Pericarditis: Treatment and Diagnosis Pocket Card

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Hi all,

This post contains a pocket card for the evidence based diagnosis and treatment of pericarditis as of 2014.  This came up after a recent U of C EM Journal Club in which the residents commented that there was just too much to remember with regard to the use of colchicine, it’s dosing, contraindications, etc. when treating pericarditis on shift.

You can take a look at my post reviewing the evidence on colchicine for pericarditis over at REBEL:EM, as well as the recent Calgary journal club review of Imazio’s ICAP paper, here.

This card will serve as a quick resource which you can put into your evernote or download onto your phone as a pdf file for on shift use.

Disclaimer: Everything here is evidence based, but the dosing of NSAID or ASA has not been compared/optimized in studies.  The listed dosing regimens are my own suggested ones, but feel free to modify as you see fit.

pericarditisPVcardCalgaryversion

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To download a PDF version of the pocket card,  click here.

pericarditisPVcardCalgaryversion

Cheers,

Chris

 

 

 

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Pericarditis and Myocarditis (Calgary EM Journal Club)

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The December journal club reviewed two papers, first up was Imazio’s paper investigating the benefits of treating pericarditis with colchicine.  You should definitely know this paper and be implementing it into practice. This is a must read.

The second paper was a retrospective review looking at the presenting symptoms and labwork abnormalities in pediatric myocarditis.

Paper #1

Imazio et al. A Randomized Trial of Colchicine for Acute Pericarditis NEJM 2013

METHODS/SETTING/DESIGN/NUMBER OF PATIENTS INCLUDED

  • Multicenter, double-blind randomized trail
  • 240 patients, 120 per study group

INTERVENTION/CONTROL

  • Colchicine at a dose of 0.5mg BID for 3 months for pts weighing > 70kg or 0.5 mg once daily for patients weighing <= 70 kg, vs placebo.
  • Each participant also took a tapering dose of conventional anti-inflammatory therapy with aspirin, Ibuprofen, or corticosteroid.
  • PPIs were also prescribed for GI prophylaxis

INCLUSION CRITERIA

  • 18 years of age or older
  • First episode of pericarditis
  • Etiology either idiopathic, viral, after cardiac injury, or associated with connective tissues disease
  • Acute pericarditis was diagnosed with 2 of the following:
    • Typical chest pain (sharp and pleuritic, improved by sitting up and leaning forward), or pain radiating to trapezius ridge.
    • A pericardial friction rub
    • Suggestive changes on ECG (widespread ST segment elevation or PR depression)
    • New or worsening pericardial effusion

EXCLUSION CRITERIA

  • Tuberculous, neoplastic, or purulent pericarditis
  • Evidence of myopericarditis as indicated by elevation in serum troponin levels. This has become controversial with the new use of high sensitivity trops.
  • Severe liver disease or current aminotransferase levels of more than 1.5 times the upper limit of the normal range
  • Serum creatinine level of more than 221 umol/L
  • Skeletal myopathy or a serum CK level above upper limit of the normal range
  • Blood dyscrasia
  • Inflammatory bowel disease
  • Hypersensitivity to Colchicine or CI to it’s use
  • Current treatment with Colchicine
  • Life expectancy of < 18 months
  • Pregnant, lactating women, or women of childbearing potential who were not protected by contraception

OUTCOMES

Outcome measure(s):

Primary

  • Incessant or recurrent pericarditis

Secondary

  • Symptom persistence at 72 hours
  • Remission within 1 week
  • Number of recurrences
  • The time to the first recurrence
  • Disease-related hospitalization
  • Cardiac tamponade
  • Constrictive pericarditis

RESULTS

PRIMARY OUTCOME

  • Incessant or recurrent pericarditis occurred in 20 patients (16.7%) in the colchicine group, and 45 patients (37.5%) in the placebo group
  • Relative risk reduction in the colchicine group of 0.56; 95% CI
  • NNT to prevent on case of incessant or recurrent pericarditis was 4

