort trial has led to the development of the ‘Ottawa Subarachnoid Hemorrhage rule’ for patients presenting with new severe non- traumatic headache reaching maximum intensity within an hour. The six high risk variables requiring investigation are: age 40 years and over, neck pain or stiffness, witnessed loss of consciousness, onset during exertion, ‘thunderclap headache’ (instantly peaking pain) and limited neck flexion on examination. Further validation is required before it can be routinely applied in clinical practice (JAMA 2013;310:1248–55).

Hold on – maybe not (where did I put the LP kit?)

We have heard that later-generation CT scanning performed within six hours after headache onset is extremely sensitive for subarachnoid hemorrhage (SAH), prompting some to question the need for lumbar puncture (LP) when early CT is negative. A previously reported clinical decision rule (age 40 years or older, neck pain or stiffness, loss of consciousness and/or headache onset during exertion) was applied retrospectively to 55 case patients who presented between 2000 and 2011 with non-traumatic SAH diagnosed by LP despite a head CT that was negative and 168 matched controls with SAH ruled out when both CT and LP were negative (Ann Emerg Med 62(1):1, 2013).The calculated sensitivity and specificity of the clinical decision rule for SAH were 97.1% and 22.7%, respectively. However, of the 55 cases with false-negative CT, 11 had the CT performed within six hours of headache onset.

“You talkin’ to me?” – Ambulance to ED handovers

The development of standard procedures of communication in patient handovers is one of WHO’s top five priorities for patient safety in developed countries. Miscommunication between professionals appears to be the main source of errors and mishaps. A review article suggests a number of improvement strategies to optimise communication between EMS providers and emergency department clinicians. These include the use of standardised tools to structure handover information and the transmission of patient information electronically. However, it is not clear what impact cultural differences, such as language between professions, has on the handover process. Acta Anaesthesiologica Scandinavia (2013;57:964–70).

FASTer Simulation

We examined the effect of addition on simulated ultrasound (using the edus2 simulator) on diagnostic accuracy, diagnostic confidence and diagnostic precision for residents during 72 standard trauma scenarios. The use of a simulator is a convenient way of supplementing training in both trauma and ultrasound. By incorporating PoCUS into trauma simulations participants were significantly more likely to arrive at the correct diagnosis, have more confidence in their conclusions and also have a narrowed differential diagnosis. (Local data)

Gut feeling – Gastrointestinal trauma in children

Children present infrequently to hospital with gastrointestinal injuries. A multicentre retrospective study reviewed 97 patients who presented to 10 European paediatric surgical centres over an 11 year period. The majority of injuries followed blunt trauma in the form of motor vehicle collisions or bicycle crashes. Most patients were symptomatic from abdominal injury at the time of hospital presentation. Initial diagnostic tests provided the correct diagnosis in only 71% of cases, underlining the need for patients with initially negative results to be observed. The authors suggest a role for diagnostic laparoscopy in selected cases to reduce the number of non- therapeutic laparotomies. Acta Paediatrica (2013;102:977–8).

Obstruction

Although frequently reported on CT, we demonstrated that the presence of unilateral renal obstruction does not predict the failure of medical management or the need for operative intervention. In a retrospective review of 202 patients with unilateral ureteric calculus, independent of other factors, obstruction was not predictive of 30-day re-presentation after diagnosis (OR=0.67) or of operative intervention (OR 1.20). Stone size, number of renal colic ED visits before CT- diagnosis, and proximal stone location predicted surgical intervention. In the absence of absolute indicators for operative intervention, the CT-finding of obstruction should not alter the acute management plan of the renal colic patient. (Local data)

Double-double? How many cups of coffee?

Coffee is consumed by many emergency care workers. Coffee is a major source of antioxidants, with potential beneficial effects on inflammation. Potential adverse effects arise from caffeine stimulating the release of epinephrine, inhibiting insulin activity and increasing blood pressure. In a longitudinal study published in the Mayo Clinic Proceedings (2013;10:1066–74) involving over 40 000 participants spanning 31 years, it was found that heavy coffee consumption (greater than 28 cups a week) had a higher all-cause mortality in those aged less than 55 years. The authors suggest younger people keep coffee consumption below four cups a day.

Best regards,

Dr. Paul Atkinson
Emergency Medicine,
Dalhousie & Memorial Universities, Saint John Regional Hospital, NB

Sources:

1.Emergency Medicine Journal 2013/14

2.Emergency Medicine Abstracts 2013/14

3. ACEP Now 2014

4.Evidence Updates (BMJ/McMaster) 2014

5. Local Research

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