In Case You Missed It – Spring 2015

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

 

1. ACS – do you know the rules by heart?

2014 AHA Guideline For The Management Of Patients With Non-ST-Elevation Acute Coronary Syndromes: Executive Summary

Amsterdam, E.A., et al, J Am Coll Card 64(24):2649, December 23, 2014

2014 update of the guideline for the management of patients with non-ST-elevation myocardial infarction (NSTEMI) and unstable angina.

Initial evaluation should include risk stratification, and a 12-lead ECG within ten minutes of ED arrival. When the initial ECG is non-diagnostic, serial ECGs every 15-30 minutes are advised when the clinical suspicion of ACS is high (ongoing pain, etc);

It is reasonable to include leads V7-V9 and/or to perform continuous 12-lead ECG monitoring.

The HEART score may be useful for risk stratification.

Troponin levels should be measured at presentation and three to six hours after symptom onset; if levels are normal additional measurements should be performed beyond six hours after symptom onset (or after presentation if the timing of onset is uncertain) if the risk for ACS is intermediate or high.

When troponin assays are available, measurement of CK-MB and/or myoglobin is not useful.

Additional troponin measurements should be performed beyond six hours if prior levels are normal but the suspicion for ACS is intermediate to high.

When objective variables are negative, it is reasonable to observe in a chest pain or telemetry unit, to perform stress testing before or within 72 hours after discharge, and to discharge low-risk patients on aspirin, short-acting nitroglycerin and other appropriate medications with instructions for follow-up.

 

 

2. Not So Normal Saline…

Crystalloid Fluid Therapy: Is The Balance Tipping Towards Balanced Solutions?

Young, P.J., et al, Intens Care Med 40(12):1966, December 2014

Each day, more than one million liters of IV 0.9% saline are administered to patients world wide. Although this solution has been termed “normal saline” its composition is not physiologic as it contains a chloride concentration that is about 1.5 times that of normal plasma. These authors from New Zealand briefly reviewed the growing controversy over possible harm due to 0.9% saline infusion.

Rapid infusion of 0.9% saline can cause acidosis, decreased renal perfusion, decline in glomerular filtration rate and, ultimately, death.

The effects of chloride overload must be separated out from the effects of concomitant volume overload using the “volume-adjusted chloride load,” and this measure has shown an association between rising chloride load during resuscitation and an increase in hospital mortality. Comparisons of high-chloride versus balanced solutions in various populations also suggest greater adverse effects with high-chloride solutions, with a possible dose-dependent association. However, limitations of such studies include the confounding effect of concomitantly high sodium content, differences in patient populations given high- versus low-chloride solutions, and differences in other practice patterns among physicians who choose one solution over another. Studies are under way in Australia and New Zealand to compare 0.9% saline versus balanced solutions.  Chloride load in resuscitation fluid may be a modifiable risk factor for poor outcomes. The authors suggest, however, that until definitive results are published physicians can confidently use 0.9% saline (for now!!)

 

 

3. Hang on – run it by me first…

Emergency Department resource use by supervised residents vs attending physicians alone

Pitts, S.R., et al, JAMA 312(22):2394, December 10, 2014

The authors, coordinated at Emory University, examined data from the 2010 National Hospital Ambulatory Medical Care Survey to compare resource use in a representative sample of patient visits to 336 EDs treated by attending physicians alone (25,808) or by residents supervised by attending physicians (3,374). Study outcomes included hospital admission, length of the ED stay, and the use of advanced imaging and blood tests.

Supervised visits were associated with significantly more frequent hospital admission (OR 1.42), use of advanced imaging (OR 1.27) and longer ED stays (OR 1.32), but no significant difference in the frequency of blood testing.

Graduate medical education appears to be associated with greater ED resource use, although these findings were less clear when results were stratified by hospital ED teaching type.

 

 

4. Old PEople

Accuracy Of The Wells Clinical Prediction Rule For Pulmonary Embolism In Older Ambulatory Adults

Schouten, H.J., et al, J Am Ger Soc 62(11):2136, November 2014

The Wells clinical prediction rule and a negative D-dimer test have largely involved younger patient populations.

These Dutch authors examined the utility of a low-risk Wells score (4 points or lower) plus a negative qualitative D-dimer result (Clearview Simplify D-dimer assay) for the exclusion of PE in 294 nursing home or community-dwelling persons aged 60 and older (mean, 76) with suspected PE. Nearly half of the patients (44%) were nursing home residents. PE was diagnosed on the basis of imaging or follow-up in 28% of the study participants.

85 patients (28.9%) had a low-risk score in combination with a negative D-dimer result. PE was diagnosed in five of these individuals (failure rate, 5.9%).

Lowering of the Wells cut-off to 2 points would have identified two additional patients with PE at the expense of referring 37 additional subjects for further evaluation. The failure rate with this strategy was 2.9%. Use of a quantitative rather than a qualitative D-dimer assay, which has a higher sensitivity for PE, would have identified four of the five cases of missed PE in this series.

Use of the Wells score plus D-dimer testing might be an unreliable strategy for risk stratifying older ambulatory patients with possible PE.

 

 

5. Grey-Dimer Scale…

Assessing 2 D-Dimer Age-Adjustment Strategies To Optimize Computed Tomographic Use In ED Evaluation Of Pulmonary Embolism

Gupta, A., et al, Am J Emerg Med 32(12):1499, December 2014

Recent studies have suggested that the use of age-adjusted D-dimer cutoffs in older patients being evaluated for venous thromboembolism increases the specificity of this test.

The authors, from Brigham and Women’s Hospital, applied two age-adjusted D-dimer calculations to a retrospective cohort of 1055 patients aged 18-96 who underwent CT angiography and quantitative latex-based D-dimer testing for possible pulmonary embolism (PE).

A yearly-based cutoff was calculated for those over 50 (age in years x 10ng/ml).

With the exception of two patients using the yearly-based cutoff, sensitivity remained at 100% for the two age-based methods. Use of the decade-based cutoff would have avoided CT angiography in 37 patients, and use of the yearly-based cutoff would have avoided 52 CT angiograms. Use of age-adjusted D-dimer cutoffs improve specificity in older patients with possible PE and may reduce unnecessary use of CT angiography.