SECONDARY OUTCOME

  • Reduced frequency of symptom persistence at 72 hours (19.2% vs 40.0%, P=0.001)
  • Reduced number of recurrences per patient (0.21 vs 0.52, P=0.001)
  • Reduced rate of hospitalization related to pericarditis (5.0% vs 14.2%, P=0.02)
  • Improved rate of remission within 1 week (85% vs 58.3%, P< 0.001)
  • Prolonged time to first recurrence (24.7 weeks vs 17.7 weeks, P <0.001)
  • No significant difference in the incidence of adverse events (9.2% vs 8.3% for GI side effects)
  • Multivariable analysis showed independent risk factors for recurrence were the use of glucocorticoids (OR 4.17,95% CI, 1.28 to 13.53; P=0.02) and CRP elevation at presentation (OR 3.15; 95% CI, 1.05 to 9.49; P=0.04)

STUDY CONCLUSION

  • In patients with acute pericarditis, colchicine, when added to conventional anti-inflammatory therapy, significantly reduced the rate of incessant or recurrent pericarditis

CRITICAL APPRAISAL

Pros: This was a well designed, randomized, double-blind placebo controlled trial that was powered to find a clinically meaningful difference in a patient-centred outcome. The population studied was fairly representative of the patient population we will be seeing in the ED, and the follow-up interval was adequate, with excellent treatment adherence.

Cons: This study was not powered to detect differences in the more rare side effects that can be associated with colchicine, though it is not pragmatic to design such a trial. As there was no pre-planned subgroup analysis of patients who received the weight-adjusted lower dose versus those who received the conventional dose, and there is no evidence to suggest why a cut-off of 70kg was used, it is not accurate to state that low dose and conventional dose colchicine are equally efficacious, though it is biologically plausible and also supported by the results of the CORE and COPE trials.

Discussion Points: In light of the strong methodology of this trial, as well as multiple other favorable trials of colchicine in acute pericarditis (eg. CORP, COPE, recent Cochrane Review), using colchicine in first-episode, uncomplicated pericarditis patients will be considered by most staff. The trial used dosing regimens of 0.5-1.0mg daily based on patient weight; however, in Canada, colchicine is available as 0.6mg tablets, which would result in a 20% higher dose than that in the study. The clinical criteria used to define acute pericarditis in the trial are helpful to making the diagnosis of pericarditis in practice. Surprisingly, there was no increase in adverse GI side effects in the colchicine group.

Paper #2

Freedman et al. Pediatric Myocarditis: Emergency Department Clinical Findings and Diagnostic Evaluation Pediatrics 2007

OVERVIEW: This was a retrospective study aimed at describing the clinical presentations of pediatric patients with myocarditis– a very rare disease. This article was used to discuss how to critically appraise retrospective studies.

METHODS/SETTING/DESIGN/NUMBER OF PATIENTS INCLUDED

  • Retrospective chart review looking at patients from May 2000 to May 2006
  • Hospital for Sick Children in Toronto
  • 31 patients with Myocarditis (16 with biopsy proven/definite myocarditis, and 15 with probable myocarditis)
  • Charts were reviewed twice by single investigator, and two investigators independently classified patients exclusively into 1 of 5 presentations

INTERVENTION/CONTROL

  • 5 ED clinical presentations were defined:
    • Respiratory (rhinorrhea, cough, shortness of breath)
    • Gastrointestinal (nausea, vomiting, diarrhea, or abdominal pain)
    • Cardiac (chest pain or palpitations)
    • Hypoperfusion (lethargy, lightheadedness, dizziness, syncope, or seizure)
    • Kawasaki associated
  • CXR defined as abnormal and associated with myocarditis if cardiomegaly, pulmonary vascular congestion, or pleural effusion present
  • ECG defined as abnormal and associated with myocarditis if one of the following present: axis deviation, decreased ventricular voltages, ST segment or T wave abnormalities, atrial enlargement, ventricular enlargement, heart block, or an infarction pattern
  • Echocardiogram findings defined as consistent with myocarditis included increased ventricular end systolic or diastolic dimension, reduced shortening or ejection fractions, atrioventricular valve regurgitation, and regional wall motion abnormalities
  • Lab tests used age appropriate normal values were used (troponins were not used)

INCLUSION CRITERIA

  • All patients < 18 yrs of age
  • Diagnosed at Hospital for Sick Children as having myocarditis between May 2000 and May 2006
  • Initial presentation was to an emergency department (either Hospital for Sick Children or transferred from another institution) or if the child underwent autopsy at Hospital for Sick Children and had a diagnosis of myocarditis
  • Initial presentation with myocarditis
  • Either having definite myocarditis (biopsy proven) or probable myocarditis (diagnosis assigned by pediatric cardiologist on basis of history, physical examination, and investigation results in the absence of an endomyocardial biopsy or in presence of negative biopsy results)

