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Primary Survey

Primary Survey March 2017

23 Feb, 17 | by scarley

It’s March 2017 and time for a quick review of the best of the EMJ this month

Under pressure: does cricoid improve laryngoscopy?

Whether or not we should use cricoid during emergency intubation is fast becoming one of the greatest modern controversies in Emergency Medicine. While we await data from randomised controlled trials, in this month’s issue Caruana et al have provided some important new evidence. In a retrospective analysis of 1195 patients undergoing pre-hospital intubation, cricoid pressure was not found to be associated with difficult laryngoscopy. After propensity score matching, there were no apparent differences in the incidence of complications with or without the use of cricoid pressure, other than an increase in the proportion of patients sustaining airway trauma when cricoid pressure was used. Ultimately we now have further reason to question the routine use of cricoid pressure, but is it sufficient to change your practice?

Statistics made much easier!

Reading the phrase ‘propensity score matching’ may have just made you feel a little uncomfortable. If so, you’re not alone. Most emergency physicians could do with a little help when it comes to interpreting some of the more complicated statistical analyses we encounter in the literature. If you feel that way, I’m sure you’ll be pleased to see that this month we have the first in an occasional series of articles on statistical concepts that go beyond the basics. These articles aim to provide a helpful tutorial to readers to increase their skills of critical appraisal for the future. To help illustrate the concepts, we will link them to original articles that we publish. This month, we’ve linked to the work by Caruana et al, which is free to access as the editor’s choice.

Who calls ambulances and doesn’t wait?

Most of us can appreciate that calling for an emergency ambulance is not to be taken lightly. When emergency services are facing severe and increasing pressure, it can be extremely frustrating to observe that some patients arrive in the Emergency Department by ambulance but don’t wait to be seen. In this issue, Doupe et al explore the characteristics of patients who do just that. Compared with other patients, they found that patients who called an ambulance and did not wait were more likely to have a history of substance abuse ad to live in low income areas. Identifying the characteristics of patients who exhibit this behaviour will help emergency physicians to create individual management plans to deal with apparently unhelpful patterns of seeking healthcare.

A new device to help metrics for ED weighting

Rapidly and accurately estimating the weight of children presenting to the Paediatric Emergency Department is highly important for drug dosing but often challenging. Emergency physicians commonly use formulae or aids such as the Broselow tape. This month, Jung et al report on the accuracy of a novel ‘rolling tape’ electronic device with wireless transmission. They demonstrate that its use enabled faster and more accurate weight estimation than the Broselow tape. However, they go further still: using the rolling tape led to faster orders for resuscitation drugs and defibrillation in cardiac arrest. Could this revolutionise how we measure patients’ weight in the Paediatric Emergency Department?

The trajectory of an academic emergency physician

If you’re a research active emergency physician, you may be interested in tracking your academic progress in relation to other emergency physicians. Is your progress fast or slow? In this issue, Miro et al explore whether we can develop a guide to the progress of researchers in Emergency Medicine. They tracked the h-index of a selected group of academic emergency physicians. The h-index tries to combine an author’s impact with their productivity. If an author has, for example, 5 articles that have been cited 5 times or more, then their h-index is 5. Miro et al have derived a formula to track the rise in h-index for ‘fast’, ‘medium’ and ‘slow’ growth academics. Where do you fit in? Don’t be discouraged, though. All the authors included in this sample were highly reputable academic emergency physicians. Even those in the ‘slow growth’ category may therefore be elite researchers. You may, however, find that this article spurs you on!

Can doctors measure pain in children?

Brudvik et al report a fascinating study in which they asked children to score their pain in the Paediatric Emergency Department, while doctors and parents were asked to estimate the score. How do you think we did? Read the full article to find out the detail, but you may be surprised to find out how much we under-estimate pain and how often we withhold analgesia, even for children with severe pain. It’s a sobering reminder that the pain of an individual is a very personal experience and cannot be accurately measured by others.

vb

Rick Body

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http://dx.doi.org/10.1136/emermed-2016-206657

Primary Survey: November 2016.

22 Oct, 16 | by scarley

primary

Richard Body, Associate Editor

The Manchester derby for paediatric early warning scores

There is clearly a need for a validated physiological early warning score for specific use in the paediatric emergency department (PED). In this issue, Cotterill et al compare two paediatric early warning scores developed in Manchester: the Royal Manchester Children’s Hospital Early Warning System (ManCHEWS) and a modified version, the Pennine Acute Trust Paediatric Observation Priority Score (PAT-POPS). The modified score incorporates the original physiological scoring system but also takes account of the nurse’s judgement and specific elements of a patient’s background. This Manchester derby was a close call: but will the marginally superior accuracy of PAT-POPS for predicting hospital admission ultimately win over the simplicity of ManCHEWS?

Future emergency care: the (citizen’s) jury has spoken

In Queensland, Australia, Scuffham et al took an extremely interesting approach to patient and public involvement. They convened a citizen’s jury to deliberate on matters relating to the delivery of emergency care. The jury’s verdict is intriguing and highly relevant to the future of Emergency Medicine. The participants were clearly amenable to alternative models of emergency healthcare delivery including care provided by allied health professionals and decisions not to transport patients to hospital from the pre-hospital environment.

What is ‘productivity’?

If you sometimes feel that measuring productivity in the Emergency Department has the potential to create a dehumanized production line (and even if you don’t), this month’s paper by Moffatt et al is a ‘must read’. In a series of semi-structured interviews with healthcare practitioners working in an Emergency Department, this team explores their feelings about the notion of ‘productivity’. The findings are heartening and are sure to kindle a warm feeling in the heart of any emergency physician. Hopefully this important work will lead to greater recognition of the need to retain compassion in our practice, promote an appropriate balance between ‘care’ and ‘efficiency’ and avoid the “sausage factory” mentality, to quote one of the participants.