 

 

6. Hold that Flo(max)? Medical expulsive therapy in adults with ureteric colic: a multi-centre, randomized, placebo-controlled trial.

Pickard R, Starr K, MacLennan G, et al. Lancet. 2015 May 18. pii: S0140-6736(15)60933-3.

This multicentre, randomized, placebo-controlled trial, recruited adults (aged 18-65 years) undergoing expectant management for a single ureteric stone identified by CT at 24 UK hospitals. Participants were randomly assigned to tamsulosin 400 mug, nifedipine 30 mg, or placebo taken daily for up to 4 weeks, using an algorithm with centre, stone size (</=5 mm or >5 mm), and stone location (upper, mid, or lower ureter) as minimization covariates. Participants, clinicians, and trial personnel were masked to treatment assignment. The primary outcome was the proportion of participants who did not need further intervention for stone clearance within 4 weeks.

1136 patients were included in the primary analysis (17 were excluded because of ineligibility and 14 participants were lost to follow-up). 303 (80%) of 379 participants in the placebo group did not need further intervention by 4 weeks, compared with 307 (81%) of 378 in the tamsulosin group (adjusted risk difference 1.3% [95% CI -5.7 to 8.3]; p=0.73) and 304 (80%) of 379 in the nifedipine group (0.5% [-5.6 to 6.5]; p=0.88). No difference was noted between active treatment and placebo (p=0.78), or between tamsulosin and nifedipine (p=0.77).

Serious adverse events were reported in three participants in the nifedipine group and in one participant in the placebo group.

Tamsulosin 0.4 mg and nifedipine 30 mg are not effective at decreasing the need for further treatment to achieve stone clearance in 4 weeks for patients with expectantly managed ureteric colic.

 

 

6. “5” is long enough after all…

Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Walters JA, Tan DJ, White CJ, et al. Cochrane Database Syst Rev. 2014 Dec 10;12:CD006897.

Standard methodological procedures as expected by The Cochrane Collaboration were used to review eight studies with 582 participants met the inclusion criteria, of which five studies conducted in hospitals with 519 participants (range 28 to 296) contributed to the meta-analysis.

The authors conclude that five days of oral corticosteroids is likely to be sufficient for treatment of adults with acute exacerbations of COPD, and this review suggests that the likelihood is low that shorter courses of systemic corticosteroids (of around five days) lead to worse outcomes than are seen with longer (10 to 14 days) courses. They graded most available evidence as moderate in quality because of imprecision; further research may have an important impact on our confidence in the estimates of effect or may change the estimates. The studies in this review did not include people with mild or moderate COPD; further studies comparing short-duration systemic corticosteroid versus conventional longer-duration systemic corticosteroid for treatment of adults with acute exacerbations of COPD are required.

 

 

7. TNK or PCI…?

ST-segment-elevation myocardial infarction patients randomized to a pharmaco-invasive strategy or primary percutaneous coronary intervention: strategic reperfusion early after myocardial infarction (stream) 1-year mortality follow-up

Sinnaeve P.R., et al, Circulation 130(14):1139, September 2014

Delays in performing primary PCI, which is unavailable in many healthcare facilities, have been shown to have negative effects on the morbidity and mortality of patients with ST-segment-elevation myocardial infarction (STEMI).

This multinational follow-up study to assess one-year mortality in 1,877 STEMI patients included in the open label randomized STREAM trial that compared a pharmaco-invasive strategy (936) (tenecteplase with antiplatelet and anticoagulant therapy and coronary angiography within 6-24 hours) with primary PCI (941). All of the patients presented within three hours after symptom onset but did not undergo primary PCI within one hour after first medical contact.

The STREAM trial reported a nominal nonsignificant advantage of initial pharmaco-invasive (TNK then delayed PCI) management for the composite 30-day endpoint (death, shock, congestive heart failure [CHF] and reinfarction). At one year, the all-cause mortality rate was 6.7% in the group receiving initial pharmacologic management and 5.9% in the primary PCI group (p=NS), and the corresponding cardiac mortality rates were 4.0% vs. 4.1% (p=NS).

These findings suggest that the dose-adjusted early pharmacologic regimen utilized in the STREAM trial can be a safe and effective alternative to primary PCI in STEMI patients who are unable to undergo primary PCI within one hour after presentation.

 

 

8. Make a B-line for CHF diagnosis…

Point-Of-Care Ultrasonography For The Diagnosis Of Acute Cardiogenic Pulmonary Edema In Patients Presenting With Acute Dyspnea: A Systematic Review And Meta-Analysis

Al Deeb, M., et al, Acad Emerg Med 21(8):844, August 2014

This review of seven prospective cohort or case-control studies (1,075 patients) of B-lines on point-of-care ultrasonography (POCUS) by non-radiologist physicians to establish a diagnosis of acute cardiogenic pulmonary edema in patients with undifferentiated dyspnea.

PoCUS was performed in the ED in two of the studies, in the prehospital setting in one, and in the ICU or hospital ward in the remaining four. POCUS had an overall sensitivity and specificity for cardiogenic pulmonary edema of 94.1% and 92.4%, respectively, and positive and negative likelihood ratios of 12.4 and 0.06, respectively. Findings were not significantly affected by study type, patient population, or the type of ultrasound protocol that was used.

B line-based POCUS might facilitate the identification of cardiogenic pulmonary edema in patients with acute dyspnea, although further study in the ED setting is advised. The authors suggest that a positive study is highly suggestive of this diagnosis in patients with a moderate to high pretest probability, and that the diagnosis can “almost” be excluded by a negative study in a patient with a low pretest probability.

 

9. Lazarus to the lab…stat…

Cardiac Catheterization Is Associated With Superior Outcomes For Survivors Of Out Of Hospital Cardiac Arrest: Review And Meta-Analysis

Camuglia, A.C., et al, Resuscitation 85(11):1533, November 2014

It has been suggested that survivors of pre-hospital cardiac arrest may benefit from invasive cardiac assessment and coronary angiography to achieve revascularization. These Australian authors performed a systematic review and meta-analysis of studies reporting on early coronary angiography in patients resuscitated after pre-hospital cardiac arrest.

