The BREACH

Reviews and summaries of the latest Emergency Medicine research papers. We try to cover 10 of the best articles each month. Please visit our website for written summaries and to search past editions: www.the-breach.com

June 16th, 2019    

Does your patient really have a UTI?

 

Background

 

How often do we test the urine of patients with no urinary symptoms? How often are we prompted to send samples for culture after a random dipstick test? How often are these patients prescribed antibiotics even when they have no clinical signs of a UTI? If your Emergency Department is anything like mine, each of these things happen quite often.

 

"What's the harm?" you may ask. Well, besides poor use of resources, there are the side effects of treatment, increasing antimicrobial resistance, and the risk that you miss another condition because you stop workup when a UTI is 'found'.

 

Like any test, you've got to know why you're running it and what you are looking for.

 

  • Suspected renal colic? Useful test
  • Urinary frequency, urgency, dysuria or suprapubic pain? Useful test
  • Abdominal pain or PV bleeding in a woman of child-bearing age? Useful test
  • Type 1 diabetic with abdominal pain and vomiting? Useful test
  • Pregnant woman with hypertension and headache? Useful test
  • Elderly lady who is a little more confused than usual? Actually not so useful
  • Gentleman who fell while getting out of the bath? Not useful
  • Middle-aged lady who had an episode of chest pain? No
  • Young chap with a cough? Oh come on!

 

 

The paper

 

Nicolle L, Gupta K, Bradley S. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis. March 2019 [Epub ahead of print]​[1]​

 

This is an updated guideline from the IDSA on asymptomatic bacteriuria (ASB). ASB is defined as the presence of bacteria in the urine (seen on laboratory culture) without any signs of symptoms of urinary tract infection. It might be helpful to start with the question: how common is ASB? Here's a summary table adapted from the article...

 

Population Prevalence
Children (boys) <1%
Children (girls) 1-2%
Pregnant women 2-10%
Elderly men in the community 4-19%
Elderly women in the community 11-16%
Elderly men in a long-term care facility 15-50%
Elderly women in a long-term care facility 25-50%
Intermittent self-catheterisation 20-70%
Indwelling catheter (short-term) 3-5% per day
Indwelling catheter (long-term) 100%

 

 

The rest of the article consists of a somewhat laborious meander through lots of situations where we might want to screen for and treat ASB. They reference nearly 200 studies to support their recommendations, which are based on the fact that ASB is common in many patient groups and treating it is usually a waste of time: your patient will feel no different, and their urinary tract will just become recolonised once they finish your antibiotics.

 

The bottom line

 

Do not test the urine of patients without symptoms of a UTI, and do not prescribe antibiotics unless they are pregnant or undergoing an invasive urological procedure.

 

 

That's right. The IDSA states that if your patient has no features suggesting a UTI, only dipstick the urine if they are pregnant or about to have urological surgery (doesn't often happen in the ED). It might be useful to list some of the situations where they specifically recommend against screening for ASB...

 

  • Elderly residents of long-term care facilities
  • Elderly confused patients
  • Those with kidney transplants
  • Those with a spinal cord injury affecting micturition
  • Those with an indwelling catheter

 

What about my confused elderly patient?

 

 

Investigation and management is always harder in patients who are unable to give an account of their symptoms. For the 'generally unwell' elderly patient, a recent review article​[2]​ suggests the following algorithm:

 

'Non-localising' symptoms (fever, rigors or clear-cut delirium) ​
+
No symptoms suggesting infection at another site (e.g. pneumonia)
+
Pyuria (positive leukocyte esterase on dipstick)

Possible UTI

 

Clinically stable: send urine culture, hydrate and observe for 48hr

 

Clinically unstable (sepsis): begin empirical antibiotics

 

 

What about the UK?

 

"The accuracy of dipstick testing in adults aged 65 years and over can vary. It is therefore important that factors other than the results of dipstick testing are taken into consideration when diagnosing urinary tract infections in older people to ensure appropriate management and avoid unnecessary use of antibiotics."​[3]​

 

"Dipstick testing is not an effective method for detecting urinary tract infections in catheterised adults... To ensure that urinary tract infections are diagnosed accurately and to avoid false positive results, dipstick testing should not be used."​[4]​

 

 

References

 

  1. Nicolle LE, Gupta K, Bradley SF, Colgan R, DeMuri GP, Drekonja D, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of Americaa. Clinical Infectious Diseases [Internet] 2019;Available from: http://dx.doi.org/10.1093/cid/ciy1121
  2. Cortes-Penfield NW, Trautner BW, Jump RLP. Urinary Tract Infection and Asymptomatic Bacteriuria in Older Adults. Infectious Disease Clinics of North America [Internet] 2017;673–88. Available from: http://dx.doi.org/10.1016/j.idc.2017.07.002
  3. National Institute for Health and Care Excellence (NICE). Diagnosing urinary tract infections in adults aged 65 years and over [Internet]. Urinary Tract Infections in Adults.2015 [cited 2019 Jun 16];Available from: https://www.nice.org.uk/guidance/qs90/chapter/Quality-statement-1-Diagnosing-urinary-tract-infections-in-adults-aged-65-years-and-over
  4. National Institute for Health and Care Excellence (NICE). Diagnosing urinary tract infections in adults with catheters [Internet]. Urinary tract infections in adults2015 [cited 2019 Jun 16];Available from: https://www.nice.org.uk/guidance/qs90/chapter/Quality-statement-2-Diagnosing-urinary-tract-infections-in-adults-with-catheters

 

June 8th, 2019    

New standards of care for cauda equina syndrome

Background

  

Lower back pain is common and cauda equina syndrome (CES) is rare, but the consequences can be devastating. Young people can be left with lifelong incontinence and paraplegia if surgery is delayed or the diagnosis is missed. 

