March 2016: New in EM

[Direct Download Podcast MP3]

Welcome to the first in a new series of monthly podcasts at the RCFN looking at recent literature. There’s been a lot of feedback requesting literature round ups and hopefully this podcast will help to scratch that particular itch.

We are very much standing (maybe wobbling) on the shoulders of giants here and it’s worth noting some of the guys who have been doing this type of thing long before us:

Paper Number 1

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This is a perpetual fight in the ED I find. Increasingly we seem to have moved toward VBGs for almost everything and the ABG has got quite a pounding for being painful, cumbersome and unnecessary. The two areas with dubious accuracy have been hypercarbia and the VBG in severe shock. This is now the second paper (including AM Kelly – the VBG guru) we’ve seen looking at an algorithm that avoids an ABG for every COPD exacerbation. (note the NICE  guidelines recommend this).

This paper is observational data – everyone got paired venous and arterial and they tried to correlate the ph, HCO3 and CO2 etc… They enrolled 234 pts and found good correlation for all the numbers apart from CO2 which is not surprising. Effectively they suggest if you have a normal VBG (ph, HCO3 and CO2 <6) then an ABG is not going to help you. This would have saved 2/3 of people from an ABG. They also suggest a reasonable algorithm about when to do the ABG. 

VBG COPD Algorithm

Click for source – open access

Other FOAMed resources

 

Paper Number 2

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Simple but effective trial – important to give adequate analgesia in patients with hip fracture. No-one was previously sure which block was better for pain relief. Physicians all have personal preference. This RCT shows FIB equivalent to femoral nerve block in the ED.

Other FOAMed resources:

  • StEmlyns - check out their references for some comprehensive FOAMed reading…

 

Paper Number 3

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This is a really important topic with the trend towards more ED led airway management to catch up with Australian and US practice. This systematic reivew was looking to quantify how much experience is needed in order to get to 80 and 90% ETI intubation success rates.

  • 13 studies with a total of over 1,400 students and over 19,000 patients.
  • The students were first year residents, medical students or paramedic students.
  • Studies were performed in operating theatres (excluding one).

They found that 51-75 of ET intubations needed to be performed to achieve a success of intubation of at least 90%, with 1-43 intubations required to achieve an 80% success rate. To achieve first pass success rate of at least 90% one paper demonstrated there was a requirement for over 200 ET intubations.

Questions to be answered - what first pass success rate is acceptable? Can we extrapolate that to ED practice as not ED based papers? How are we likely to proceed with airway management in the UK?

 

Paper Number 4

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Relevant and useful, CVC insertion can take a while and butchering with multiple attempts at peripheral iv cannuala insertion with futility is bad! This was a convenience sample – not necessarily the sort of patients I’d be going for; 7 discharged from ED and 26 admitted. They were also using longer than our standard cannualae! What ever happened to the good old external jugular!! There’s a great discussion on this paper over on Ryan’s site and the comments are well worth a read.

Paper Number 5

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A lot of research on how we make decisions is based around theoretical cases with various nuggets provided at different stages to see how that changes things. This is real time in-situ decisioning making research. They followed a bunch of experienced french EPs and did qualitative research on how and why they did what they did. They said this was “focussed ethnography” research which was a new thing to me. The doc wore a camera – something like a GoPro or a Google Glass it sounds like and these were used with interviews to talk about how decisions were made. the quotes make this paper INMHO and its nice to see it documented that the reason we make decisions is governed by such subtle, complicated factors as “I know frank…”  Hat tip to Jeremy Fried and LITFL for the tip off to this paper

Paper Number 6

 

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The HEAT trial examined patients with a fever on ITU being treated for infection and randomly assigned 6 hourly paracetamol or placebo until either resolution of fever/cessation of treatment for infection or until discharge from ITU. Primary outcome of ITU free days at 28 days. They found no statistically significant difference in the number of ITU free days between the groups and interestingly they also found no difference between 28 or 90 day mortality between the 2 groups. Goes with an increasingly large evidence base that the knee jerk reaction to treat an infection driven fever is not proven to be in the benefit of the patient.

Personally I like Paul Young’s take on his own trial:

Other FOAMed resources:

 

 

Cutting Edge Advances in Major Trauma Care 2015

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September 2015 brought us the superb RCEM Annual Scientific Conference in Manchester. Rick Body and the Organising Committee did a superb job of providing us with 3 days of education, entertainment and networking.

For those of you who weren’t able to attend and for those of you who want to listen again to some of the great talks, this month we’ll be bringing you some of the superb plenary sessions on the podcast.