Fifteen nonrandomized controlled studies compared outcomes in survivors of pre-hospital arrest who underwent early coronary angiography versus those managed without angiography. Overall survival was significantly improved in the angiography groups (58.8% vs. 30.9% in patients not undergoing angiography, odds ratio [OR] 2.77, 95% CI 2.06-3.72). A similar pattern was observed for the secondary endpoint of survival with a good neurologic outcome (58.0% vs. 35.8%, OR 2.20, 95% CI 1.46-3.32). There have been no randomized trials assessing the role of acute angiography in pre-hospital cardiac arrest patients.

Early coronary angiography appears to be associated with improved outcomes in survivors of pre-hospital cardiac arrest. The authors caution against reliance on the 12-lead ECG to identify patients with acute coronary occlusion.

 

 

10. Myth busting for Motrin (and other NSAIDs)

Fracture Healing And NSAIDs

Taylor, I.C., et al, Can Fam Phys 60(9):817, September 2014

Some methodologically limited retrospective cohort and case-control studies have reported that treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) impairs fracture healing. Nevertheless, NSAIDs provide relief of pain that has been found to be at least as good as other analgesics, often with fewer adverse side effects.

These authors, from the University of Alberta and writing for the “Tools for Practice” series of the Canadian Family Physician, provide a brief review of three randomized controlled trials of NSAID treatment in patients with fractures. Two trials performed in 140 adults (predominantly middle-aged women with Colles fractures) reported no difference between NSAIDs (flurbiprofen or piroxicam) or placebo for the outcomes of recovery time, need for physical therapy, malunion or nonunion, functional recovery or healing. One study of 336 children with fractures of the arm who were randomized to ibuprofen or acetaminophen/codeine reported no difference between the groups in fracture nonunion. Pain relief with ibuprofen was comparable to that of the comparison drug but produced less functional impairment and fewer adverse effects. The authors acknowledge that data from randomized controlled trials are limited, but do not support impairment of fracture healing with NSAID therapy. They note that studies have found that pediatric fracture patients, in particular, often receive inadequate analgesia.

They conclude that short-term NSAID therapy should not be withheld from patients presenting with fractures.

 

11. O Canada – it ain’t so bad…Work stressors affecting emergency physicians and residents; an international survey.

De Haan et al. CAEP 2015

High levels of occupational stress can cause health and performance issues within the specialty of emergency medicine (EM). These issues can lead to increased burnout and attrition from the profession. We examined workplace stress experiences for both trainees and certified EM specialists in settings where the specialty of EM is new (South Africa) and better established (Canada).
An online cross-sectional survey of EM trainees and physicians in both countries was conducted using the validated Management Standards Indicator Tool (MSIT, Health and Safety Executive, UK), a 35-item questionnaire where each item is weighted on a five-point scale. There were 77 South African, and 510 Canadian respondents.

In Canada, specialists (N=396) had significantly higher Demands (2.6 (95%CI 2.6-2.7) vs. 3.0 (2.8-3.1)) and Manager support stressors (3.3 (3.3-3.4) vs. 3.9 (3.6-4.0)) than trainees (N=36). Canadian trainees had higher Role stressors (4.0 (3.9-4.1) vs. 4.2 (4.2-4.3)).

In South Africa, trainees (N=39) had higher stressors than specialists (N=36) on Demands (2.2 (2.1-2.3) vs. 2.7 (2.5-2.8)), Control (2.6 (2.4-2.7) vs. 3.5 (3.3-3.7)), Role (3.6 (3.4-3.7) vs. 4.0 (3.7-4.3)) and Change (2.4 (2.2-2.6) vs. 3.0 (2.7-3.3)). South African trainees had significantly higher stressors on ALL domains than Canadian trainees. While South African specialists had lower Control stressors than Canadian counterparts, they had higher Peer support and Relationship stressors.
Risk factors for work-related stress are higher in all domains among South African EM trainees compared with Canadian trainees, and differ from South African EM specialists. Canadian EM trainees reported a lack of role clarity. Canadian specialists had lower work control, but better peer support and work relationships than SA specialists.

 

Best regards,

 

Dr. Paul Atkinson

Emergency Medicine,

Dalhousie & Memorial Universities,

Saint John Regional Hospital, NB

Paul.atkinson@dal.ca

 

Sources:

  1. Emergency Medicine Journal 2014/15
  2. Emergency Medicine Abstracts 2014/15
  3. ACEP Now 2014/15
  4. Evidence Updates (BMJ/McMaster) 2014/15
  5. Local Research

 

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In Case You Missed It – Fall 2013

ED Handover

A model for Emergency Department (ED) multiprofessional morning handover is described in the Clinical Teacher (2013;10:219–23). The authors describe how prior to the introduction of multiprofessional handover, the ED used to adopt the traditional approach of separate handovers for medical and nursing staff. Their multiprofessional handover has an emphasis on enabling all staff to enhance their learning and was generally well received.

STICH II

The second randomized trial comparing early surgery with initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral hematomas (STICH II) has been published in the Lancet (2013;382:397–408). The study recruited patients from 78 centres in 27 countries, excluding those who had any intraventricular hemorrhage. It found little benefit of surgery for conscious patients with a superficial intracerebral hemorrhage with a volume of 10–100 mL. However, early surgery might yet have a role to play in a small subgroup of patients with a poor prognostic score or whose neurological status progressively deteriorates.

Sigmoid Diverticulitis

The natural history of a first episode of sigmoid diverticulitis was investigated in a prospective study from Switzerland and published in the British Journal of Surgery (2013;100:976–9). Patients were included if they presented with a first episode of uncomplicated sigmoid diverticulitis which was confirmed on CT scanning and required admission to hospital. Interestingly, the diverticulitis in most patients followed a relatively benign course without recurrence. When it did recur, the diverticulitis was very rarely complicated. In contrast to previous beliefs, there was no evidence that it followed a more aggressive course in younger patients.

