>In Case You Missed It – Spring 2103

An egg a day is ok

As a low carb fan it is was good to learn from research published in the BMJ (2013;346:e8539) that consumption of up to one egg per day is not associated with an increased risk of stroke or coronary heart disease. This news follows the widely publicized counter-intuitive message from research which appeared in JAMA (2013;309:71–82) that ‘overweight people live longer’.

Chest compression only CPR

Arguments continue about whether compression only cardiopulmonary resuscitation (CPR) is better than conventional CPR for adult patients who suffer sudden unexpected out of hospital cardiac arrest. A nationwide, prospective, population-based observational study was conducted in Japan in order to investigate this. Details from 1376 bystander witnessed out of hospital cardiac arrests were analyzed—all cases had initially shockable rhythms and a nearby automated external defibrillator. The Japanese researchers conclude that compression only CPR was more effective than the conventional method (Circulation 2012;126:2844–51).

Bystander effect

A thought provoking article published in the N Engl J Med (2013;368:8–9) discusses what is known as the bystander effect—‘the human tendency to be less likely to offer help in emergency situations when other people are present’. Originally applied to the pre-hospital context, the authors express concern that this effect may have moved into our hospitals where patients are cared for by a large number of health care providers, with a sometimes overwhelming array of investigations to interpret, especially in the critical care domain. They argue the need to guard against becoming passively involved in patient care as more and more experts enrol in the case. Teamwork and coordinated co-operation should be something the EM team is familiar with.

The FOUR HOUR target

In 2005, a controversial target was introduced into English hospitals in an attempt to limit the length of patient stays in the emergency department (ED) to less than 4 hours. The well publicized ‘4 hour target’ has generated considerable comment (both positive and negative) in the medical and popular press. Following analysis of 777 525 patient visits to 15 English EDs, researchers found no evidence that the 4 hour target impacted negatively on the quality of ED care. There was also little apparent effect on the use of investigations (Ann Emerg Med 2012;60:699–706).

More on tranexamic acid in trauma

A Cochrane Review of four trials involving 20 548 randomised patients (2012;(12):CD004896) reinforced the message that tranexamic acid safely reduces mortality in bleeding trauma patients, without increasing the risk of adverse events. Tranexamic acid needs to be given as early as possible, as administration later than 3 h after injury is unlikely to be effective, and delayed administration may even be harmful. Further trials are ongoing to determine the effects of tranexamic acid in patients with isolated traumatic brain injury.

The scrap rule

Increasing availability of CT scanning has resulted in a lowered threshold for its use in chest trauma. However, such scans involve significant amounts of radiation. Canadian researchers have developed a (‘SCRAP’) rule with the aim of ruling out major thoracic injury and reducing use of chest CT scans in adult blunt trauma patients. In a retrospective study of patients with a Glasgow Coma Score of more than 8, the following five clinical variables were found to be particularly predictive of injury: low oxygen Saturation, abnormal Chest radiograph, Respiratory rate of 25 or more, chest Auscultation abnormality, and abnormality on thoracic Palpation. The authors argue that if all five of the SCRAP variables are normal, chest CT is not necessary. The rule awaits prospective validation (Canadian J Emerg Med 2012;14:344–53).

Medical errors

Patient safety and patient suffering following medical errors are topics that understandably generate much concern. Less attention is focused on helping and supporting the health care worker involved. Researchers from Philadelphia explore these and related issues in Med Educ (2012;46:1141–51). They argue for the development of curricula to teach how to recognise and address the emotional impacts of errors and adverse events on health care workers. They also discuss the provision of peer support, and establishing forums in which health care workers can safely share their experiences.

Venous blood gas analysis

Acid-base and oxygenation status can be assessed from peripheral venous blood, but agreement with arterial values is not always clinically acceptable. Researchers from Denmark present some data to support an interesting mathematical arterialization method (Eur J Emerg Med 2012;19:363–72).

Neonatal urine collection

Researchers in Madrid describe a new technique to obtain midstream urine samples in neonates. It is based on bladder and lumbar stimulation manoeuvres, with the baby held dangling under the armpits and a midstream urine sample then being caught in a sterile container. The technique was successful in 86% of infants studied. It appears to be quick and safe, whereby the discomfort and waste of time often associated with various bag collection methods can be avoided (Arch Dis Child 2013;98:27–9). Just don’t tell the cleaners!

Croup and cold

 

In our study of children presenting to a teaching hospital Emergency Department (ED) in New South Wales, Australia we asked whether the pattern of croup attendances in a warm temperate climate was associated with changes in weather (Emerg Med J 2013;0:13. doi:10.1136/emermed-2012-201876).

The number of daily diagnoses of croup over a 2 year time period was compared with detailed climatic records for the same time period. Only one daily variable, ground temperature at 9 am, was significantly associated with the number of croup attendances. There was a stronger correlation between the calculated mean monthly temperature and the monthly number of croup admissions.

It appears that even in this milder climate, croup does seem to be disease associated with cooler weather.

Obesity is AAA risk

A Swedish population-based cohort study searched for a relationship between obesity and the risk of developing an abdominal aortic aneurysm (AAA). It found that an increased waist circumference resulted in an increase in the risk of developing an AAA. The investigation did not find a relationship between an increased body mass index and AAA incidence, suggesting intra-abdominal adiposity to be an important factor (Br J Surg 2013;100:360–6).