EXCLUSION CRITERIA

  • No ED visit
  • Patients who did not meet the definitions of definite or probably myocarditis
  • Inadequate documentation of initial presentation
  • Discharge diagnosis other than myocarditis

OUTCOMES

Outcome measure(s):

Primary

  • Relative frequency of ED presenting symptom complexes in children with myocarditis

Secondary

  • Sensitivity of clinical exam findings, laboratory investigations, chest radiographs, ECGs, and echocardiograms in diagnosis myocarditis

RESULTS

PRIMARY OUTCOME

  • The most common presenting symptoms at the time of ED presentation relate to the respiratory system
  • These are age related and patients > 10 years of age present predominantly with chest pain, and < 10 with respiratory symptoms. Overall more presented with respiratory symptoms

SECONDARY OUTCOME

  • Sensitivity of clinical exam findings: most common physical exam feature was respiratory distress (68%), followed by tachycardia (18%)
  • Sensitivity of laboratory investigations: AST level is most sensitive marker for myocarditis with an elevated value in 85% (including 1 child who had normal ECG and CXR
  • Sensitivity of CXR: 55% sensitivity with cardiomegaly being most common abnormality (42%), followed by pulmonary venous congestion (32%)
  • Sensitivity of ECGs: 93% of cases, with ST or T wave abnormalities being the most common (67%), and Axis deviation second with 37%
    • 97% of children with either ECG or CXR done had an abnormality on one test
  • Sensitivity of echocardiograms: 87% had abnormalities consistent with myocarditis with myocardial dysfunction detected more frequently among those with definite myocarditis

STUDY CONCLUSION

  • Pediatric myocarditis presents primarily with respiratory and cardiac complaints
  • Maintain a high index of suspicion for myocarditis even in absence of clinical findings of CHF
  • When adequate clinical suspicion exists, screening tests should include CXR and ECGs
  • Evidence of elevated liver enzyme levels should raise additional concern regarding myocarditis in the appropriate clinical scenario

CRITICAL APPRAISAL

Pros: Given how rare the diagnosis of myocarditis is (0.5/10000), the retrospective design of this trial was very appropriate. Moreover, the authors strengthened the quality of their chart review and limited potential bias as best possible by clearly defining variables a priori, drawing on multiple databases for patients to include, describing how missing or conflicting variables were dealt with, and using a third reviewer to clarify discrepancies in coding of the primary outcome.

Cons: Given that the lab tests and other investigations in the study were not necessarily applied to the entire population, a true sensitivity cannot be calculated based on the results.

Discussion Points: This article was used as an example to discuss how retrospective studies can be methodologically strengthened. Troponins were not checked routinely in this patient population. Key clinical take-homes include: the overall very low incidence of myocarditis, the biphasic age distribution, and that young children tend to present with respiratory symptoms, while older children tend to present with cardiac symptoms.

Thanks to Anjali Pandya (PGY-3 FRCPC EM program) and Tasha Haiduk (CCFP-EM resident) as well as Shawn Dowling for the journal club appraisals.

Cheers,

Chris

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Problems with the Alvarado and Pediatric Appendicitis Scores (Calgary EM Journal Club)

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In part 1 of this journal club, we reviewed the utility of a clinical decision rule for the inconclusive ultrasound in appendicitis.  Today we look at a meta-analysis of the Alvarado and Pediatric Appendicitis Score (PAS).

Onto the article.

Ann Emerg Med. 2014 Oct;64(4):365-372.e2. doi: 10.1016/j.annemergmed.2014.02.025. Epub 2014 Apr 14.

What are the most clinically useful cutoffs for the Alvarado and Pediatric Appendicitis Scores? A systematic review.

Ebell MH1Shinholser J2.

Methods/Setting/Design

This systematic review included articles from a PubMed search and a search of reference lists of previous systematic reviews. Only prospective studies were included. Likelihood ratios were calculated for each of low, moderate and high-risk score groups for each score from the set of articles.

Total number of articles included for analysis: 26, with n = 3193 in adult studies and n = 4776 in pediatric studies.

The outcome measure was likelihood ratios calculated for various levels of Alvarado and PAS score cutoffs, deemed low (<4), moderate (5-7) and high-risk scores (>7) at various levels of pre-test probability for appendicitis.