SERIAL MULTIPLE BIOMARKERS IN THE ASSESSMENT OF SUSPECTED ACUTE CORONARY SYNDROME: MULTIPLE INFARCT MARKERS IN CHEST PAIN (MIMIC) STUDY

Macdonald, S.P.J., et al, Emerg Med J 30(2):149, February 2013

METHODS: This prospective observational Australian study evaluated the utility of a biomarker panel consisting of myoglobin, CK-MB, cTnI and B-type natriuretic peptide (BNP) (Biosite Triage) in facilitating early identification of suitability for discharge in 1,758 adults presenting to two tertiary and three general hospital EDs with acute chest pain without definitive EKG findings. Patients were tested on presentation and after two hours, and any abnormal result was considered to represent a positive test. Final diagnoses were based on standard cTnI testing, EKGs and 30-day follow-up.

RESULTS: AMI was diagnosed in 11% of patients with sufficient data, and the secondary outcome of all-cause mortality, MI or unplanned coronary revascularization at 30 days occurred in 14%. When considered in isolation, the biomarker panel had a sensitivity of 90% for AMI on presentation and 84% for the 30-day combined outcome. Sensitivity improved to 99% for each outcome if biomarker panel results were combined with a TIMI clinical risk score of 0, but this combination would have identified only 9.4% of patients as suitable for discharge from the ED. Sensitivities were 98% for MI and 95% for the 30-day outcome if biomarker panel results were combined with a National Heart Foundation of Australia score of low-to-intermediate clinical risk, which would have identified 28% of patients as being suitable for discharge from the ED.

CONCLUSIONS: The two-hour biomarker panel in isolation does not appear to be suitable for identifying chest pain patients who would be suitable for early discharge from the ED. Combining panel results with clinical risk stratification might prove to be more useful.

 

ULTRASOUND-GUIDED PERIPHERAL INTRAVENOUS ACCESS PROGRAM IS ASSOCIATED WITH A MARKED REDUCTION IN CENTRAL VENOUS CATHETER USE IN NONCRITICALLY ILL EMERGENCY DEPARTMENT PATIENTS

Shokoohi, H., et al, Ann Emerg Med 61(2):198, February 2013

 

BACKGROUND: Central venous catheter-associated bloodstream infections are more common when these devices are placed in the ED rather than in other settings (24 vs. 1.7 per 1000 catheter-days). Difficult peripheral IV access in noncritical patients sometimes prompts central venous catheter placement in the ED.

METHODS: This retrospective study, from George Washington University, evaluated central venous catheter use in ED patients after implementation of a program of instruction in ultrasound-guided peripheral IV catheter placement in patients with difficult peripheral access. Instruction was provided for all emergency medicine residents beginning in 2005 and for all ED technicians beginning in 2008.

RESULTS: During a six-year period (2006-2011), central venous catheters were placed in 0.39% of patients treated in this urban academic ED. Despite a 24% increase in the ED census, central venous catheter placement decreased by 80%, from 0.81% in 2006 to 0.16% in 2011. The average monthly decrease was much greater in noncritical patients than in those admitted to the ICU (4.4% in patients admitted to telemetry, 4.8% in those admitted to a medical/surgical ward and 7.6% in patients discharged from the ED vs. 0.9% in critical patients). By 2011, no patient who was discharged from the ED had a central venous catheter placed while in the department.

CONCLUSIONS: The authors acknowledge the methodologic limitations of their study, but suggest that implementation of training in ultrasound-guided peripheral IV access can be associated with a dramatic decrease in central venous catheter placement in the ED.

 

Post-Concussion Symptoms

A study of children and young adults who had sustained a head injury with post-concussion symptoms investigated the risk factors for prolonged symptoms. 280 patients aged between 11 and 22 years who presented to a tertiary care children’s hospital in Boston were enrolled. Most of the head injuries were sustained during a sporting activity. Those individuals who had a previous history of minor head injury were at increased risk of developing prolonged symptoms—this effect was particularly pronounced for patients with very recent or multiple head injuries (Pediatrics 2013;132:8–17).

 

RISK OF TRAUMATIC INTRACRANIAL HEMORRHAGE IN PATIENTS WITH HEAD INJURY AND PREINJURY WARFARIN OR CLOPIDOGREL USE

Nishijima, D.K., et al, Acad Emerg Med 20(2):140, February 2013

 

BACKGROUND: There is uncertainty about the need for head CT scanning after mild blunt head trauma in older patients taking anticoagulant or antiplatelet drugs.

METHODS: This prospective observational study, coordinated at the University of California, Davis, attempted to identify variables associated with a low risk for intracranial hemorrhage (ICH) in adults presenting to six Northern California EDs with mild blunt head trauma during treatment with warfarin or clopidogrel (Plavix). The study included 982 patients (mean age 75.4) presenting after blunt head trauma with an initial GCS score of 13-15, regardless of loss of consciousness or amnesia. Head CT scanning was performed in all of the patients.

RESULTS: Preinjury warfarin use was documented for 72.7% of the patients and clopidogrel use for 28.4%; just under 5% were also taking aspirin. The most common mechanism of injury was a ground-level fall (83.6%). The initial head CT demonstrated ICH in 6.1% of the patients (30 on warfarin and 30 on clopidogrel), 20% of whom (12/60) required neurosurgical intervention and 17% of whom (10/60) died during the hospital course. Of eleven variables that were evaluated, there was substantial overlap between patients with and without ICH. Only two independent predictors of ICH were identified (vomiting – relative risk [RR] 3.53, and abnormal mental status – RR 2.85). A model that included these two predictors had a sensitivity for ICH of only 37%, a specificity of 87%, and positive and negative predictive values of 16% and 95%, respectively.

CONCLUSIONS: The authors were unable to develop a reliable prediction rule for ICH after mild blunt head trauma in patients taking preinjury warfarin or clopidogrel, and they therefore recommend a liberal policy for head CT scanning in this population.

