New in EM 008: Do minor ankle sprains need physiotherapy?

Originally Published on RCEM Learning Podcast June 2017

As part of the RCEM Learning Podcast I record reviews of recent literature with Dave McCreary. We’ve been doing this for about a year now and you can hear them all on the RCEM Learning Podcast each month. I’d like to have them here and searchable on this site too so I’ll be posting the ones I find most relevant here. You can hear the newest ones by subscribing to the free RCEM Learning Podcast. 

Audio:

Authors: Dave McCreary, Andy Neill

Codes: CC21,CAP 33

Clinical Question:

  • Do minor ankle sprains need physiotherapy?

Title of paper:

Journal

  • British Medical Journal 2016

Author

  • Robert Brison

Background

  • We see lots of low grade sprains in the ED
  • Clinical standards for the treatment of them arent well defined
  • Physiotherapy is a great but finite resource so we need to know if they add anything to these injuries

Study type

  • Parallel group RCT

Patients

  • 16 years
  • Simple grade I & II ankle sprain
    • Included clinically unimportant avulsion fracture (<3mm displacement)
    • Within 72 hours of injury
  • Excluded: multiple injury, other condition limiting mobility, ankle injury requiring immobilisation, unable to accommodate time consuming protocol

Intervention

  • Supervised program of physiotherapy plus usual care

Comparison

  • Usual care
    • Written instructions for RICE, graduated weight bearing activities

Outcomes

  • Primary – proportion of participants reporting excellent recovery
    • Assessed with foot and ankle outcome score (FAOS)
    • Defined as 450/500 at 3 months
    • Difference of 15% increase in absolute proportion of participants with excellent recovery deemed clinically important.
  • Secondary:
    • Assessment of excellent recovery at one and six months
    • Change from baseline using continuous scores at 1, 3, 6 months
    • Clinical and biomechanical measures of ankle function at 1, 3, 6 months

Results

  • 504 patients randomised
  • No significant difference in excellent recovery at 3 months
    • 43% PT group vs 37% usual care
    • Absolute difference 6%, CI 3-15%
  • Trend towards benefit PT did not increase in the per protocol analysis and was in opposite direction at 6 months

Bottom Line

  • There is no clinically important improvement in functional recovery when providing supervised physiotherapy in addition to standard care for grade I/II sprains presenting within 72 hours of injury.
  • I suppose it depends on your institution whether this is something you do anyway, but based on this Ill probably be less inclined to consider it.
  • Obviously this doesnt go for the potentially higher grade sprains or the ones you cant assess for stability on initial assessment…and I suppose for professional footy players unless youre really brave…

Further Reading

New in EM 007: Is RV dilation on PoCUS useful to diagnose PE during a cardiac arrest?

Originally Published on RCEM Learning Podcast June 2017

As part of the RCEM Learning Podcast I record reviews of recent literature with Dave McCreary. We’ve been doing this for about a year now and you can hear them all on the RCEM Learning Podcast each month. I’d like to have them here and searchable on this site too so I’ll be posting the ones I find most relevant here. You can hear the newest ones by subscribing to the free RCEM Learning Podcast. 

Audio:

“Is RV dilation on PoCUS useful to diagnose PE during a cardiac arrest”

Authors: Dave McCreary, Andy Neill

Codes: CC21,U8, HMP2

Clinical Question:

  • Is RV dilation on PoCUS useful to diagnose PE during a cardiac arrest

Title of Paper:

Journal

  • Critical Care Medicine, 2017

Author

  • Aagaard

Background

  • PE is on everyones list of Hs and Ts during a cardiac arrest. If the patient is in arrest from a PE then they probably should received thrombolytics and we probably should continue CPR long enough for those lytics to take effect
  • A potential tool for this is PoCUS. We know big PEs cause RV dilation in shocked patients so why not big RVs in dead people?

Patients studied

  • Female crossbred Landrace/Yorkshire/Duroc pigs (27 32 kg) So not people then…
  • This is pure animal work
    • Lab setting
    • Anaesthetised pigs with a nice model of cardiac from PE and other causes. They created the PE by taking some of the pigs own blood into a glass jar, letting it clot and then injecting it back in.
    • Lots of monitoring

What they did

  • Compared 3 different models of porcine cardiac arrest
    • PE
    • Hypoxia
    • VF
  • Took lots of pre and intra arrest transthoracic echocardiograms (they actually had to remove part of rectus abdominus to get the view and cant recommend that in humans)
  • They then compared them all to see if RV dilation during a pulse check reliably predicted PE

What they found

  • 24 pigs, 8 in each of the 3 groups
  • All groups had RV dilation and it was slightly more in the PE group but not enough to be in any way meaningful
  • (they actually had a sub study where they showed a bunch of docs the images and asked them to distinguish between moderate and severe RV dilation and they couldnt do it suggesting that any differences in the amount of RV dilation are not clinically meaningful

Bottom line

  • In pigs (and probably in humans) during cardiac arrest the RV tends to dilate no matter what the cause. PEs make it a little bigger but not in any clinically useful manner. Dont get too trigger happy with your tPA just cause the RV looks a bit big in a dead patient. If theyre shocked but not dead, whole different story

New in EM 006: Can you make a baby wee on demand?

Originally Published on RCEM Learning Podcast June 2017

As part of the RCEM Learning Podcast I record reviews of recent literature with Dave McCreary. We’ve been doing this for about a year now and you can hear them all on the RCEM Learning Podcast each month. I’d like to have them here and searchable on this site too so I’ll be posting the ones I find most relevant here. You can hear the newest ones by subscribing to the free RCEM Learning Podcast. 

Audio:

Can you make a baby wee on demand? (and why would you want to?)

Authors: Dave McCreary, Andy Neill

Clinical Question:

  • Can you make a baby wee on demand?

Title of Paper:

Journal

  • British Medical Journal 2017

Author

  • Kaufman

Background

  • UTIs are common in kids
  • It can be bloody difficult to get a urine sample from a pre-continent infant
  • Anecdotally clinicians have noted infants tend to wee during the cleaning process for a clean catch (and parents have probably noticed that during nappy changes)
  • They reckon there is a cutaneous voiding reflex – it works in animals

Study type

  • Randomised controlled trial
  • Non-blinded
  • Superiority trial

Patients Studied

  • Infants aged 1-12 months requiring urine sample collection

Intervention

  • Gentle suprapubic cutaneous stimulation with a cold saline soaked gauze for 5 minutes (The Quick-Wee method)

Comparison

  • Standard clean catch with no stimulation for 5 minutes

Outcomes

  • Primary – voiding of urine within 5 minutes
  • Secondary – Successful collection / contamination rate / parent and clinician satisfaction

Results

  • Quick-Wee wins
    • 31% vs 12% (p<0.001) voided within 5 minutes
    • Greater satisfaction scores (2 vs 3 on Likert scale)
    • No difference found in contamination
  • NNT 4.7 to successfully collect one additional pot of wee within 5 minutes

Bottom line

  • Quick-Wee is a really simple method that significantly increases likelihood of voiding and catching it within 5 minutes
  • I imagine the novelty would wear off after my first successful attempt and suddenly 5 minutes would seem like a long time – what are the chances we can get the parents in on the action?

Further Reading