Managing whiplash injury

Practitioners working in emergency medicine will be familiar with patients presenting with neck pain and associated symptoms, especially following road traffic collisions. The annual cost of whiplash injuries is quite considerable, both in terms of the cost of treatment and time off work due to continuing symptoms. The results of two large randomized trials of patients presenting to emergency departments are presented in the Lancet (2013;381:546–6). The authors conclude that the provision of active management consultation did not provide any additional benefit. They argue for a single physiotherapy advice session to be provided for those patients with persistent symptoms.

Anterior cruciate rupture

Many young adults who sustain anterior cruciate ligament ruptures are treated with early reconstructive surgery. A controversial paper in the BMJ (2013;346:f232) questions this traditional aggressive surgical approach. The researchers argue that some moderately active adults with isolated anterior cruciate ligament tears can function well without reconstruction. In an editorial in the same issue (BMJ 2013;346:f963), other experts argue that their results should be treated with caution.

Facial palsy

Although many clinicians seem to believe that lower motor neuron facial nerve palsy equates with Bell’s palsy, there are numerous other causes. The etiology of facial palsy is described in a review article in the Br J Gen Pract (2013;63:109–10). Treatment very much depends upon the underlying diagnosis, emphasizing the importance of establishing the cause.

Handover education

A lack of formal training in delivering (and receiving) patient handover is believed to result in a risk to patients in the acute setting. An article in Clin Teach (2013;10:32–7) describes the introduction of an hour long teaching session on patient handover delivered to medical students. It incorporated the use of role play, video examples and discussion. Feedback from the students indicated it to be a satisfactory learning experience, which they felt improved their knowledge of handing over care.

Competencies or competence?

A review in the Postgrad Med J (2013;89:107–10) explores the limitations of the widespread use of competencies to drive forward modern medical education. It highlights the paucity of robust evidence to support their use. The authors examine the ability of competency based training to satisfy the requirements of different professional stakeholders and they question the overall ability of competency based curricula and assessment. They suggest that sub-optimal care for patients may result from a failure of the system to provide holistic workplace based experience and education to trainees.

Acetaminophen overdose

Legislation was introduced in the UK in 1998 which restricted the number of pills contained within a pack of acetaminophen (paracetamol). Analysis of national data indicates that this legislation has been successful in helping to reduce the number of deaths from acetaminophen overdose (BMJ 2013;346:f403).

Patient satisfaction

‘Patient centred care’ are current buzzwords, and for good reason. The measurement of patient satisfaction may understandably be assumed to be a marker of quality of care. However, re-interpretation of a large retrospective study (Evid Based Med 2013;18:e10) suggests that small groups of (sicker) people who utilize hospitals frequently may skew the data. Unsurprisingly, these groups are associated with a worse outcome. Care is needed when measuring and interpreting patient satisfaction data.

Minor head injury

A large cohort study which followed more than 300 000 male Swedish conscripts has produced some interesting results. The authors controversially conclude that low cognitive function is a risk factor for mild traumatic brain injury, rather than a consequence of it (BMJ 2013;346:f723)!!

Publication quality

Are we paying lip service to the mantra of Evidence Based Medicine? Or is it just really hard to conduct good quality and ethically sound research in an emergency setting? Research published in the Am J Emerg Med (2013;31:297–301) examines recent publications in the top ranked Emergency Medicine journals. Concerns are expressed that an alarming number of papers make no direct reference to ethics approval and even fewer mention informed consent. Few papers represent level 1 evidence (ie, randomised controlled trials), with most being single centre cross-sectional and cohort studies very much centred in the developed world. Prehospital studies represent less than a fifth of the literature. The authors argue that if we wish to encourage evidence based practice, we need to focus resources on high quality research despite the real obstacles of lack of time, research grants, and undertaking research in the chaotic emergency environment.

Pediatric procedures

A study from a high volume tertiary US pediatric Emergency Department (Annals Emerg Med 2013;61:263–70) may be pertinent to many developed world settings. Researchers examine how often ED staff perform critical pediatric procedures, such as tracheal intubation, intraosseous and central line insertion and cardioversion. Due to a combination of generally low acuity of pediatric presentations and the ready availability of (sometimes competing) practitioners, ED faculty and residents appear to be each performing relatively few critical pediatric procedures. The results raise concerns about the training in pediatric emergency medicine, as well as skill retention of established specialists. The attainment and maintenance of critical skills in pediatric emergency medicine appear to require more than relying solely upon clinical exposure. The authors propose mandatory maintenance of skills programs and quality assurance to ensure optimal care, safety and training opportunities. Perhaps SimBaby was a good investment!

Pawper tape

From South Africa, Sophia brings news of early validation of a new weight estimation device which has produced good results in a local study—Resuscitation (2013;84:227–32). The device is a tape incorporating an assessment of body habitus (through a five point ‘habitus score’) into the estimation. It proved to be more accurate than traditional length based measures (which in turn are superior to formula based estimates), especially in older children. Although further validation is still required, this method shows promise and is available at low cost or free to print off, as opposed to some expensive commercial devices presently inaccessible to much of the developing world. Could be useful in Saint John perhaps.

Nurses can manage people with well controlled asthma

Patients with well controlled asthma seem to do equally well when managed primarily by nurses or by doctors, say researchers from the Netherlands. In a systematic review of five good quality randomized trials, participants managed either way had comparable symptoms, quality of life, and lung function. They had similar rates of hospital admissions and exacerbations during follow-up. Nurses were a little cheaper in the one trial that included costs, although the saving on personnel didn’t translate into lower healthcare costs overall. Patients may get more contact time with nurses, and good economic evaluations should be done alongside future trials, say the authors.

 

 

 

Best regards,

 

Paul Atkinson

Site Director Research

 

Sources:

  1. Emergency Medicine Journal 2013
  2. BMJ 2013
  3. Local Research Report 2013
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