 

CANADIANS’ WILLINGNESS TO RECEIVE CARE FROM PHYSICIAN ASSISTANTS

Doan, Q., et al, Can Fam Phys 58(8):e459, August 2012

 

BACKGROUND: Physician assistants (PAs) have been utilized for the provision of healthcare in the United States since the 1960s, but their incorporation into the Canadian healthcare system has only recently been considered. Primary care capacity shortages in Canada have resulted in decreased resources and longer wait times to be seen by a physician. The use of PAs could improve patient flow and decrease the costs of care.

METHODS: In this study, mothers accompanying children to be seen at the British Columbia Children’s Hospital were surveyed about their willingness to be treated by a PA for minor injuries. The scenarios that were presented included a sprained ankle and a forearm laceration in the respondent, and a forehead laceration in a child. Wait times that were presented were four hours to be treated by a physician vs. 30 minutes, one hour or two hours to be treated by a PA.

RESULTS: Responses were received from 229 of 270 potential participants (mothers who were familiar with PA services were excluded from participation). Nearly all of the respondents (99%) opted for treatment by a PA for at least one of the time trade-off scenarios for an ankle sprain or forearm laceration in themselves. Choice of a PA over a physician increased from about 85% if the wait to see the PA was two hours to 99% if the wait to see the PA was 30 minutes. For a forehead laceration in a child, 96% of the respondents opted for treatment by a PA for at least one of the time trade-off scenarios, increasing from 67% if the wait for a PA was two hours to 96% if the wait was 30 minutes.

CONCLUSIONS: The results of this survey suggest that Canadian patients would be willing to be treated by PAs for lower acuity complaints if this option would reduce the time to treatment.

Stroke Thrombolysis Over-rated?

A controversial article highlighting the continuing problem of conflicts of interest among authors and sponsors of clinical guidelines will resonate with many emergency practitioners. Using the now discredited practice of giving high-dose steroids for acute spinal cord injury as a historical example, the article focusses upon the evidence (or lack of it) that underpins the current practice of stroke thrombolysis (BMJ 2013;346:20–2).

Satisfaction of Trauma Patients

Does Sophia really know who our most satisfied trauma patients are? According to a recent epidemiological study, it is those elderly patients who require surgery that are essentially happy with all aspects of their care. In contrast, least satisfied are the younger, non-operatively treated patients, who experience complications in their care ( J Trauma 2013;75:110–15).

Diaphragmatic Rupture

Interrogation of a large US trauma registry revealed that 773 patients had sustained traumatic diaphragmatic injury. The reputation of this injury as being elusive and associated with a high mortality continues. Unsurprisingly, concomitant cardiac injury carried a particularly poor prognosis ( J Trauma 2013;74:1392–8).

Thoracolumbar Spine Injuries

There are two validated clinical guidelines that are widely used around the world to help guide the investigation and ‘clearance’ of patients who present with possible cervical spine injuries. In contrast, there are no such guidelines to help clinicians assess patients with injuries of the thoracolumbar spine. Writing in an editorial in Injury (2013;44:881–2), a group of trauma experts call for the development of clear, evidence-based decision rules to help redress this. They share their concerns about the relatively large amount of radiation exposure involved in computerised tomography of the thoracic and lumbar spine.

Backboard Time

Questions have arisen over the evidence behind routine use of backboards in trauma care, as well as the possible harm associated with their use. Early removal of the backboard is generally considered to be best practice. A study undertaken in a US level 1 academic trauma centre observed that patients with a lower perceived need for emergency care may have to wait longer for backboard removal, thereby putting them at increased risk of potential harm. Factors increasing the total backboard time need to be recognised and addressed within individual units (Int J Emerg Med 2013;20:17).

MANAGEMENT OF OESOPHAGEAL COINS IN CHILDREN

Nafousi, O., et al, Emerg Med J 30(2):157, February 2013

 

BACKGROUND: There are conflicting recommendations for the management of children with an asymptomatic esophageal coin.

METHODS: These British authors did an implicit chart review of 63 children aged 8 months to 13 years (median, 4 years) presenting from 2004 through 2010 with a radiologically confirmed esophageal coin. They excluded children with prior tracheal or esophageal surgery or coin ingestion more than 24 hours prior to presentation.

RESULTS: Most of the children (42/63) were asymptomatic. Among these asymptomatic children, the coin was located in the upper esophagus in 13, the middle esophagus in 10 and the lower esophagus in 19. Thirty-seven of the 42 children were managed conservatively with observation and repeat x-rays after 18 hours. Spontaneous passage was confirmed on repeat imaging in all but four of these 37 children. No asymptomatic child observed for a coin in the middle or lower esophagus subsequently underwent a procedure requiring general anesthesia, and no child who was managed conservatively developed complications.

CONCLUSIONS: The authors suggest that a period of observation for 18 hours (perhaps at home) followed by repeat x-rays may be an effective strategy for the management of asymptomatic children with an esophageal coin ingested within 24 hours prior to presentation in the absence of prior tracheal or esophageal surgery. Retained coins can be managed according to local practice. They do note that the British penny, the coin most commonly ingested in this study, is larger and heavier than the US penny, and caution that what they found may perhaps not be generalizable to other countries.

 

LONG-TERM FOLLOW-UP OF PATIENTS AFTER CHILDHOOD URINARY TRACT INFECTION

Hannula, A., et al, Arch Ped Adol Med 166(12):1117, December 2012

 

BACKGROUND: Guideline updates from several professional organizations, including the American Academy of Pediatrics, no longer recommend routine voiding cystourethrography (VCUG) after a first urinary tract infection (UTI) in children in the absence of risk factors for renal abnormalities.

METHODS: This observational study from Finland reports on the follow-up of a random sample of 193 patients undergoing ultrasonography (US) and VCUG after a childhood UTI in whom major renal dysplasia or obstructive uropathy had been excluded on an initial US exam. The patients entered the study from 1993 through 2003 at an age of 0-14, and underwent final follow-up exams in 2009 and 2010 after a mean follow-up of 11.1 years.

