Journal club: Canadian C-spine and NEXUS rules

 

Neck pain post blunt trauma is a very common ED problem.

This review looks very briefly at the two main clinical decision rules used in these patients: NEXUS and CCR.

The link to the NEXUS and CCR article is here.

The link to the NEXUS and CCR analysis, and the CASP guidelines used are here.

One interesting feature that comes up going through the literature is that these decision rules were made with XR as the gold standard of imaging, something which has changed in the last few decades due to publications of papers showing XR having a sensitivity of roughly 50%[1].

However, both of these decision rules had very good follow up (telephone questionnaires in CCR and review of local neurosurgical records and quality assurance logs in NEXUS) without missed injuries being identified.  Not sure what to do with that!

Personally, when possible I prefer to use the CCR rule due to the higher specificity, addition of ROM and a study[2] which compared CCR to CT which showed no missed injuries (Population 3,200 with 192 fractures).

This article was interesting in that it’s results suggested that the CCR rule had a specificity of only .6% for C-spine fractures…which again I’m not sure how to interpret.

 It’s reassuring to know that none were missed however.       

Would be very keen to hear how other people approach this problem.

Cheers.


 

[1]Mathen R, Prospective evaluation of multi-slice computed tomography versus plain radiographic cervical spine clearance in trauma patients, Journal of trauma, 2007, 62(6) 1427

[2]Duane T, Canadian Cervical Spine rule compared with computed tomography: a prospective analysis, Journal of Trauma, 2011, 71(2), 352-355.

3AM Rundown: Sympathetic acute crashing pulmonary oedema

Those that listen to Scott Weingart on EmCrit will recognise that this is basically taken from his podcast on SCAPE.

I’ve used the management plan on a number of patients’ now and find it really effective.

Saved me a couple of intubations.

If you want some more information or a more entertaining presentation I would recommend checking out podcast 1.

Should emphasise that this algorithm is geared towards the typical 6am patient presenting with marked sympathetic overload (diaphoretic/hypertensive) and signs of acute pulmonary oedema as compared to the patient with a bit of fluid in their lungs secondary to CCF

Run down:

  1. Pathophysiology: Afterload mediated heart failure.

- Aim of treatment is to decrease SBP rapidly and remove the oedema from the lungs with PPV

    2.   Treatment:

- PEEP: Start at 6-8 and titrate up to 10-12 as tolerated

- GTN Infusion: Loading dose of 400mcg/min for 1-2 minutes (or until lose radial pulse) and then decrease to 60mcg/min.

- Dosing using our infusion concentrations: 50mg in 500mls = 100mcg/mL

- Would start the infusion at 240mls/hr and decrease to 60mls/hr after any of the endpoints below:

  •          SBP normalising
  •          Infusion lasting 2 minutes
  •          Losing radial pulse (it comes back quickly!)

Titrate to blood pressure: Goal roughly SBP of 120mmHg

- Can use low dose captopril once patients stabilised to facilitate weaning of GTN drip (3.125mg-6.25mg)

- Don’t waste your time with frusemide: GTN more effective and patients with SCAPE can often be volume deplete.

If you have any thoughts/criticisms about this protocol feel free to post in the comments.

Cheers.

3AM Rundown: Automonic dysreflexia

The idea for these posts are to have some brief rundowns/management plans for critical pathologies that may come in overnight when you don’t have the time/head space to review the correct management.

If you had any additional thoughts/tips for the topics covered then please feel free to add those in the comments…any suggestions would help make this resource much better.

The first post is on autonomic dysreflexia.

I’ve only seen two patients with this, and the algorithm listed was incredibly helpful in working through the issues.

Algorithm listed here.

The Rundown:

1. Pathophysiology: Loss of coordinated autonomic responses to stimuli due to spinal cord damage above T6

2. Important tip: Normal blood pressures concerning in spinal patient.

- If SBP > 20mmHG above resting BP = Autonomic dysreflexia till proven otherwise

3. Symptoms: Headache/flushing are concerning

4. Causes: Retention and constipation big two.

- If not these then a head to toe exam for other painful stimuli required.