Gareth Davies is the speaker for this podcast on cutting edge advances in major trauma care 2015.

Pee Values

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Routine urinalysis in patients with a blunt abdominal trauma mechanism is not valuable to detect urogenital injury
Dominique C Olthof, Pieter Joosse, Cornelis H van der Vlies, Theo M de Reijke, J Carel Goslings.
Emerg Med J doi:10.1136/emermed-2013-202651

Description

This was a retrospective observational cohort study conducted by a group of Dutch trauma specialists in the Netherlands between 2008-2011.

Summary

1815 consecutive adult (>16yrs) trauma patients who passed through the ED. Data was retrieved from a local trauma registry. The study looked at whether patients had urinalysis and/or imaging performed. ‘Imaging’ included: FAST, AUSS, or CT. Investigation results were correlated with ‘clinical consequences’.
Clinical consequences were defined as
-additional imaging
-intervention eg embolisation, catheterisation, laparotomy
-patient admitted for a period of observation
-patient scheduled for follow-up as outpatient.

Results

75% of patients had urinalysis performed. The remaining patients had no urinalysis but may have had imaging.
In all the patients who had urinalysis, approximately 80% had no haematuria. 20% had microscopic haematuria. Approximately 1 % had macroscopic haematuria
8% of all patients in the study had a urogenital injury diagnosed.

Patients were divided into 4 groups depending on whether they had urinalysis and or imaging performed.

Group A: Urinalysis and imaging performed. (1032 patients):

Urogenital injury in this group was 5%

20% (220 patients) had microscopic haematuria.
- 5% (11 patients) of patients with microscopic haematuria had ‘clinical consequences’.-
- However 9 of these 11 clinical consequences were further scans or follow-up.-
- 1 of the other 2 patients had massive abdominal injuries and therefore the dipstix test was unlikely to be the decision maker.
- Only 0.5% of patients (n=1) with microscopic haematuria had an intervention.

2% (16 patients) had macroscopic haematuria.
- 69% (11 patients) had clinical consequences.
- 2/11 were interventional procedures for abnormalities picked up on imaging. The rest was observation, more scans and follow-up.

Patients with a negative urine dip (77%) had no clinical consequences.

Group B Urinalysis performed. No Imaging. (332 patients):
16% had micro haematuria. No clinical consequences.

Group C Imaging but no urinalysis. (268 patients):
1% (4 patients) of this group had urogenital injury and all had an interventional procedure. All interventions were variations on catheterisation.

Group D consisted of patients who had neither urinalysis nor imaging. (184)
As such no injuries were detected and no clinical consequences arose..

Headline Results

Group A (1031, 57%) had both imaging and urinalysis
Findings of microscopic haematuria was associated with clinical consequences in only 5% of patients. 1% of patients required an intervention.

Findings of macroscopic haematuria was associated with clinical consequences in 69% of patients – whether a procedure , observation, further imaging or follow-up. The number of interventions was low (2) and in fact most people either had further imaging or were admitted for observation.

Group B (332, 18%) urinalysis, no imaging.
Findings of microscopic haematuria wasn’t associated with clinical consequences in any patients.

Limitations

Validity:
● Retrospective study
● No gold standard limits analysis obviously it isn’t ethical to CT scan every patient.
● Whether the scan was done because of the urine results or for another reason. The authors say that only imaging performed to diagnose urogenital injury were analysed, which would imply it was because of the dip. However, they included FAST scans……..
● What type of scan- not surprising had a normal fast.
● If a patient had an intervention and was then admitted for observation was that counted twice?
● Follow up period- how long were they followed up for.

Generalisability:
● No issues noted
● Similar population to UK
● Similar type of trauma
● Similar access to CT

So what now?

Urinalysis does not carry much weight over and above the rest of your clinical assessment in the decision to scan or not to scan.

Could it add unnecessary investigation and follow-up?

A study mentioned in the introduction suggests that abdominal tenderness and haematuria had a sensitivity of 64% for intra-abdominal injury. This isn’t very impressive as a screening test, and the study was in 1998 prior to the widespread use of early trauma CT.

In both studies the absence of haematuria does appear to be re-assuring. But we cannot infer that a negative dip would be the deciding factor in the decision to image.

The paper suggests potential subgroups in whom urinalysis may be useful, (eg fall from height, fall from horse, direct blow to the flank) however in practice we think these groups will have a higher chance of being scanned, and we question whether urinalysis would be the deciding factor in this decision.

Finally – patients with microscopic haematuria should be followed up by the GP for repeat testing, in case there is a medical cause for the haematuria.