RESULTS: Just over half of the patients (53%) were managed with antibiotic prophylaxis and 22% underwent urinary tract surgery during childhood. In the 150 patients who underwent ultrasonography during follow-up, 15% (22/150) had unilateral renal parenchymal defects and 3% (5/150) had unilateral retardation of kidney growth. It was estimated that the potential frequency of new renal defects was about 3% overall. Twenty-one of the 22 patients with parenchymal defects had grade 3 to 5 vesicoureteral reflux on VCUG. When compared with patients without parenchymal defects on US, those with defects more frequently experienced recurrent UTIs (82% vs. 40%), more often received antibiotic prophylaxis (95% vs. 60%), and more frequently underwent urinary tract surgery (68% vs. 21%). All of the patients in the series had serum cystatin C concentrations, estimated GFRs, blood pressure values and height that were within the normal range.

CONCLUSIONS: The authors acknowledge the limitations of an observational study design, but suggest that the risk of long-term adverse sequelae of childhood urinary tract infection appears to be low.

 

 

Knee Meniscal Injuries

Osteoarthritis is a common cause of pain and reduced mobility, yet relatively little is known about the risk factors contributing to its pathogenesis. A prospective study from the University of Pittsburgh concluded that certain medial meniscal tears can predispose to osteoarthritis, a finding that may help guide future surgical management (Am J Sports Med 2013;41:1238–44).

 

Minor Ailment Schemes

If you want to avoid Emergency Department waiting times or need to get that appointment slot with your general practitioner, then a pharmacy-based scheme may be helpful. That is what a new systematic review published in the British Journal of General Practice (2013;63:e472–81) suggests. Evidence points to high patient satisfaction with such services, which from an economic standpoint, are cheaper to provide. How this fits in with the numerous other minor ailment service providers in both primary and secondary care has yet to be determined.

 

META-ANALYSIS: SERUM CREATININE CHANGES FOLLOWING CONTRAST ENHANCED CT IMAGING

Kooiman, J., et al, Eur J Rad 81(10):2554, October 2012

 

METHODS: These Dutch authors performed a meta-analysis of 40 studies (19,563 patients) of the incidence of contrast-induced nephropathy (CIN) after contrast-enhanced CT scanning. All of the studies were published after the year 2000, after which the use of high osmolar contrast markedly decreased. In all of the studies, CIN was defined as an increase in serum creatinine in excess of 25% or a level above 44mmol/L after contrast-enhanced CT.

RESULTS: The mean patient age in the 40 studies ranged from 44 to 74, and the mean amount of contrast administered ranged from 10ml to 230ml. Most of the studies (33/40) included patients with chronic kidney disease and in three-fourths of these studies, prophylactic hydration was advised. The incidence of CIN in the individual studies varied from 0% to 25%, but the weighted pooled incidence was 6.4%. In 20 studies that followed the course of renal function after a diagnosis of CIN, a decline in renal function persisted in 1.1% of all patients undergoing contrast-enhanced CT. The weighted pooled incidence of a need for renal replacement therapy was only 0.06%. The risk of CIN after contrast-enhanced CT was increased in patients with chronic kidney disease (8.8%, odds ratio [OR] 2.3) and in those with diabetes (9.3%, OR 3.1).

CONCLUSIONS: The overall risk of CIN after contrast-enhanced CT scanning in published studies is about 6%, but this decline in renal function persists as long as a week in only about 1%, and the need for renal replacement therapy is extremely rare. The risk of such an (almost always transient) increase in creatinine is slightly higher in patients with chronic kidney disease or diabetes.

 

 

VITAL SIGNS ARE UNRELIABLE

Yeh, D.D., et al, ANZ J Surg 82(9):574, September 2012

 

Unrecognized hemorrhagic shock can result in failure to transport trauma victims to designated trauma centers as well as a failure to appropriately triage in the ED setting. The authors, from Harvard Medical School, comment on the weaknesses of relying on stepwise vital sign abnormalities for assessing a patient’s status. They note that, in contrast to conventional models, 20-45% of hypotensive patients are bradycardic rather than tachycardic, and that hypotension is “usually a late (stage) finding.” Interpretation of blood pressure and heart rate is further confounded by alcohol, illicit drugs, and stress-response emotions (pain, fear, and anger). Elderly trauma patients present further challenges due to higher ‘normal’ blood pressures required for vital organ perfusion, and an absence of tachycardia due to medications such as beta-blockers or age-related decreased capacities for tachycardia. The authors suggest that alternate strategies might be superior to vital signs for assessing trauma victims. Elevated lactic acid levels are robust prognosticators of outcomes from shock, and are associated with the need for blood transfusion and other interventions. The potential value of a shock index (heart rate/systolic blood pressure) above a reference range of 0.5-0.7 is currently being evaluated. The authors conclude that the reliability of trauma triage criteria recommended by ATLS and most prehospital systems should be reevaluated, and that the best tool for assessment of the condition of a trauma patient is the clinical acumen of an experienced physician who considers all related variables including injury patterns and mechanism, lab abnormalities and the response to volume. They note that reliance on vital signs can result in under-triage of patients in early shock.

 

 

Best regards,

 

Paul Atkinson

Site Director for Research

 

Sources:

  1. Emergency Medicine Journal 2013
  2. Emergency Medicine Abstracts2013

 

 

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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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In Case You Missed It – Fall 2012

Bad news for shift workers

Many of you will be interested in a paper published in the BMJ 2012;345:e4800). A systematic review and meta-analysis investigated some of the potential risks associated with shift work and discovered a rather worrying answer. Shift work is associated with myocardial infarction, coronary events and ischaemic stroke and although the relative risks are modest, the population attributable risks are not insignificant. It is possible that disruption of circadian rhythms may be responsible for predisposing shift workers to vascular events.

Out of hospital cardiac arrest

In 2005, the American Heart Association published their ‘chain of survival’ concept for resuscitation of patients with out of hospital cardiac arrest. The chain will be familiar to many practitioners, comprising four links: early access to emergency medical care, early cardiopulmonary resuscitation, early defibrillation and early advanced cardiac life support. A recent paper in Circulation (2012;126:589–97) recommends the implementation of a fifth link: transfer to a tertiary hospital where patients may receive intensive post-resuscitation care, appropriate circulatory and respiratory support, therapeutic hypothermia and percutaneous coronary intervention. Data suggests that implementation of the fifth link is associated with a significant improvement in neurological outcome after out of hospital cardiac arrest.