5. Why concern?: Hypertensive crisis. Seizures/Cardiac arrests/ICH

6. Treatment: As per algorithm.

7. Who to call for help: Rehab physician unless at large centre (Spinal Consultant)

Could this be Necrotising Fasciitis: The LRINEC study

I recently undertook a literature search surrounding this, after I was asked the question on a shift and found out that I really had no idea how to distinguish between necrotising fasciitis (NF) and severe cellulitis.

Unfortunately, it appears that this is a common issue, with the largest trial showing that only 15% of patients with NF were diagnosed on admission.

Which is a problem, seeing as the main predictor of mortality is time to surgical debridement.

Thankfully there are some tools to help us with this, in particular a clinical decision rule (LRINEC), bedside US, and the “finger test”.

The link to the LRINEC study is here

This was analysed using the CASP questions on clinical prediction rules: Analysis.

- For Questions please reference CASP UK website

The link to the finger test description is here.

- Page 1027 of this article or 1539 of the LRINEC study.

The link to the US study is here.

- Videos of normal and positive US are listed as well.

Bottom line:


1. Pathophysiology: Rapidly progressive infection involving the fascia and subcutaneous tissue with thrombosis of the cutaneous microcirculation.

- Moves from horizontal to vertical plane of spread.

2. Mortality rate = 34%. 

- Early operative debridement key to decreasing mortality.

- Appearance early difficult to distinguish from cellulitis or abscess

3. Clinical triad: Exquisite pain (98%)/swelling (92%) and fevers (80%)

4. Appearance: Initial = Redness with ill-defined borders.

 - Horizontal plane: Rapidly progressing with severe pain and tenderness beyond apparent area of involvement

- Vertical plane: Bullae →Gangrene (Necrosis/ulceration/crepitus and SC emphysema)

5. Investigations:

- Bedside US = STAFF examination:  Subcutaneous thickening, air, fascial fluid = 93% Specific

- LRNIEC scoring system: Score ≥ 6 requires further investigations

- Finger test: ↓Bleeding/”dishwater pus”/lack of resistance to blunt dissection post 2cm incision positive findings

- CT/ MRI helpful in ambiguous cases

6. Any patient with a LRINEC score of 6 requires further investigations for NF

- Quick algorithm listed here

website re-design

I am contemplating on re-designing the website a little to make it more 'user-friendly' on the front and back end, especialy on mobile devices.  Unfortunately, that means there would be a few changes in the ways we can access the website. 'User-friendly' usually means complex programs and software running in the background, all of which do not play nice with the arachiac versions of windows Internet Explorer, the web browser of choice on all HNEH computers.   Before I bite the bullet and go ahead, I am interested to hear many of your opinions on the matter and whether there is anything more or less you would like on our department website.  PLEASE, fill out this short survey and/or comment to this post.

 

Create your free online surveys with SurveyMonkey , the world's leading questionnaire tool.

 

Journal club: Transfusion strategies for acute upper GI bleeding

The study: in 921 patients with severe acute upper GI bleeeding, 461 were randomally assigned to a restrictive strategy (transfusion when Hb < 7 g/dL) & 460 were randomally assigned to a liberal strategy (transfusion when Hb < 9g/dL).

 

Result: In patients with severe acute upper gastrointestinal bleeding the outcomes were significantly improved with a restrictive transfusion strategy (Threshold < 7 g/dL). The restrictive group received significantly less transfusions. This resulted in a reduction in cost & use of blood. The restrictive group had a lower mortality, rebleeding & complication rate.

 

BOTTOM LINE: Having a transfusion threshold of < 7g/dL appears to have increased benefit, reduced harms & reduced costs. It appears to be a safe option for managing haemdynamically stable patients with upper GIH who are not exsanguinating. (It is important to note that patients with acute coronary syndrome, transient ischaemic attack, stroke and symptomatic peripheral vasculopathy were excluded from this study & therefore need to be considered for a more liberal transfusion strategy.)

 

Link to the full article

 

Link to the full review