The results of this systematic review found that in adults with a pre-test probability of >60%, and Alvarado score >7 suggests a very high likelihood (>85%) of appendicitis, while a pre-test probability of <50%, with an Alvarado score <4 suggests a very low likelihood of appendicitis (<3%).

In children with a pre-test probability of appendicitis >60%, an Alvarado score <4 suggests a very low likelihood of appendicitis (<3%), while a pre-test probability of >50% with an Alvarado score of >7 suggests a very high likelihood of appendicitis (>85%). The Pediatric Appendicitis Score was not as predictable at various pre-test probabilities for rule-out or rule-in of appendicitis.

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Critical appraisal and journal club consensus:

The literature search in this systematic review was incomplete, searching only one database for full-text articles, whereas a more comprehensive strategy would have searched the grey literature (published abstracts, conference abstract presentations) and there should have been a more systematic approach to searching the reference lists of published reviews. Furthermore, there were many non-English articles included and there is risk of misinterpretation of results in all of these articles. Articles included had a high degree of heterogeneity of results and should not have been pooled for analysis.

While the overall objectives of the review aim to identify clinical score cutoffs that reliably predict important clinical outcomes (i.e. >85% likelihood of appendicitis and <3% likelihood appendicitis), their results may not be easily applied to ED patient care. The results are presented in an algorithm of estimation of pre-test probability combined with either Alvarado Score or Pediatric Appendicitis Score to lead to “rule-out” or “rule-in” decisions. Estimating pre-test probability is often not so straightforward in EM practice. Estimating pre-test probability is often not so straightforward in EM practice. Additionally, we are not simply “ruling-in” appendicitis at a >85% likelihood threshold and sending patients off to surgery, as the article suggests may be done, as this would result in an unacceptable 15% negative laparotomy rateThis study does not address imaging for appendicitis as an adjunct to clinical evaluation for appendicitis, as is the common practice in the ED.

Discussion at journal club emphasized that “pre-test probability” is a difficult to quantify value, and many clinicians will rely on clinical gestalt and components of the Alvarado (+/- Pediatric Appendicitis Score) when determining pre-test probability. It follows that if forming a pre-test probability of appendicitis based on components of the scoring systems, continuing on to use the same scoring system to reach a different post-test probability is not logical or clinically sound. Furthermore, the findings rely heavily on a structured clinical scoring system to “rule out” appendicitis, which is a clinical condition that can present atypically as often as it presents typically.

Thanks to Kathryn Crowder (CCFP-EM resident) and Shawn Dowling for this summary.

Cheers,

Chris

 

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The Negative or Inconclusive Ultrasound in Appendicitis – Can a CDR help?

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The September edition of journal club featured two articles focused on the diagnosis of appendicitis.  These articles each highlight some critical EBM points, which is why I’m breaking them apart into separate posts. This post will only focus on the first article, which examined a potential clinical decision rule for the management of patients with inconclusive or negative ultrasonography in the setting of suspected appendicitis.

 

 

Acad Emerg Med. 2014 May;21(5):488-96. doi: 10.1111/acem.12374.

A simple clinical decision rule to rule out appendicitis in patients with nondiagnostic ultrasound results.

Leeuwenburgh MM1Stockmann HBBouma WHHoudijk APVerhagen MFVrouenraets BCobben LPBossuyt PMStoker JBoermeester MAOPTIMAP Study Group. 

 

Objective
  • Intent of the clinical decision rule (CDR) was to create a tool that could rule out appendicitis in patients with negative or inconclusive ultrasounds without additional imaging such as a CT or MRI and be safely discharged and seen the following day for reassessment.
  • Their aim was to identify low risk patients for appendicitis with negative or inconclusive ultrasound that they defined as <10%.
Setting
  • Carried out in the Netherlands at University and Teaching hospitals
Population and Inclusion Criteria
  • Development and Validation data were retrospectively extracted from 2 different imaging studies occurring at different times.
  • There were 199 patients in the development set and 120 patients in the validation set.
  • In both the development and validation set, subjects were selected from a diagnostic accuracy study and were patients with clinically suspected appendicitis that presented to the Emergency department who had negative or inconclusive ultrasound results.
  • All patients in both groups received additional imaging such as a CT scan. An expert panel that based its decision on all data attained including pathology and clinical course determined a final diagnosis of appendicitis.