Injuries from bouncers

Lausanne is famous for its nightlife, with 30 000 night clubbers enjoying it on a typical weekend. However, there may be another side to the story. A study published in the Journal of Forensic and Legal Medicine (2012;19:341–4) describes injuries allegedly inflicted by nightclub security guards on 70 of their ‘clients’ in the city over a 3 year period. 18 of these clients sustained one or more fractures (all involving the face or head). Based upon their results, the authors raise concerns about the violent way that nightclub security guards interact.

Suicide

Evidence that the current economic downturn may be responsible for increased rates of suicide is presented in the BMJ (2012;345:e5142). The data suggest that a significant proportion of the increase in the number of suicides may be attributed to rising unemployment. In what might be considered to be an equally depressing article in the same journal (BMJ 2012;345:e4972), a randomized controlled trial failed to show any significant effect for assertive outreach intervention after a failed suicide attempt.

Diagnosing appendicitis in children

Diagnosing appendicitis in the pediatric population is often challenging due to the lack of clear historical and physical examination findings. The use of CT scanning in suspected appendicitis has increased, but the importance of minimizing radiation exposure has resulted in the development of clinical practice guidelines. The evaluation of one set of clinical guidelines was undertaken in a US Emergency Department. Researchers found that implementation of guidelines based on risk-stratification, staged imaging and early surgical intervention in high-risk cases resulted in lower rates of negative appendectomy and missed appendicitis. 58% of patients were managed without a CT scan (Academic Emergency Medicine 2012;19:886–93).

Poisoning in young children

In the 1950s most cases of childhood poisoning were due to ingestion of household products. However, today, an overwhelming majority of overdoses in children are due to ingestion of medication and pharmaceutical agents. Recent data reveals a 20% rise in ED visits of children aged less than 5 years presenting with medication overdose between 2005 and 2009. This may be due to the increasing availability of medicines in the home. An expert from the UK National Poisons Information Service argues that blister packs (which are excluded from standards set for child-resistant packaging) should also be adapted to protect children, along with further education of parents regarding storage of medicines. While child-resistant packaging has undoubtedly been a great advancement in the protection of children against accidental poisoning, it is clear that further action still needs to be taken (Arch Dis Child 2012;97:831–2).

Administration of medication in children

The potential for over-dosage and administration of sub-therapeutic dosage is much greater in children than in adults. This may partly reflect inconsistencies in the various devices used to measure oral medication, including metal spoons, calibrated spoons and oral syringes. A study from Cambridge found that although oral syringes produce the smallest variance in volume, parents are most accurate at administering medication with a calibrated spoon. The researchers conclude that in order to further improve dosing accuracy, parents should be educated on the correct use of oral syringes (Arch Dis Child 2012;97:838–41).

Treatment of bronchiolitis in children

The mainstay of treatment for bronchiolitis in children is supportive care with an emphasis on fluid replacement, gentle suctioning of nasal secretions, prone positioning, and respiratory support if needed. For a long time, pharmacological agents were not thought to be of any benefit in the treatment of this self-limiting viral respiratory tract infection. However, a review of recent literature published in Archives of Diseases in Childhood (2012; 97: 827–30) suggests that the combination of nebulized adrenaline with either oral dexamethasone or mixed with 3% nebulized hypertonic saline can be beneficial in treating the acute symptoms of bronchiolitis, as well as decreasing the length of hospital stay. Although both strategies appear to be safe and well tolerated, further research is needed to clarify their roles in clinical use.

Post-intubation hypotension

A retrospective study of 336 consecutive patients intubated in the ED examined the relationship between post-intubation hypotension and mortality rates. Post-intubation hypotension was relatively common, occurring in 23% of all cases. It was associated with increased mortality and increased length of hospital stay. The study was conducted in a single, large ED in the USA where etomidate and suxamethonium were the standard RSI drugs. Patients with post-intubation hypotension were more likely to have left ventricular dysfunction, to be taking β-blockers and to have required intubation for respiratory failure. Although post-intubation hypotension was an independent risk factor for death, the design of the study does not allow any comment regarding causality. Further work looking at aggressive correction of hypotension after intubation with vaso-active drugs would be useful (J Crit Care 2012;27:417.e9–13).

Improving arrest outcomes

A very large study of community cardiac arrests in the USA has revealed a major reduction in hospital mortality rates (from 70% to 58%) between 2001 and 2009, despite an increase in the number of relevant co-morbidities. The authors postulate that interventions such as therapeutic hypothermia, promoting uninterrupted chest compressions and increased public access to automatic external defibrillators may be responsible (Circulation 2012;126:546–50).

Bedside Focused Echocardiography as Predictor of Survival in Cardiac Arrest Patients

This systematic review in Acad Emerg Med 2012:19 confirmed that bedside echocardiography is able to help predict which patients will and will not survive cardiac arrest, when combined with clinical findings. It also demonstrated though that patients should not be pronounced deceased on the basis of a single ultrasound scan alone. It called for a larger trial to be done, which we are currently participating in (REASON).

 

 

Statins and sepsis

It has been suggested that statins may modulate the immune cascade in severe infection. A small, retrospective cohort study of 91 patients examined outcomes in patients admitted to the intensive care unit with severe sepsis, focusing particularly upon whether they were already on statin treatment prior to presentation. Severity of illness appeared to be similar in both groups. Patients taking statins required mechanical ventilation for significantly fewer days and there was a strong trend to improved mortality compared to those patients not taking statins. Future researchers might consider investigating the effect of commencing statins on presentation in patients with severe sepsis (Eur J Em Med 2012;19:226–30).

Stroke thrombolysis at 6hours?

The Lancet reports on the largest trial to date of stroke thrombolysis (2012;379:2352–62). The third international stroke trial (IST-3) recruited patients of all ages and treated with thrombolysis up to 6 h after the onset of symptoms. The majority of patients were over 80 years of age and the mean time to thrombolysis was 4.2 h. Mortality rates and the number of patients living independently at 6 months follow up were similar. The study was slow to recruit and despite involving 3000 patients underpowered.