A SuPAR new biomarker of serious illness?

In Emergency Medicine we are becoming accustomed to the use of biomarkers that may lack specificity for any one particular condition, but that provide important prognostic information. Lactate could be considered one such biomarker, and its interpretation has become an important skill for emergency physicians. This may suggest that we are at the dawn of a new era for biomarkers. Our traditional ‘binary thinking’ about diagnostics, whereby tests can simply tell us whether a patient does or does not have a particular disease, is beginning to seem crude and outdated. In this issue, Rasmussen et al measured SuPAR at the time of admission to an Acute Medical Unit in a cohort of over 4,000 patients. SuPAR was shown to predict mortality and the need for hospital re-admission even after adjustment for confounders. The findings are impressive, and this work must lead on to further research to identify how this interesting non-specific biomarker can be used to guide real life healthcare decisions.

Health inequality and the global importance of emergency care

We know surprisingly little about the relationship between emergency care provision and the impact of emergent conditions on health, internationally. Of course, emergency physicians might expect that failure to provide adequate emergency care would lead to greater mortality and morbidity from such conditions. In this issue, Chang et al quantify this problem. In an analysis from 40 countries, they found that all fifteen of the major global causes of mortality and morbidity can present emergently, and identified that insufficient access to emergency care is clearly associated with higher mortality and morbidity. This makes sobering reading as a demonstration of global health inequality, and highlights the pressing need to develop Emergency Medicine internationally.

vb

Rick Body

@richardbody

Primary Survey August 2016. EMJ

4 Aug, 16 | by scarley

Richard Body, Associate Editor

Editor’s choice: Nurse versus computer for paediatric triage

This month, Takahashi et al present a retrospective cohort study evaluating the impact of allowing nurses to change the triage priority assigned by the computerised Japanese Triage and Acuity algorithm (JTAS), which is based on the patient’s presenting complaint, historical factors and physiological parameters. In particular, the nurses could assign a lower triage category if they felt that the triage category was inappropriately high based on physiological parameters recorded when a child is distressed or looks otherwise well. The re-categorised triage priorities more appropriately predicted the need for hospital admission. This study presents early evidence to suggest that the ‘gestalt’ of experienced triage nurses could be used to avoid over-treatment and it provides an excellent platform for future work that is designed to evaluate safety outcomes.

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Head injury: after the ‘golden hour’ come the danger hours?

It might seem reassuring when patients present late after a head injury. If a patient is going to have an intracranial haemorrhage, in usual circumstances we expect it to become apparent in the first 24 hours after injury. Marincowitz et al investigated the incidence of traumatic abnormalities in 101 late presenters. They also evaluated the performance of the National Institute for Health and Care Excellence (NICE) criteria for computerised tomography (CT) scanning in that group. There were two very interesting findings. First, an astounding 9.9% of late-presenting patients had a traumatic abnormality, 3% required neurosurgery and 1% died. We should bear in mind that the sample size is small and there is potential for selection bias: only patients who underwent CT scanning were included. We therefore wouldn’t expect such a high incidence in undifferentiated late-presenting patients, so it is important that clinicians don’t over-react to this initial finding.

Second, however, is the fact that the NICE criteria for cranial CT scanning missed 30% of traumatic abnormalities. While you may react to that figure by questioning the clinical significance of those injuries, when you read this paper you should note that 25% of patients who required neurosurgery or died were also missed by the NICE criteria. This work therefore appears to clearly demonstrate the need for a bespoke clinical decision rule to guide the management of patients who present >24 h after head injury.

Paediatric procedural sedation: is the UK falling behind?

The literature on procedural sedation for children in the Emergency Department extends back at least 25 years. As long ago as 1998, McGlone et al described the use of ketamine as an alternative to “brutacaine” in the Journal of Accident & Emergency Medicine.1 The benefits of avoiding hospital admission and general anaesthesia are readily apparent. It is alarming, therefore, that the qualitative analysis of focus group data by McCoy et al this month reveals that emergency physicians in the United Kingdom are still experiencing many barriers in delivering this service. In a linked editorial, Krauss and Green provide a number of helpful tips for Paediatric Emergency Departments in the United Kingdom, based on their experience in the United States where procedural sedation protocols are long established. Both papers clearly highlight a pressing need to develop practice in parts of the United Kingdom. They call for a national response to improve training and competency assessment for this important skill.

Do nice doctors get sued?

According to an old medical myth, less skilled surgeons may make up for what they lack in technical ability by being excellent communicators. In this issue of the journal, Smith et al report an innovative randomised controlled trial in which patients in an Emergency Department waiting room were each shown a video of a doctor-patient encounter but were randomised to see a video that included some empathic statements made by the doctor or one that did not. The patients viewing videos of an ‘empathic’ doctor were less likely to report that they would sue the doctor if something went wrong. It seems, therefore, that nice doctors are less likely to be sued. However, before we step up our communication skills training at the expense of honing clinical skills, we should read the full paper and exercise caution. Nice doctors may have been slightly less likely to be sued but the difference was small and some patients would still have sued the ‘nice’ or ‘empathic’ doctors.