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Methods
  • 14 clinical variables associated with appendicitis were identified from the two diagnostic accuracy studies.
  • Development population: Univariate logistic regression methods were used to estimate odds of appendicitis based on each variable. Those with positive association were included in a multivariable logistic regression model; ultimately they came up with the most promising variables to build the CDR. CRP was added on to see if it would increase sensitivity.
  • 4 variables were identified to make a CDR (male, migration of pain to RLQ, vomiting and WBC >12), they applied this to the development and validation population retrospectively.
Results/Conclusion
  • The 4 variables identified as most promising were male, migration of pain to RLQ, vomiting and WBC >12.
  • The addition of CRP>10 did not significantly improve the sensitivity of the rule.
  • The authors applied their 4 variable CDR to both the development and validation population set. In the development set they claim that use of the rule would reduce the probability of appendicitis from 26% (51/199 – these are the number that had +ve appy) to 12% (15/126 that were discharged ultimately had appendicitis)
  • In the validation set, applying the CDR reduced the probability of appendicitis from 20% (24/120 – total in group that had +ve appy) to 6% (4/72 – these were discharged home that ultimately had +ve appy).
  • They compare the NPV of the CDR as 94% (CI 87-98%), which was comparable to the NPV of CT and MRI (there was no statistical difference).
  • The authors conclude that their CDR significantly reduces the probability of appendicitis in negative and inconclusive u/s and those patients could be safely discharged home with next day evaluation.

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Critical Appraisal/Group Discussion

There are multiple methodologic standards for interpreting a CDR.  The Annals of Emerg Med has a nice 2014 update on this here.  This would be a good paper to read or bookmark for residents.

The clinical scenario in which an emergency physician is presented with a young patient with clinically suspected appendicitis and an inconclusive ultrasound is common and one that could benefit from a well designed CDR to rule out disease in a moderate to high risk patient. Unfortunately, other than asking a relevant question, there are several limitations of this CDR that prevents it from being clinically useful.

First, the rule would have been more helpful if it resulted in a definitive course of action such as CT vs No CT or discharge only, rather than next day re-evaluation for all. Its design and methodological standards were also not ideal. Data for both the development and validation were retrospectively taken from two separate diagnostic accuracy studies that a priori were not designed to create a CDR. Patients were selected as a convenience sample introducing sampling and spectrum bias and there was no mention of blinding. Resident and staff radiologists performed ultrasounds, which is not the standard here in Canada. This may also explain the high rate of positive appendicitis in negative ultrasounds as the skill level of the ultrasonographers varied immensely.

It was also puzzling that the authors included negative ultrasounds in their study, as most physicians with a negative ultrasound would typically send the patient home with clear discharge instructions. In addition, the radiologists were aware of the fact that they were involved in a diagnostic accuracy study that likely introduced a performance bias and may have influenced the high inconclusive ultrasound rate (22 and 47%). In addition to the aforementioned, external validity was also limited by the CDR performance difference in the development and validation set (12% vs 6% miss rate) and by a high prevalence of appendicitis (52-60%). There were a few experts in pediatric appendicitis in attendance and our local data was quite different – we had a much lower prevalence of incompletely visualized appendices.

Ultimately there was consensus that a ‘miss rate’ of 12% was too high for both pediatric and adult populations. A miss rate of 3-5% would be more reasonable. In general when most staff are presented with a negative ultrasound, if there is a re-assuring re-examination of the patient they will discharge them with very clear instructions of when to return to medical attention. With respect to an inconclusive ultrasound, where there is a lot more diagnostic uncertainty, most staff will proceed to a CT scan if clinically concerned in the adult population. Our pediatric emergency colleagues typically get their patients admitted for serial examinations from general surgery.

An inconclusive ultrasound in the context of clinically suspected appendicitis remains a clinical presentation that would benefit from a CDR that is both methodologically rigorous in derivation and leads to a defined clinical action.

Look for more on appendicitis in the coming weeks.  We review a meta-analysis of the Alvarado Score and Pediatric Appendicitis Score, and focus on measures of heterogeneity within a meta-analysis.

Thanks to Natasha Wright (PGY-2) for contributing and Shawn Dowling (FRCPC) for reviewing this summary.

