EM Journal Club – The BUCKLED Trial

Presenter: Dr. Casey Jones (RCPSC EM PGY1)
Host: Dr. David Lewis 


Ultrasonography or radiography for suspected pediatric distal forearm fractures

Snelling et al., for the BUCKLED trial group

NEJM, 2023; 388:2049-2057.


PICO

  • Research Question: Is ultrasonography non-inferior to X-ray with respect to ..
  • Population: Children and adolescents between 5–15 years old presenting to an ED with an isolated, acute, clinically non-deformed distal forearm injury
  • Intervention: Randomization to either POCUS by a trained ED practitioner or radiography for injury evaluation
  • Comparison: POCUS vs Radiography
  • Outcome: Self-reported physical function of affected arm at 28 days

 

Background

  • Forearm fractures represent 40-50% of all childhood fractures
  • Distal third of forearm accounts for ~75% forearm fractures and 20-25% of all pediatric fractures
  • Most fractures are buckle fractures, treated conservatively with a wrist splint
  • Other pediatric fracture patterns include greenstick, Monteggia, Galeazzi, and Salter-Harris fractures
  • POCUS for distal forearm fractures is accurate, timely, and confers no radiation.
  • Ultrasonography may be more accessible in low and middle-income countries.
  • Is POCUS just as good as x-ray in diagnosing distal forearm fractures in pediatric patients?

 

Methods

  • Bedside Ultrasound Conducted in Kids with Distal Upper Limb Fractures in the Emergency Department (BUCKLED) trial
  • Study Design: Multi-center, open-label, noninferiority, randomized controlled trial
  • Setting: Four centers in Queensland, Australia (large tertiary pediatric hospital, two large mixed academic hospitals with dedicated pediatric treatment areas within their emergency departments, and one mixed hospital without a dedicated pediatric treatment area)
  • Inclusion criteria
    • Age 5-15
    • Distal forearm injury requiring radiological evaluation
    • Ability to follow up (distance from centre, telephone, internet access)
  • Exclusion criteria – many, but namely:
    • Obvious angulation
    • Injury sustained >48 hr prior to presentation
    • Compound / open fracture, neurovascular compromise, known bone disease
    • Suspicion of non-accidental injury, additional injuries
  • Imaging modalities
    • X-Ray – minimum 2 views performed by radiography. Classified by treating clinician (not radiologist) into either: no fracture, buckle fracture, other fracture
    • POCUS – 6-view forearm POCUS protocol with assessment of secondary signs (Snelling et al., 2020, BMJ)

 

  • POCUS credentialling
    • Scans in the study were done by either: nurse practitioner, physiotherapist, or emergency physician
    • Training course – 2 hour simulated course with lectures and staged learning (scanning)
    • 3 proctored scans on actual patients
    • Logbook of total 20 patients with a mix of at least 10 buckle and cortical breach fractures, then image interpretation quiz
  • Outcome measures:

  • Statistical analysis

    • Assumed true between-group difference in PROMIS score of 0 at 4 weeks, with noninferiority margin of 5 points (chosen by experts from trial group)
    • Power: 300 participant enrollment  outcome data for 224 participants (112 per group)  90% power with one-sided alpha of 0.025
    • Primary outcome of PROMIS score at 4 weeks was analyzed for noninferiority of ultrasonography to radiography
    • Primary analysis was with linear regression modeling to assess noninferiority of POCUS to radiography

Results

  • Participant characteristics (Table 1)
    • Well randomized groups for ultrasound and radiography (n=135 each group)
  • Primary outcome:
    • PROMIS (physical function score) at four weeks showed no difference between ultrasonography and radiography

  • Secondary outcomes:
    • No difference in physical function scores at week 1 or 8 between POCUS/X-ray
    • Parent / caregiver-reported satisfaction (5-point likert scale) appeared to be greater in POCUS group vs X-ray at 4 weeks (0.19 points) and 8 weeks (0.20 points)
    • Patients in POCUS group had shorter length of stay in the ED (median difference: 15 minutes), and shorter treatment time (median difference: 28 minutes) versus X-ray group
    • No substantial difference between groups in number of follow-up radiography films obtained up to week 8

 

Authors Discussion and Conclusions

  • The authors show that point-of-care ultrasound can be used as an initial diagnostic test in distal forearm injury in pediatric patients, with XR reserved for features suggestive of a diagnosis that leads to casting and follow-up (i.e. POCUS best suited for diagnosing buckle fractures)
  • Reduced initial radiography at initial ED presentation, especially in patients with buckle fracture or no fracture.
  • A diverse group of health care practitioners (physicians, nurse practitioners, physiotherapists) were trained to use ultrasound for this purpose
  • “The present randomized trial examined the feasibility, safety, acceptability, and timeliness of using an ultrasonography-first approach to the diagnosis of clinically non-angulated distal forearm injury in children and adolescents who presented to the emergency department.”