The human side of pre-hospital research

Most readers are likely to be familiar with PARAMEDIC, a large cluster randomised controlled trial evaluating the use of a manual compression device in pre-hospital cardiopulmonary resuscitation.2 The trial enrolled 4,771 patients in the pre-hospital environment, which was a huge success. In this issue of EMJ, Pocock et al explored the human factors that influenced delivery of the trial by paramedics. The findings of this survey provide some fascinating insights into the requirements for successful research delivery. This paper is therefore essential reading for anyone contemplating undertaking research in this highly challenging environment.

References

Primary Survey July 2016

4 Jul, 16 | by scarley

Mary Dawood, Associate Editor

“People attend ED because they choose to”

Emergency Department (ED) attendances over the past decade have been rising both in western countries as well as in the developing world. One school of thought attributes this to an increase in patients who would be better managed in primary care. Various initiatives have been put in place in the UK in recent years which include hospital based unscheduled care services staffed by GP’s and other primary care clinicians aimed at diverting patients away from the ED. You could be forgiven for questioning the success of these initiatives if your ED is crowded most of the time.

On this note you might then be interested to read both the editorial by Derek Burke as well as a review of the literature by Ramlackhan and colleagues from Sheffield relating to the impact of GP delivered hospital based unscheduled care services. Their study focused particularly on process outcomes, cost effectiveness, and patient satisfaction. They found a paradoxical increase in attendance and the evidence for improved output to be poor, moreover there was no evidence of improved patient satisfaction. In one study patients actually expressed a preference for care in an ED as opposed to a new co located walk in centre. The authors concluded that there is little evidence to date to support the implementation of co–located urgent care models of care. In the absence of more robust evidence it is worrying to see the on-going proliferation of such alternative models of care. In his editorial, Derek Burke suggests that unscheduled care is a now a consumer item and seen by users as no different to 24 hour shopping. If this is the case then perhaps we should just ask patients where they would prefer to be treated and listen to what they say, now there’s a novel idea!

Doctor Triage?

This can be a contentious issue in the ED, some clinicians abhor the notion citing “not the best use of doctor time” while others enjoy the opportunity. The introduction of multidisciplinary rapid assessment teams (RAT) has in some cases further muddied the waters, so it was interesting to read a systematic review by Abdulwahid and colleagues from the UK to determine if placing a senior doctor at triage (SDT) versus standard single nurse in an emergency department improves ED performance. They reviewed the evidence from 25 comparative design studies using several quality indicators.

They concluded that SDT can enhance performance. This in itself is not entirely surprising as doctors, more than nurses can see, treat and discharge patients at triage thereby reducing the overall load. I would suggest nurse practitioners at triage may have a similar impact. The findings that were perhaps more interesting and warrant further investigation were that STD did not demonstrate benefit in terms of patient satisfaction or cost effectiveness or for that matter change the occurrence of adverse events. So perhaps SDT may be a pyrrhic victory for performance if outcomes elsewhere are unchanged or more expensive. Clearly more research is needed.

Quantity, Quality or both

Quantitative methodology is traditionally the mode of scientific enquiry in medicine. More recently, mixed methods, that is coordinating qualitative and quantitative research is slowly gaining credence in emergency medicine because of its effectiveness in achieving a deeper understanding of complex issues such as medical error, communication and teamwork. In this issue, Hansen and colleagues from Oregon introduce the fundamental concepts and approaches of mixed methods research using specific examples from the Children’s Safety Initiative Emergency Medical Services (CSI-EMS), a large National Institute of Health (NIH) funded project to describe the interrelation and complementary features of quantitative and qualitative methods. This is an interesting paper about the identification and prevention of errors in out of hospital paediatric care in the USA but also, a very comprehensive overview of mixed methodology and well worth reading if you are considering this approach to research.

Snakes alive

Assessing and treating snakebites is not “run of the mill” type presentation in most ED’s but it accounts for 10% of all presentations in the hot summer months in a South African Hospital and this may well be the case in similar climates elsewhere in the world. So it was fascinating to read a study by Wood and Sartorious in this issue describing the use of ultrasound to determine the site and degree of cytotoxic swelling from snake bites in patients presenting to their department.

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They scanned the envenomed limb of 42 patients at the point of maximum swelling comparing it with the same site of the unaffected limb. More than half of their patients were children under the age of 12 years. Tissue expansion was noted in both the subcutaneous and the muscle compartments of the envenomed limbs. Their study highlights the benefits of ultrasound as a non invasive and painless procedure which can assist the clinician assessing and monitoring the progress of the swelling. This paper is a good read, it is original and informative especially the incidence and pathology of envenomation, furthermore, the study lends a truly international feel to this issue.

Have fun

We are becoming increasingly aware of the value of simulation training as an effective learning tool in emergency care but its’ use still varies from place to place. This may be due to perceived difficulties in instituting this in busy ED’s or from perhaps less than enthusiastic or even sceptical responses from your colleagues. If you feel this applies to your department then read the paper in this issue a by Spurr and colleagues. It’s a very useful top 10 tips +1 to setting up simulation training in your department. After reading all 10 tips you might find No 11 the “+1” the best tip of all. It recommends having fun! Now this is a great starting and finishing point and a universally recognised essential ingredient for successful team building and surviving the high’s and low’s of an ED career.

Primary Survey June 2016

4 Jun, 16 | by scarley

Mary Dawood, Associate Editor

Helping people do the things they want to do

Figure 1

Being a patient in hospital can be a disconcerting experience, this is especially true for older patients who desperately want to stay in the familiar surroundings of their own homes. Getting frail elderly patients safely discharged from the ED can pose significant risk so it was very reassuring to read in this issue a paper from Scotland about the role and potential of the Occupational Therapist in the ED. In “The view from here” Kristin James opens the window for us on the practicalities of daily living that are suddenly jeopardized for the older person by an emergency admission. She describes how the expert intervention and advice of an occupational therapist can tip the balance and be the difference between safe discharge home or admission as an inpatient. Do read this paper, it conveys a simple message about seeing the patient in the context of their life and not just the presenting problem, but also, how the OT’s in the ED “can help people to do the things they want to do”.