Cheers,

Chris

 

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The Spectrum App : A Must Have for Calgary Physicians and Residents

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Disclaimer: I am not paid for the following overwhelmingly complimentary review of an app.

If you are a doctor or nurse working in Calgary, you should immediately click this link on your iPhone and download the free Spectrum App.

Okay, I guess you may want to know what this is.  The Spectrum App is a fantastic program containing local Calgary antibiograms describing the sensitivities of community-acquired, hospital-acquired and ICU-acquired bacterial infections.  There is actually even more than that, but these alone are worth the 10 seconds required to download this.

In addition to the antibiograms, there are details for antibiotic doses and cost, a dosing calculator for renal adjustment, as well as criteria for diagnoses (eg. Cholecystitis, Febrile neutropenia, SBP) and much more.  I haven’t even fully explored this App, but wanted to get the word out now.  Soon I will realize its full power!

Thanks to one of the EM residents, Kathryn Crowder, for telling me about this awesome app.

Cheers,

Chris

 

 

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Should we use tetracaine for corneal abrasions? Calgary EM Journal Club

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Hi all,

This month’s Calgary EM Journal Club had a fantastic turnout with almost 40 attendees, 25% of which were staff EM docs.  It also marked the first time we saw a heated, debate style showdown at the end from residents advocating for and against the use of topical tetracaine in treatment of corneal abrasions.  Two articles were reviewed, one by Ball et al. from CJEM 2010, and another by Waldman et al. from Academic Emerg Med 2014.  For previous journal club reviews, check out the journal club page.

The traditional dogma prohibiting use of topical tetracaine for treatment of corneal abrasions has been challenged in the past few years, gaining steam with the recent publication of Waldman’s article in April, 2014.  Textbooks tell us that topical tetracaine is toxic to corneas, and will result in corneal thinning, ulcers, keratitis and other ocular complications.  However, this is based primarily on animal, case report and case series data.  Fortunately, my friends Salim Rezzaie of Rebelem.com and Ken Milne of TheSGEM.com have posted about this dogma already, and I encourage you to check out their reviews, as well as Ken’s podcast over at TheSGEM.

The complete critical appraisal of both articles is available if you scroll down, however we’ll get to the bottom line right away as it is slightly different than what some others in the FOAM world are saying.

Clinical Bottom Line:

Given the current evidence, few physicians would universally provide topical tetracaine for the treatment of corneal abrasions, although some would consider it on a case-by-case basis until new data is available.

Prior to the evening’s discussion 9/38 journal club attendees would consider short-term topical anesthetics for corneal abrasions with 16/38 attendees considering this after discussion.

Cornealabrasion

As the main concern of the therapy is with respect to safety with potentially vision-threatening complications, a (0-6.1%) confidence interval was thought to be not yet ready to conclusively prove safety.  In order to prove safety, we are probably going to need somewhere in the realm of  1000 patients with corneal abrasions, and I think we have just over 100 right now in the EM literature. The photorefractive keratectomy (PRK) literature from the ophtho world can’t be grouped with the ED corneal abrasions because these are sterile, surgical incisions.

Furthermore, polling the ophthalmology consultant group, there is essentially no support of this treatment strategy, citing local anesthetic’s inhibition of corneal healing.

This will be the most important determinant of tetracaine use in your local center.  Will your ophtho colleagues support you? Will they support you in the case of a complication?

Below are full summaries of each article.

 

Article #1

Acad Emerg Med. 2014 Apr;21(4):374-82. doi: 10.1111/acem.12346.

Topical tetracaine used for 24 hours is safe and rated highly effective by patients for the treatment of pain caused by corneal abrasions: a double-blind, randomized clinical trial.

Waldman N1Densie IK, Herbison P. 

METHODS/SETTING/DESIGN

  • Double blinded randomized controlled trial from 2011 to 2012.
  • Study population: 116 patients with simple acute corneal abrasions presenting to a tertiary care Emergency Department in New Zealand
    • This size was a convenience sample with a post hoc 95% confidence interval for 0 complications of (0-6.1%)

INCLUSION CRITERIA

  • Simple, uncomplicated corneal abrasion from mechanical trauma, UV keratitis or foreign body.

EXCLUSION CRITERIA

  • Patient characteristics: age < 18, previous eye surgery, cataracts, deaf, unable to give informed consent, were unable to follow-up in 48 hours, and contact lens users.
  • Presentation > 36 hours
  • Ocular infection, herpes keratitis, concurrent injury requiring urgent ophthalmologic evaluation*
  • Bilateral Abrasion
  • Grossly contaminated foreign body.