Curb-65 could be sweeter

A German study published in the BMJ (2012;344:e3397) interrogated a database of community acquired pneumonia patients (‘CAPNETZ’) and reports the association of hyperglycemia on admission and death. Mortality rates were not only higher in diabetic patients, but also in patients who had high glucose levels without being known to be diabetic. An admission glucose of 11 mmol/l or more significantly increased the risk of death. Future research is needed to examine benefit on glycemic control.

Pain in the elderly

A retrospective study of a large American database of patients attending the ED with painful conditions revealed that elderly patients (aged 74 or over) were much less likely to receive opioid analgesia or indeed, any analgesia. The authors suggest that doctors may be over-concerned about possible adverse effects of analgesia or pre-occupied by diagnosis in the elderly (Ann Emerg Med 2012;60:199–206).

Don’t give magnesium

In some centres, an intravenous infusion of magnesium sulphate solution is given as standard therapy following aneurysmal subarachnoid hemorrhage. Magnesium is believed by some to have a neuro-protective role in cerebral ischemia. The Magnesium for Aneurysmal Subarachnoid Hemorrhage (MASH-2) trial involved 1204 patients treated in specialist neurosurgical centres with either daily intravenous magnesium sulphate (64 mmol per day) or placebo. There was no difference in dependence or mortality rates at 3 months after hemorrhage (Lancet 2012;380:44–9).

D-Dimer cut off for DVT

A Dutch study of primary care patients suspected of having a deep venous thrombosis (DVT) found that increasing the cut off value for D-Dimer (from 500 to 750 μg/l) in patients aged 60 years and over reduced the number of false positives by 5% without missing any more DVTs. The authors argue that changing the cut off value would reduce the cost and inconvenience of subsequent Doppler ultrasound testing (BMJ 2012;344:e2985).

Scaphoid fractures

News from a systematic review and meta-analysis of the management of acute scaphoid fractures published in Surgeon (2012;10:218–29). Having reviewed the available evidence, the authors conclude that undisplaced fractures of the scaphoid can be satisfactorily managed by a period of immobilization in a Colles type cast. They argue that operative treatment for displaced fractures (using an open rather than percutaneous approach) may help to provide a higher union rate.

Sudden unexpected death in young childhood

A paper in the Arch Dis Child (2012;97:692–7) reports the analysis of all Sudden Unexplained Deaths in Children (SUDC) in 1–4-year-olds in Ireland for a 15 year period and makes comparisons to Sudden Infant Death Syndrome (SIDS). Although rare, SUDC rates are increasing. Unlike SIDS, SUDC cases often have a history of preceding illness or febrile seizures, slept alone and are found prone. The evidence presented suggests that the two events are not degrees of the same spectrum, but have different causal factors.

Survival after cardiac arrest in hospital improves in the US

Survival after cardiac arrest in hospital improved significantly between 2000 and 2009 in a study from the US (N Engl J Med2012;367:1912-20). A large group of well motivated hospitals saw overall survival rise from 13.7% to 22.3% (P<0.001 for trend), while the prevalence of neurological disability in survivors fell from 32.9% to 28.1% (P=0.02). The authors report significant improvements in survival for adults with asystole or ventricular fibrillation, for men and women, and for adults under and over 65 years.

The positive trends remained significant through extensive adjustments for changes in patient and hospital characteristics, including a shift in initial rhythm (proportion with asystole or pulseless electrical activity 68.7% in 2000 and 82.4% in 2009).

By 2009, more people were surviving their initial arrest, and more of those survivors were making it home. The authors suspect that improvements in care before, during, and after an arrest are responsible and call for further work to find out. They analyzed data from a register of cardiac arrests that did not record response times, quality of resuscitation techniques, or specific treatments such as hypothermia.

In all, 374 hospitals across the US contributed data to the register, which was set up as part of a quality improvement initiative. These findings may not extend to hospitals outside the network or to patients who arrest in emergency departments, procedure suites, and operating theatres, say the authors. All 84 625 adults in this study had their cardiac arrest on wards and intensive care units.

Administer tranexamic acid early to injured patients at risk of substantial bleeding

In a systematic review of antifibrinolytic drugs in trauma the only trial to assess hemorrhage was the randomised placebo controlled CRASH-2 trial (Cochrane Database Syst Rev 2011;1:CD004896.), which evaluated the effects of tranexamic acid in 20 211 adult trauma patients with or at risk of bleeding in 274 hospitals in 40 countries. Tranexamic acid given within eight hours of injury reduced all cause mortality from 16.0% to 14.5% (relative risk 0.91, 95% confidence 0.85 to 0.97), and the risk of death resulting from bleeding from 5.7% to 4.9% (0.85, 0.76 to 0.96). There did not seem to be more vascular occlusive events, nor did the effect of tranexamic acid seem to vary by baseline risk of death. Subsequent re-examination of the 1063/3076 (35%) deaths that resulted from bleeding found that the benefit of tranexamic acid was greatest when given early (<1h: 0.68, 0.57 to 0.82; 1-3 h: 0.79, 0.64 to 0.97) and that, when given more than three hours after injury, an unexpected increase in deaths from bleeding was observed (1.44, 1.12 to 1.84). Extrapolation of the CRASH-2 data led to estimates that more than 100 000 in-hospital deaths globally could be averted annually and 315 to 755 life years saved per 1000 trauma patients, at a cost of $45-$64 (£28-£40; €35-€49) per life year saved.

How should we change our practice?

Administer tranexamic acid 1g intravenously in 100 mL normal saline over 10 minutes then 1 g over eight hours, starting as early as possible and no later than three hours after injury, to trauma patients who have or are at risk of major hemorrhage. Prehospital services with capacity for drug administration should consider incorporating its administration into protocols for trauma care.

 

Best regards,

 

Paul Atkinson

Site Director Research

 

Sources:

  1. Sophia Series. Emergency Medicine Journal 2012
  2. Clinical Topics: Emergency Medicine. BMJ 2012

Local Research Report

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