How effective are health promotion campaigns?

I often wonder how effective large scale expensive health promotion campaigns are and to what extent the target audiences are receptive to such information? This thought must have also crossed the minds of Mellon and colleagues from Dublin who undertook a study in a cohort of stroke survivors to examine their knowledge of stroke warning signs, risk factors and help seeking behaviour when faced with symptoms. A secondary aim of their study was to examine the association between patient characteristics, stroke awareness and onset-to-door (OTD) time when stroke symptoms occurred. They concluded that changing health seeking behaviour during stroke onset is not a simple process and indeed is fraught with complexity. Their findings provide a basis for further stroke educational campaigns which suggest the need for multiple interventions at different levels to focus on improving the publics’ stroke knowledge, and recognition of symptoms. This approach hopefully could minimize the delays to hospital arrival that continue to be a barrier to effective treatment.

Also in this issue, the need for health education weaves its way into another paper from the other side of the world. Cullen and colleagues in Australia and New Zealand sought to examine whether time to presentation with possible acute coronary syndrome (ACS) has any association with one year outcome. Well, perhaps unsurprisingly, their findings suggest it does. They collected data from adult patients presenting with suspected ACS to two ED’s in both countries and followed them up prospectively for a year. They found that there is an independent association between time to presentation and one year cardiac outcomes following initial attendance in ED with possible cardiac chest pain. The authors of this paper again reiterate the need for effective public health campaigns to improve health outcomes in these patients.

Appearances can be deceptive

Increasing longevity in western societies has seen a corresponding increase in the incidence of major trauma in the elderly. Traumatic brain injury (TBI) is not uncommon and its severity is traditionally classified using the Glasgow Coma Scale (GCS). One might expect elderly trauma patients to score a lower GCS than their younger counterparts. However two recent small studies suggest that the elderly may present with a higher GCS than younger patients with an equivalent anatomical severity of TBI. In this issue, Kehoe and colleagues in the UK set out to confirm this finding by interrogating the trauma audit research network (TARN) database of all adult cases of severe isolated TBI between 1988–2013. They concluded that the GCS is higher in older patients at each level of injury severity irrespective of mechanism of injury or type of intracranial injury and the difference is more apparent the more severe the injury. This paper is a must read for pre hospital and hospital clinicians managing major trauma, we should not allow an unexpectedly high GCS lull us into a false sense of security. These older patients may be more severely injured than initial findings suggest and irrespective of age, early neurosurgical intervention may be indicated to improve outcomes.

After reading the Kehoe paper I would recommend a thought provoking paper by Battle and colleagues in the UK who investigated current management of the anti-coagulated trauma patient in ED’s. Again this study concerns the older trauma patient where there is a lack of consensus regarding management of this group. A survey exploring management strategies of anti-coagulated trauma patients was developed with two patient scenarios concerning assessment of coagulation status, reversal of INR, management of hypertension and management strategies for each patient. 106 respondents from 166 hospitals replied with 24% of respondents working in major trauma units. The results of the survey highlighted both similarities and variation in practice and the authors felt this may reflect the differences evident in the available guidelines for these patients. Clearly there is a need for consensus and an evidence based guideline to ensure optimal management of this group.

Pre hospital identification of sepsis

Severe sepsis is still the commonest cause of death in critically ill patients making the need for early identification and intervention as urgent as ever. Emergency Medical Services (EMS) practitioners are often the first contact for these patients yet the importance of their role and the crucial part they play in identifying septic patients has not been widely discussed in the literature. So I was keen to read in this issue a systematic review by Lane and colleagues from Canada of studies that evaluated the pre hospital identification or treatment of patients with sepsis by EMS. No randomized controlled trials were found but review of 16 cohort studies suggests that EMS practitioners can identify sepsis patients with modest sensitivity and specificity using vital signs criteria. However the authors caution that the included studies were characterized by high heterogeneity and thus further research in this area is needed. So back to the drawing board on this one!

Be sure to look at the wrist X-ray in the Image section. Wrist injuries are common and very much core business in emergency settings, so we should be competent in interpreting images particularly of common fractures. Every so often there is a variation on a theme and this one is interesting. Read the history and spot the injury.

Highlights from the May 2016 issue.

11 May, 16 | by scarley

Simon Carley, Social Media Editor

Graphic

I’m rather hoping that in the Northern Hemisphere at least, our May edition will feel as though summer has arrived with perhaps slightly more time for personal and organisational development. Winter was tough here in the UK, so let’s hope the better weather brings a bit of relief. Even now crowding looms large in our collective memory with an interesting paper and accompanying editorial focusing on its effect on our emergency departments (EDs).

The complexities of measuring crowding in the ED

Adrian Boyle and colleagues examined two scoring systems, NEDOCS and sICMED together with staff perceptions to look at ways of measuring crowding in the ED. Clearly crowding is a multifactorial perception including aspects such as patient load, flow and severity. They collected real time data using these measures demonstrating that some of this data can be collected in real time but that they cannot reflect hour by hour variation. Further work is needed to give us a score that could be used to track and compare ED crowding and it’s inherent dangers to patients and staff.