*Although what mandates urgent ophthalmologic evaluation was not explicitly defined, suggested examples include complicated corneal abrasions, change in visual acuity and large corneal abrasion.

INTERVENTION/CONTROL

  • 1:1 sealed envelope randomization to either intervention or control:
  • Control envelope: 3x 1000mg acetaminophen tablets every 6 hours, 1% preservative chloramphenicol + 5cc saline eye drop placebo.
  • Intervention envelope: 3x 1000mg acetaminophen tablets every 6 hours, 1% preservative chloramphenicol + 5cc preservative-free 1%(undiluted) tetracaine.

OUTCOMES

Outcome measure(s):

Primary

Complication rate, as defined by any of: delayed healing, enlarged abrasion, corneal ulceration, toxic keratitis, surface keratopathy, corneal stromal infiltrates, infectious keratitis, uveitis and corneal infiltrates. This was assessed by combination routine 48 hour follow-up ED assessment/telephone interviews, and discretionary ophthalmologic follow-up.

Secondary

Pain scores on a 100mm visual analog scale.

Patient ratings of treatment effectiveness on a numeric rating scale during telephone follow-up.

RESULTS

– PRIMARY OUTCOME

  • There was no statistically significant difference in complication rates between treatment and control groups. No patients had any significant objective complications requiring changes in management.
  • These complications at 48 hours included persistent reuptake (23.9% v 21.3%) and persistent symptoms (21.7% v 21.35.) Of these patients, 5 required reassessment by ophthalmology but none required any additional treatment.

– SECONDARY OUTCOME

  • There was no clinically significant difference in pain scores at any time during the 48 hour treatment period, however there was a significantly higher mean followup NRS of tetracaine’s effectiveness. (7.7 v 3.8; p<0.0005.)

STUDY CONCLUSION

  • Topical 1% tetracaine is a safe and effective symptomatic treatment for acute, uncomplicated corneal abrasions.

 

Article #2

CJEM. 2010 Sep;12(5):389-96.

Dilute proparacaine for the management of acute corneal injuries in the emergency department.

Ball IM1Seabrook JDesai N, Allen L, Anderson S.

PMID:20880433

METHODS/SETTING/DESIGN

  • Double blinded randomized placebo-controlled trial.
  • 2 tertiary level care EDs in London, Ont.
  • 33 patients
  • Powered to detect with 80% power a 2cm difference in a 10cm visual analog pain scale.

INCLUSION CRITERIA

  • Adults with corneal injuries.

EXCLUSION CRITERIA

  • Inability to consent
  • Allergy to medication
  • Inability to followup
  • Previous eye injury or pathology

INTERVENTION/CONTROL

  • 1:1 randomization to topical fluoroquinolone, pain log, acetaminophen+codeine, and:
  • Intervention: topical proparacaine to 0.05%
  • Control: topical saline drops matched by colour and smell.

OUTCOMES

Outcome measure(s):

Primary

Difference in pain immediately before and 5 minutes after drop administration. Pain recorded on 2 separate 10cm visual analog scales. Pain log handed in at 5 days.

Secondary

Self-reported patient satisfaction on a 10cm visual analog scale.

Complications as assessed by a single ophthalmologist at 1,3, and 5 days, defined as:

  • Delayed wound by fluorescein
  • Increased corneal thickness
  • Corneal opacification
  • New corneal epithelial defects
  • Any other ocular pathology that could be related to the injury or medication

RESULTS

– PRIMARY OUTCOME

  • There was a significant decrease in pain in the intervention group. Mean reduction was 3.9 in the intervention group, and 0.6 in the control (p=0.007)

– SECONDARY OUTCOME

  • The intervention group had an improvement in patient satisfaction scores of 8 compared to 2.6 (p=0.027).
  • There were no complications in either of the 2 groups.

STUDY CONCLUSION

  • Topical diluted 0.05% proparacaine reduces pain due to corneal injuries and likely does not cause complications.

 

Thanks to Geoff Lampard (PGY4), Michael Szava-Kovats (PGY4) and Shawn Dowling for this month’s journal club. For more U of C Journal Club reviews, click here

Chris Bond

@scomobem

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