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Primary Survey April 2017.

18 Apr, 17 | by scarley

This month’s primary Survey is written by Mary Dawood. Don’t forget to visit the journal site to see more and keep in touch with us on Social Media.

Also, don’t forget to listen and subscribe to our podcast to keep you up to date on the journal and topics in emergency medicine.

Organ Donation in the ED

Possibly one of the most sensitive and daunting conversations that takes place in the ED is about organ donation. By virtue of circumstances this conversation usually occurs subsequent to breaking news of death or imminent death. Broaching the subject of organ donation can seem ill timed, insensitive and is difficult for even the most skilled clinicians. Even so, organ donation is a core competency in emergency medicine as is the management of patients in the final stages of life, furthermore we have a duty as healthcare professionals to explore this potential at the end of life. In the UK in 2015–16 a record number of organs were donated and transplanted but the consent rate is still one of the lowest in Europe. At the end of 2015 there were nearly 7000 people waiting for a transplant, 429 died while waiting and a further 807 were removed from the list most likely due to deteriorating health. Despite ongoing teaching of emergency staff and expert support from specialist nurses, opportunities for organ donation can still be lost in the urgency and fast pace of the ED as well as the perceived difficulties of managing the logistics of donation before death (DBD) or donation after circulatory death (DCD). Outcomes from DBD are better but an ongoing shortage of organs is seeing the reintroduction of a long abandoned practice of (DCD). This month’s issue includes a very informative paper by Gardiner and colleagues along with a commentary by Bernard Foex about organ donation. Gardiners paper describes current transplantation practice in the UK, associated ethical and legal issues, the classification of deceased donors and future developments promising greater numbers of organs. Foex’s commentary discusses withdrawal of life sustaining therapy and the case for delay.

Both these papers are a ‘must read’ for ED clinicians everywhere to remind us that the potential to change lives for better is enormous and the urgency for organ donation is greater than ever as we live longer.

Saving money

Containing the ever increasing costs of healthcare is both a challenge and a necessity in all health economies. We are constantly entreated by our ‘money masters’ to find not only more cost effective ways of delivering care but cheaper consumables. In the minds of many clinicians cheaper consumables often equate to poorer quality so it was very interesting to read of a study by Riguzzi et al from San Francisco comparing cost of commercially produced ultrasound gel which is relatively expensive with an alternative corn-starched based gel. They found that the corn starched gel which cost <10 cents per bottle produced images of similar quality to those using commercial gel which costs about $5 dollars. Given that point of care ultrasound is increasingly used in low resource settings, over time, this may represent a tidy sum that could be used elsewhere. Think about this the next time you liberally squirt expensive ultrasound gel!.

Sepsis again

Lifesaving treatment for sepsis is relatively straightforward–so many more lives should be saved every year if treatment is started in a timely way. It is therefore an ongoing concern that so many people still die from sepsis every year. The difficulty is spotting this complex condition as soon as a patient presents so we need to ask whether our triage systems are sufficiently sophisticated to support early recognition. Graff and colleagues in Germany undertook an evaluation of the Manchester triage system (MTS) to assess its effectiveness in identifying septic patients. They found the MTS to have some weakness with respect to priority in patients with sepsis and that discriminators for identifying systemic infection are insufficiently considered. In view of the fact that MTS and similar versions are so widely used it is well worth reading this paper to revisit our triage systems and how we can improve detection of sepsis at triage.

Weighing patients: a guestimate?

Some EDs are fortunate to have high specification trolleys that have built in scales for weighing patients. Most of us probably don’t work with such sophisticated facilities so we resort to roughly estimating a patient’s weight in emergency situations. This is a concern when using time critical drugs that require precise dosing according to weight. I was curious then to read of a study in this issue by Cattermole and colleagues in the UK that aimed to develop and validate an accurate method for estimating weight in all age groups using mid arm circumference.(MAC) They derived a simplified method of MAC based weight estimation from a linear regression equation: weight in kg=4xMAC (in cm)−50. They found that this formula is at least as precise in adults and adolescents as commonly used paediatric weight estimation tools are in children. The authors advise that a gender specific model would improve precision but this would require a tape or smartphone. This study is well worth a read as a more accurate way of estimating weight is to be welcomed especially as rising obesity levels will call for more consistent documentation of weight and precise dosing.

Adaptive design clinical trials in the ED?

Conducting and sustaining clinical trials in emergency settings can be difficult for a variety of reasons. One reason may relate to the fixed nature of the designs that are traditionally used in ED trials, where conduct and analysis are outlined at the outset and are not examined until the trial is finished. This fixed design may in many instances take too long and be costly both to patients and staff. It may be time to consider alternative way of conducting clinical trials in the ED that may be more effective and conducive to the ED setting. In this issue, Flight et al hypothetised that the majority of published emergency medicine trials have the potential to use a simple adaptive trial design where planned interim analysis is factored in to determine whether studies should be stopped or modified before recruitment is complete. Their study reviewed clinical trials published in three emergency medicine journals between January 2003 and December 2013. They found that out of 188 trials, only 19 were considered to have used an adaptive trial design. A total of 154/165 trials that were fixed in design had the potential to use an adaptive design. For those of us grappling with the challenges of clinical trials in the ED, this approach is worthy of consideration.