Parents, paediatrics and perceptions

As a consultant who works in a paediatric ED I can understand why Astha Singal and colleagues decided to examine avoidable paediatric ED visits. Although this study is from the US, with alternative funding and insurance mechanisms the implication here about increasing numbers of primary care visits to the ED for children will be familiar to many of us, regardless of where we work. They found that the families socio-economic position, notably food security, was a strong predictor of attendance. Many parents agreed that alternative health providers could have cared for their children, but difficulties in accessing alternative services led to children being brought to the ED. This is another useful study demonstrating that public health and economic factors have significant impact on our workload and patient mix.

Paediatric early warning score scores and predictions

More paediatrics from the UK this month with an analysis of the ability of paediatric early warning score (PEWS) to predict admission and significant illness. PEWS has certainly been popular in recent years, with several papers published in the EMJ on the subject, but the score was designed to be used in the in patient setting, In this single centre study PEWS performance was assessed in the ED population. Interestingly they found a high specificity, but low specificity which is typically the opposite of what we require of an ED screening tool. The reported sensitivity, as low as 30%, means that it’s ability to screen for significant illness or admission is too low. Perhaps we need something better derived from the ED population.

Tanzanian Gestalt for anaemia

In this study clinicians were challenged to predict the outcomes of a blood count using clinical judgment (described as Gestalt in this paper). In this clinical setting anaemia is common and an important diagnostic finding. Clinically the physicians did well as measured by concordance, but that is to be expected. However, their ability to pick up severe anaemia only had a sensitivity of 64%, and for moderate anaemia only 56%. This may be on the low side for clinical practice and thus laboratory testing will still be needed. The specificity for moderate and severe anaemia was better and may be high enough to guide resuscitation whilst waiting for the lab results.

Tailored training improves CPR performance

Govender and colleagues examined the impact of a tailored teaching programme to teach CPR to paramedics. The addition of tailored pre and post interventions improved performance. The bottom line is that if you teach people more often and with a range of materials they learn more and can do better.

Transcutaneous carbon dioxide

We frequently measure CO2 levels in the ED, with the use of arterial blood gases acting as the gold standard. However, these can be difficult to obtain, painful for the patient and are not without potential complications. A non-invasive method would surely be better and such devices do exist. This month Nicolas Peschanski and colleagues compare transcutaneous readings with arterial samples amongst patients with respiratory problems in the ED (the group we would be interested). Sadly only about a third of readings were within 5 mm Hg between the non invasive method and the blood gas. Clearly we can’t abandon the blood gas yet.

Prehospital referrals for falls

Elderly fallers are a high risk population for all in emergency medicine and in prehospital care. A simple fall may be a harbinger of significant pathology that may be eminently treatable. In this systematic review by Zozula et al the evidence for prehospital teams assessing and referring patients for referral to falls services shows that the evidence base is pretty weak. In this incredibly important area we clearly need better work linked to patient outcomes before we can assess the impact of prehospital referral.

Stress tests after Troponin

There has been a huge amount of work regarding the exclusion of myocardial damage using troponin testing in the ED. However, thee have been concerns that simply troponin testing will miss patients with significant coronary disease, but who have yet not manifest myocardial damage as shown by a troponin leak. In this study by Aldous and colleagues they looked at patients who were negative for troponin tests, but who then had a stress test. Interestingly they identified 34 patients from 709 who subsequently went on to revascularization. It’s tricky to know what this means for clinical practice, and of course we must remember that the new generation of high sensitivity troponins might yield a different result.

Acute Kidney Injury in the ED

Finally, we have a review article from Patrick Nee and colleagues on the recognition of Acute Kidney Injury in the ED. This is a common problem in the ED and one where emergency physicians should have some expertise in. It’s also quite a common question in exams, so there is something for everyone on this important topic.

Highlights from the December issue: Emergency Medicine Journal.

11 Dec, 15 | by scarley

Click here for full table of contents.

Even if one does not work in a “major trauma centre,” we all see trauma. Victims of stabbings and bike accidents do not follow “trauma criteria” when they head for the nearest ED. Elderly patients with seemingly minor injuries are brought to a local hospital, only to discover that there are 4 rib fractures, a pulmonary contusion and a subdural haematoma.

2015 marks the silver anniversary of UK’s Trauma Audit Research Network (TARN). For those of you not living in the UK, TARN is a national registry that collects prospectively entered data on the epidemiology, treatment and outcomes from major trauma. TARN serves two major functions: it publicly reports its findings and it allows trauma researchers to use its large, prospectively collected data set to conduct research. Our first editorial, by Fiona Lecky, TARN’s research director, describes the humble birth, development and accomplishments of TARN over the past 25 years. In an accompanying commentary, Dr Karim Brohi, clinical lead for London Major Trauma System, takes the opportunity to pause to consider the challenges created by the growth of TARN from a local audit tool to both a national quality assurance program and a research enterprise.

To celebrate 25 years of TARN, this issue’s research and reviews are centred on the theme of trauma. There are articles from TARN, which illustrate the value of a large, prospectively collected data set. We also include several intriguing articles from France (on telemedicine in head injury), and South Africa, on the role of interpersonal violence in trauma care. Two articles—one on c-spine immobilisation and the other a review of traumatic cardiac arrest—will make you reconsider what you’ve always known.

The changing face of trauma

Using data from the TARN database, Kehoe and colleagues describe how the mechanisms and victims of major trauma have been changing over the past 25 years. Road traffic accidents are down; falls are up. Major trauma patients are increasingly elderly. This could be a matter of better data collection as a result of TARN, and improved detection with the rising use of CT. In either case, the data not only confirm what many of us are seeing, but prompt consideration of whether our systems are adapting as they should.