Discussion at journal club

Strengths

  • Well powered trial to study their question of non-inferiority of POCUS to XR
  • Feasible approach to imaging distal radius, and transferrable to many health professions
  • Showed that simple fractures can be initially imaged with POCUS only

Weaknesses

  • Children with features of a more concerning fracture (i.e. anything more than a buckle) received x-ray anyway (122 films were obtained in POCUS group vs 375 in XR group)
    • To that end, does this study show that POCUS may only be appropriate for simple fractures?

Bottom Line

This was a well-designed and executed study by this group in Australia. This method of diagnosing distal forearm injuries would be helpful in rural or resource-limited settings that don’t have readily accessible X-ray. I will certainly be using this more at the bedside in children with this injury pattern!


Further Reading

Quick Take NEJM Video

View the author’s webinar here

 

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Journal Club – Diagnostic Accuracy of ECG for Acute Coronary Occlusion resulting in MI

Presenter: Dr. Nick Byers (iFMEM R2)

Host: Dr. Colin Rouse

Article:

Research question/PICOD

  • Question:
    • Does shifting from a STEMI/NSTEMI paradigm to a new approach (ACO-MI/ non-ACO-MI) result in better identification of the patients who need acute reperfusion therapy?
  • Population:
    • Adult ED patients with ACS Symptoms
  • Intervention/Comparison:
    • STEMI/NSTEMI vs ACOMI/NACOMI
  • Outcome:
    • Composite ACO defined as one of:
      • A) Total occlusion or presence of culprit lesion on angiography with a peak troponin I level equal to or greater than 1.0 ng/mL plus an at least 20% rise within 24 h
      • B) A highly elevated peak troponin (greater than 5.0 ng/mL), which was shown to be correlated with ACO
      • C) Cardiac arrest before any troponin rise has been documented with supporting clinical evidence of possible ACO
    • All cause in hospital mortality
    • All cause long term mortality
  • Secondary Outcomes: 
    • Time from ECG to coronary angioplasty or CABG
    • The sensitivity and specificity of current criteria in diagnosing ACO
    • The sensitivity and specificity of ECG without ST-segment elevation to diagnose ACO (accuracy of ECG interpretation of acute coronary occlusion without STEMI criteria)
    • The specificity of ECG with STEMI criteria (correct ECG interpretation of false positive STEMI criteria)
    • The sensitivity of ECG with STEMI criteria (correct ECG interpretation of false negative STEMI criteria)
    • The outcome according to ECG subclassifications (outcomes of the patients who are labeled as STEMI and the patients who are labeled as having NSTEMI but have acute coronary occlusion)
  • Design:
    • Single center, retrospective case-control study in Turkey

Results

Authors conclusions

“We believe that it is time for a new paradigm shift from the STEMI/non-STEMI to the ACOMI/non-ACOMI in the acute management of MI”

 

Discussion at Journal Club

Strengths

  • 3000 patients included, 1000 per arm
  • Reviewers were blinded, disagreements were resolved by a 3rd independent reviewer
  • EKGs were reviewed again 3 months later to decrease inter-observer variability
  • Consecutive patients with an initial diagnosis of MI (i.e. not a convenience sample)
  • All patients received guideline-recommended medical treatment
  • There were documented criteria of ECG findings to classify the ECGs

Weakness

  • This was a retrospective study and at a single centre.
  • When troponins were taken was not controlled for/accounted for in any way
  • Control group age, medical comorbidities, and cardiac risk factors were much less
  • Their results suggest 17% of patients in N-ACOMI (N-STEMI Subgroup B) with angiographic ACO were missed (slide 16 results)
  • Study wasn’t powered enough to indicate modest benefit of early intervention over late
  • Extrapolating results to the real world may be difficult because ecg interpretation

 

Bottom line/suggested change to practice/actions

  • This single center retrospective chart review suggests that considering coronary occlusion vs. just ST elevation on ekg decreases long-term mortality, and has a better sensitivity, specificity, PPV, and NPV.
  • This could be a great way of getting patients better access to PCI for occlusive lesions, though inter-operator variability and time constraints are likely to be difficult to implement

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Handover from EMS to Trauma Team: an analysis

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PoCUS for Diverticulitis

Dal PoCUS Fellowship – Journal Club – Feb 2021

Dr. Mandy Peach  CCFP-EM

PoCUS Fellow

Dalhousie University Department of Emergency Medicine

 

A Prospective Evaluation of Point-of-Care Ultrasonographic Diagnosis of Diverticulitis in the Emergency Department Allison Cohen, MD*; Timmy Li, PhD; Brendon Stankard, RPA-C; Mathew Nelson

 

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