View Abstract

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Mary Dawood

  1. Emergency Department, Imperial College NHS Trust, London, UK
  1. Correspondence to Mary Dawood; Mary.dawood@imperial.nhs.uk

Primary Survey September 2016: EMJ

24 Aug, 16 | by scarley

This month’s primary survey from the EMJ.

Emergency Triage and Treatment Course in primary care health centres in Guatamala

Emergency triage Assessment and treatment (ETAT) course was developed by WHO in 1999 as part of its Integrated Management of Childhood Illnesses program for improving outcomes for children. It has been devised as a hospital based system for health services of limited resource settings.

This study took ETAT and introduced into the primary care setting, making it a self-sustaining locally led course in a district within Guatamala. The course comprised 5 modules that cover Triage, Airway/breathing, Circulation, Coma/convulsions and Dehydration which took 16 hours in total. Two courses were delivered in October 2012, and subsequently candidates were asked to undergo a written test and a survey about their confidence prior to the course and immediately thereafter, and then again at 3 months, 6 months and 12 months after the course. They were asked to take part also in a clinical skills assessment. During this time, a quality improvement program was established to identify and remedy problems that were found to be significant for candidate performance and learning.

There was an improvement in knowledge, from the pre-course to post course tests that was sustained in all subsequent tests. The clinical skills retention, assessed at 3, 6 and 12 months, all scored highly.

There was a boost in confidence before and after the course although this did start to reduce over time (but not to statistically significant standards). The level of confidence remained than that determine in the pre-course assessment.

This paper highlights that ETAT which has been shown to improve care for children in the resource limited care setting and shows that with planning and the use of QI programs, clinical skills knowledge and even confidence in a range of health care practitioners can be enhanced.

Point of care lung ultrasound in young children

This study had a ‘novice’ ultrasound operator look at the lungs of children triaged as having a respiratory problem such as wheeze or respiratory tract infection. The images were captured before any treatment was given to the children; these images were evaluated by an expert in ultrasound to determine if there were any of the following:

  • 3 or more B lines per intercostal space, consolidation+/− pleural abnormalities

  • Any of these features being present counted as a positive ultrasound.

None of the children with asthma had a positive ultrasound, whereas in pneumonia, all were positive. In children with asthma and pneumonia about half of he cases were positive as was the case in children with bronchiolitis. However, caution must be applied about just using ultrasound as the numbers in the study are small and more validation studies are required.

On a roll!

Why do log rolls in the unconscious adult patient? This retrospective study over 2 years looking at GSC 9 or less +/− intubated patients from the Alfred Trauma registry with major trauma (ISS >12) and compared the log roll findings with the CT/MRI reports on the presence or absence of thoracolumbar injury. Out of the 403 patients, about 85% did not have any abnormal findings on log roll. Out of the patients who had a thoracolumbar fracture(s), 72.5% had a normal log roll. Lesions seen included abrasions, bruising, haematoma, open wounds, foreign bodies and burns which were important in some instances for acute patient management. Using palpation in this group of patients to find any abnormalities is questionable. For determining thoracolumbar fractures, palpation has a specificity of 98.8% but a sensitivity of 8.5%. The authors therefore recommend that visual inspection is important but that palpation may not be as helpful, especially when patients may go onto have CT/MRI imaging to rule in or out thoracolumbar fractures. It should be noted that this idea needs further prospective studies to confirm or repute the proposal!

Sawbones? A potential life-saving intervention

Fortunately pre-hospital limb amputation is not common but when needed, it can be life-saving. The study used cadaver limbs, donated for medical research purposes, to see which was the most effective tool/technique to perform an amputation. Four devices were examined for the time from knife to full amputation, the number of attempts required, and perceived risk to the rescuer or “patient” during the procedure.

After the procedure, an assessment was made of the damage to the soft tissue, skin and bone, by 6 independent clinical rates according to a 5 point scale, with 5 being the most favourable result.

Ninety one seconds was the longest time taken to effect amputation, and all 4 techniques/tools had their advantages and disadvantages—a really important topic to improve patient care in difficult situations, showing practical aspects about a life-saving procedure.

Good communication makes for less ‘traumatised’ patients

Good interpersonal skill can reduce patient worry as seen in this study of acute coronary syndrome patients. The incidence of subsequent posttraumatic stress reactions decreases according to patient perception of communication with their clinician. It is important to think about how we conduct ourselves as this impacts greatly on how much better our patients can become!

“Delayed discharges and boarders”….

An ebb and flow of patients would be ideal, but as this paper shows that delay in the discharge of patients backs up patients in ED. The authors show this in their setting, in a busy hospital in Dublin and, in the discussion, show that this is a commonplace problem in many different countries throughout the world. How social and community care can improve their ‘joined-upness’ with hospital based care is essential for delivering optimum patient care.

Ian K Maconochie

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