Editor’s choice: Do anti-coagulated trauma patients have worse outcomes?

It is estimated that 1% of the UK population is anticoagulated, and the prevalence rises with age. A study in Japan showed that about 25% of patients over 80 were on anti-thrombotic therapy. Warfarin remains the most commonly prescribed anti-coagulant, and whether trauma patients on warfarin do worse is controversial. An RCT is impossible of course; but even with multivariate analysis, it is difficult to account for the substantial burden of comorbidity in the patients on warfarin. In this carefully conducted observational study using the TARN database, Battle et al used a matched case-control design to compare the outcomes of trauma patients who were receiving warfarin pre-injury and those who weren’t. The result: warfarin is indeed an independent risk factor for mortality in trauma patients.

The trauma burden of interpersonal violence: a preventable disease

In this descriptive study of a small emergency department in KwaZulu-Natal, South Africa, Bola and colleagues found 41% of surgical admissions were due to trauma, and interpersonal violence accounted for more than a third of this trauma burden. Community assault, not uncommon in the rural areas of this region, was responsible for 14% of traumas and its victims spend longer times in the resuscitation areas. Victims of interpersonal violence stay an average of 9.8 days and require significant amounts of blood (a scarce resource), and the use of imaging and theatre time, a clear additional burden to a health care system that can least afford it.

Traumatic cardiac arrest—time for a paradigm shift?

Most of us were taught that traumatic cardiac arrest had a dismal outcome. However, that may be because we were applying the wrong therapy. In this review of new evidence on traumatic cardiac arrest, Captain Surgeon Jason Smith explains that TCA may really be a low-flow state, for which traditional CPR will not work. A new approach that focuses on stopping haemorrhage and aggressive resuscitation (preferably blood) appears to have substantial promise, as evidenced by the military experience.

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So, is there more to be done to control haemorrhage?

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has the potential to bridge patients to definitive haemostasis in patients with noncompressible torso haemorrhage. However its potential for trauma patients is unknown. Barnard and colleagues used the TARN database to determine the number of trauma patients in 2012–13 who might have benefited from the intervention. Out of 72000 patients, 397 were identified. They had a median ISS of 32 and, coincidentally, a mortality of 32%. The authors point out that although the numbers are small, the patients are, without REBOA, quite resource intensive and are largely seen at major trauma centers, making it potentially worthwhile to evaluate the use of REBOA at these hospitals.

Primum non nocere…the growing evidence for self-extrication

Dixon et al placed biomechanical sensors on paramedic volunteers and studied them with infrared motion analysis when being extricated from a test crash vehicle. Compared with equipment-assisted extrication, self-extrication showed the least movement. The authors suggest that it may be time for a “spinal rule-in” policy in for stable patients, where self-extrication is the first option if the paramedics have carefully assessed the victim.

Ellen Weber.

Editor in Chief.

Highlights from the November issue: Emergency Medicine Journal

11 Nov, 15 | by scarley

Click here for full table of contents.

Bored of Boarding

I’m sure that many of us have felt pangs of guilt as we walk past rows of patients on corridors waiting to get into beds. The ‘boarded’ patient is a gentle term for what is an obvious and embarrassing symbol of overcrowding in our emergency departments. I often feel ashamed of our health care systems when we subject patients to the indignity and poor care associated with boarding, but what is it like for patients? Liu et al have examined the experience of boarding from the patient perspective using qualitative methods. They found that patients do find waiting frustrating and characterised by a lack of communication. They conclude that if we are to deliver kind and compassionate care then we must listen to the voices of our patients and eradicate the practice of boarding.

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Complications of prehospital intubation

Prehospital airway management is always controversial and so it is again this month with a retrospective review of cases intubated in the field. The data suggests a high complication rate as compared to in hospital airway care. It is interesting to note that the airway assessments suggest that views are often poor in the prehospital setting which will raise the question of whether these are difficult airways, difficult environments, or less skilled operators. No doubt it will generate debate as all papers relating to prehospital airway management appear to do.

Do we need to give antibiotics to every dog bite?

In the UK it is custom and practice to give antibiotics to all dog bites (well it is in Manchester) but the wisdom of this has been questioned many times over the years. Tabaka et al have looked at wound infection rates over a 4.5 year period to determine characteristics of wounds that get infected. The findings are interesting with a relatively low overall rate of infection and a suggestion that those that are closed, or which are puncture wounds are at higher risk. They conclude that these are high risk wounds and should be treated with antibiotics. As for other wounds, it’s tricky to say as the vast majority of wounds received antibiotics as a routine. These are interesting results although we arguably still await the randomised controlled trial that might finally answer the question.

UK Paediatric research priorities

Is an interesting study on research priorities for paediatric emergency medicine in the UK and Ireland. Paediatric Emergency Research in the UK and Ireland (PERUKI), is a group of 43 centres aiming to deliver high quality research in paediatric emergency care and they have been very productive to date, but they need to set priorities for the next generation of paediatric researchers. What is heartening is that the results clearly lead towards potential trials in the future which have the potential to significantly improve the care we give to injured and ill children. If paediatric emergency medicine is your thing, this is a must read.

Aspirin in the US

Another database study this month looks at the administration of aspirin to patients with potential acute coronary syndromes. Overall the figures from Tataris et al are a bit disappointing with fewer than half of patients receiving the medication. Beyond this the data has been mined for factors that might predict administration and interestingly race and US location appear to have an influence. However, we must be cautious as studies of this type can show association, but not necessarily causation. Read for yourself and decide.

The hurt of Head Injury Retrieval Trial

Arguably one of the most expensive trials in prehospital care, the HIRT trial has raised many controversies in the prehospital community. Originally set up as a randomised controlled trial of helicopter assisted physician led prehospital care vs. paramedic care in head injury. The final analysis is complex and requires thought on the part of the reader. Overall the data suggests that there is no statistical difference between paramedics and physician responders, though the authors point to some subgroups that may show a benefit to physician care. This study requires careful consideration as one of the largest prehospital physician trials in history. Whether it is or whether it could ever be definitive is as much a question for those interested in research design as it is for the reader.

Do we overinvestigate patients for pulmonary embolus?

Yes we do, or at least that’s the claim from Mongan et al in this month’s journal. The data supports their view with a prevalence of disease in some groups investigated as low as 0.6%. PE prevalence increases with age and yet we appear to investigate the young fit and healthy as frequently as we do the elderly. This is clearly questionable practice, particularly when the effects of investigation and therapy are associated with harm. This study based on two large data sets suggests modifications to established risk factors to raise awareness of the differences in prevalence between young and old, male and female. It hints at further refinements to diagnostic tools in the future.

Editor’s choice

You cannot deliver high quality care without staff. Underpinning this is that you cannot deliver safe care without staff, but how many staff are enough? Pope et al present data collated for the National Institute for Clinical Effectiveness on safe nursing staff levels. This is essential reading for all emergency department staff and highlights the association between low staffing and poor patient experience, quality and outcome. An accompanying editorial outlines why this paper is so important to emergency care and why we must ensure that we have the resources to deliver a safe and high quality service.

Highlights from the October issue: Emergency Medicine Journal.

11 Oct, 15 | by scarley

Click here for full table of contents

Quality care

How we care for patients with learning difficulties may vary from country to country but the evidence suggests that few emergency departments are adequately equipped to respond effectively to adolescents and young adults with Autistic Spectrum Disorder (ASD). In this issue, Lusky et al from Ontario describe the use of emergency services by adolescents and young adults with ASD in order to identify predictors of emergency use. Although a small study, their findings are informative, suggesting that patients with ASD are likely to attend the ED, thus there is a need to train emergency personnel to work more effectively with these patients and their carers. This is a timely piece of work and particularly pertinent for UK readers as NHS England has recently published a new set of rules called “The Accessible Information Standard”. This standard details how healthcare professionals should communicate with people who are disabled in any way or have sensory impairments. Healthcare organizations in the UK will be expected to meet these standards by July 2016. Lusky’s paper is a good starting point, it is well referenced and highlights many of the challenges ED’s face in improving care for this vulnerable group.

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When to fly

Employing scarce resources judiciously is key to achieving best outcome in pre hospital trauma care. London’s air ambulance provides a doctor and paramedic team 24 hours a day to compliment London Ambulance ground paramedic teams. In such a densely populated area as London, how do the air ambulance medics judge which incidents they should respond to? Wilmer et al describe their study which sought to determine which dispatch methods were most effective in terms of accuracy and time in identifying patients with serious injury. They conducted a retrospective review of three years of data 2,203 helicopter activations and found that a flight paramedic using telephone interrogation is as accurate as ambulance crews’ requests and both are significantly better than just the mechanism of injury. Combining MOI and interrogation identifies most of the seriously injured patients while minimising delays and over triage. So, if you have often wondered as I have how such decisions are made then read this interesting paper.

Chilling patients

It is recognised that mild hypothermia limits neurological injury and improves outcomes for patients following successful cardiopulmonary resuscitation, but what is the most effective way to cool a patient? This was the question de Waard and colleagues from the Netherlands sought to answer. They undertook a retrospective study comparing the effects of intravascular cooling in post cardiac arrest patients (n=97) in one university hospital with non invasive surface cooling of post cardiac arrest patients (n=76) in another university hospital. They found invasive cooling systems result in equal cooling speed as surface cooling but less variation in temperature during the cooling phase. They do point out that mean temperature during the maintenance phase may be associated with survival independently of the cooling system.

The heart of the matter

Chest pain is a very common presentation in emergency departments around the world and ruling out serious causes such as Acute Coronary Syndrome (ACS) continues to concern clinicians as is evidenced by two papers in this issue from two different countries.

Using a prospective cohort study, Body et al in Manchester aimed to validate the Manchester Acute Coronary Syndrome (MACS) decision rules with an automated h-FABP assay that could be used clinically to “rule in” or “rule out” acute coronary syndrome in the ED. The rule which incorporates heart type fatty acid binding protein (h-FABP) and high sensitivity troponin T (hs-cTnT) levels was previously validated using a semi –automated h-FABP assay but was not considered practical for clinical use. Of the 456 patients included in the study, 78 had an acute myocardial infarction (AMI) and 97 developed Major Adverse Cardiac Events (MACE). The authors conclude that their findings validate the performance of a refined MACS but recommend verification by an interventional trial prior to implementation.

In Tunisia, Boubaker and colleagues considered the need for a valid clinical score to improve diagnostic accuracy of ACS. They compared the performance of a model combining the TIMI score and a score describing chest pain (ACSDiagnostic score: ACSD Score) with that of both scores alone in diagnosing ACS in patients presenting with chest pain associated with a non diagnostic ECG and a normal troponin. They enrolled 809 patients with a normal ECG and a normal Troponin in their study. They found the ACSD score showed a good discrimination performance and an excellent predictive value which would allow clinicians to safely rule out ACS in patients presenting with undifferentiated chest pain. They recommend a larger multi centre study to validate their findings. So for now, affairs of the heart continue to exercise scientific inquiry.

Global Emergency Medicine Highlights

In this issue, we launch another new section – Global Emergency Medicine Highlights. Each month we’ll bring you an abstract selected by the editor-in-chief of the African Journal of Emergency Medicine, the Annals of Emergency Medicine, and Emergencias. We are very proud to be participating in this partnership with our colleagues from Africa, the US and Spain.

Mary Dawood

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Primary survey Highlights from the January 2015 issue. Mary Dawood, Editor

16 Jan, 15 | by scarley

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A mask tells us more than a face (Editor’s choice)
As ED clinicians we often pride ourselves on recognising the sickest patients by how they look, this skill is tacit and one that is the result of experience and longevity in emergency care. Our psychiatric colleagues have long accumulated significant research into disturbances in affect recognition in patients with mental illness, so I was intrigued to read in this issue a study by Kline and colleagues from the US which explored the variability of facial expression in patients with serious cardio pulmonary disease in emergency care settings. They found that patients with serious cardio pulmonary disease lacked facial expression variability and surprise affect. They suggest that stimulus evoked facial expressions in ED patients with cardiopulmonary symptoms may be a useful component of gestalt pre-test probability assessment. So, there may be some substance in one of the many satirical remarks made by Oscar Wilde that “A mask tells us more than a face” though I doubt his context was clinical.

It’s not the age that matters
Accurately measuring weight in children presenting to the ED is essential and particularly crucial in resuscitation situations where interventions and drug dosages are calculated by weight. The APLS formula, 2× (age+4) has been widely used in western ED’s, but as obesity in our young people is becoming more common and children are taller than previous generations , this formula may fall short in terms of accuracy and patient safety. An alternative formula (3×age)+7 by Luscombe and Owens (LO) has been suggested as more accurate than the APLS formula. Skrobo and Kelleher in Cork University Hospital Ireland undertook a retrospective study of 3155 children aged 1–15 years comparing both formulas to identify which one best approximates weight in Irish children presenting to the ED. They conclude that the LO is a safe and more accurate age based estimation over a large age range. Maybe it’s time to review our practice but do read this paper and weigh up your own thoughts, no pun intended!

Not all suffering is pain
Pain is the commonest reason patients attend the ED. Our sometimes lack of appreciation and subsequent under-treatment of pain is often a source of distress and dissatisfaction which can result in uncharacteristic behaviour. However not all suffering is pain and we may find ourselves wanting when the cause of distress is emotional rather than physical. This issue features a prospective cohort study by Body and colleagues in Oxford which sought to describe the burden of suffering in the ED. Of the 125 patients included in the study many reported emotional distress particularly anxiety as well as physical symptoms. Indeed only 37 patients reported that pain was causing their suffering. It should not come as any surprise that being seen, information, reassurance, explanation, care by friendly staff and closure were the key themes reported as relieving suffering. This approach just represents best practice but in the mounting pressures of ED’s worldwide it is all too easy to lose sight of the person and their need for compassion and understanding. Dismissing emotional suffering as perhaps someone else’s problem is detrimental to our patients and ultimately ourselves. Do read this paper; it is a timely and salutary reminder of what we should be about, why we do the job we do and what patients expect of us. There is also a podcast with the Editor in Chief and the author. Find this online alongside this issue.

Best evidence or clinical acumen (Readers’choice)
As demands for emergency care and acuity of patients presenting continues to rise globally, ED clinicians are increasingly faced with making decisions to discharge patients from high acuity areas of the ED. Patient safety and well being should govern any decision to discharge a patient but many cases are complex and weigh heavily on clinicians making such decisions. Calder and colleagues in Canada conducted a real time survey of experienced ED physicians to determine how they perceive their discharge decisions and the impact on adverse events. The authors concluded that ED physicians in their study most often relied on clinical acumen rather than evidence based guidelines and that neither approach was associated with adverse events. They recommend further research which focuses on decision support solutions and feedback interventions.

The greater good
Pulmonary embolism (PE) is a leading cause of death in pregnancy and the post partum period and a devastating event for mother and baby. When accurately diagnosed and treated the risk of an adverse outcome is low. In this paper Goodacre and colleagues explore the options for imaging and discuss the evidence for using clinical features and biomarkers for the selection of women for imaging. Their review of the literature suggests that the harm of investigation with diagnostic imaging may outweigh the benefits but that clinical predictors could be used to identify women at higher risk who could be appropriate for imaging. They also state the need for further research around clinical predictors and particularly the use of D-dimer at a pregnancy—specific threshold.

Pearls of wisdom
There is little doubt that the emergency department is a quite unique environment that offers abundant opportunities for learning. Seizing and exploiting these opportunities is not always as straightforward as we would like it to be. The constant pressure to manage multiple patients and make decisions to refer, admit or discharge against the backdrop of a ticking clock often mitigates against the teachable moment however genuine our desire or commitment to teaching is. It’s easy to feel impatient and exasperated by the seemingly slow pace of some learners when you are trying to maintain safety in a crowded department. On the plus side, however, learning in such an environment can instill a sense of urgency, something that cannot be learnt from a textbook. Nonetheless teaching and learning is integral to all our roles and so it was refreshing to read in this issue “Top 10 ideas to improve bedside teaching in a busy emergency department” by Green & Chen from California. We have probably all used some or all of these methods to teach in different circumstances but the authors imaginative use of a framework, of ‘mnemonics’ and easy to remember names such as “Aunt Minnie” and “Snapps” is amusing and lighthearted. In reading this paper, you may just find that pearl of wisdom for the next teachable moment.

 

Mary Dawood

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