 

The best initial investigation is of course an MRI, but these are expensive and difficult to get in many hospitals, especially out-of-hours. From an EM perspective, a suspected case of CES often involves protracted discussions with radiology, orthopaedics and neurosurgery and can be something of a challenge.

 

If only there were a set of nationally-agreed standards detailing which patients require an MRI and which of these need urgent surgery...

  

The paper

 

Society of British Neurological Surgeons (SBNS) and British Association of Spinal Surgeons (BASS). Standards of care for investigation and management of cauda equina syndrome. December 2018​[1]​

 

Which features should we look out for?

 

Patients with lower back pain and any one of the following features should be urgently investigated.​[1–3]​

 

Feature Symptoms and Signs
Disturbance in bowel function Faecal incontinence
Loss of anal tone
Disturbance in bladder function Urinary retention
Post-void bladder volume >100ml 
Overflow incontinence
Disturbance in genital sensation Unable to feel the passage of urine
Loss of saddle pinprick sensation
Bilateral leg pain True radicular nerve pain radiates to the feet
Bilateral leg neurology Myotomal pattern of reduced power (after adequate analgesia)
Dermatomal pattern of sensory loss with absent reflexes

 

How should we investigate?

  

  • If CES is suspected, the patient should have an emergency MRI scan
  • It cannot wait until the morning
  • It should be available at the referring hospital 24/7 (aspirational for most of us in the UK!)
  • The MRI must take precedence over routine scans
  • The decision to perform an MRI does not require discussion with neurosurgery

 

What then?

 

There are 4 possible actions...

 

  • CES confirmed: immediate referral to surgeons
  • No CES, but structural cause identified: refer to local spinal services
  • Non-compressive cause identified (e.g. demyelination): refer to appropriate service (e.g. neurology)
  • No explanation identified: further investigation as required

 

Expert commentary:

 

"CES is something we all worry about and I think we’re getting better about considering the diagnosis. However we still have barriers in getting investigations done - I think this paper makes it clear when we need to arrange a scan." 
(Dr Dwynwen Roberts, ED Consultant)

 

"I think measuring a post-void residual is a very useful test, and is likely more sensitive than anal tone." 
(Dr Robert Tan, ED Consultant)

  

More FOAMed on this topic:
Core EM
St Emlyn's
Emergency Medicine Cases 
Dr Linda Dykes 
(Dr Dykes is an EM consultant from Wales with an interest in FOAMed. She has several really useful resources on her website, including a fantastic summary poster on CES)

 

References

  1. Society of British Neurological Surgeons (SBNS) and British Association of Spinal Surgeons (BASS). Standards of care for investigation and management of cauda equina syndrome [Internet]. SNBS Policies & Publications.2018 [cited 2019 Jun 8];Available from: https://www.sbns.org.uk/index.php/policies-and-publications/
  2. National Institute for Health and Care Excellence (NICE). Sciatica (lumbar radiculopathy) [Internet]. NICE Clinical Knowledge Summaries.2018 [cited 2019 Jun 8];Available from: https://cks.nice.org.uk/sciatica-lumbar-radiculopathy#!topicSummary
  3. Koes BW, van Tulder MW, Peul WC. Diagnosis and treatment of sciatica. BMJ [Internet] 2007;1313–7. Available from: http://dx.doi.org/10.1136/bmj.39223.428495.BE

June 3rd, 2019    

Which technique is best for reducing a pulled elbow?

 

Background

 

The triage nurse comes to tell you that s/he has a toddler with a pulled elbow in triage. You want to reduce it straightaway and send the child home, high-fiving the whole family on their way out. You wonder which reduction technique is most likely to be successful...

 

 Pulled elbow is a painful condition of acute onset, resulting in sudden loss of function in the affected limb of a child​[1]​. The mechanism of injury is often a sudden pull on the ipsilateral hand/forearm (e.g. parent pulling the child up a kerb​[2]​, or even the child pulling its hand away impulsively), resulting in subluxation of the radial head. Pulled elbow can also be caused by a fall​[3]​ or twist. Typically, the child will suddenly cry out in pain and then refuse to use their arm. A snap or click may be heard​[4]​. The arm is held slightly flexed and twisted inwards​[5]​, without any bruising or swelling. Pain may be felt at the shoulder or wrist as well as the elbow​[5,6]​.

 

 Two main reduction techniques are described: supination-flexion (the traditional method) and hyperpronation.

  

Krul M, van der Wouden JC, Kruithof EJ, van Suijlekom-Smit LWA, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database of Systematic Reviews 2017, Issue 7​[7]​

 

 The paper

 

This is an update of a previous Cochrane review. An exhaustive literature search yielded 9 randomised or quasi-randomised controlled clinical trials (906 patients, age range 4.5 months to 7 years), 8 of which compared the reduction techniques of hyperpronation vs. supination-flexion (811 patients).

 

 Low-quality (due to various potential biases, not least absence of blinding) evidence was found that hyperpronation resulted in less failure at first attempt than supination-flexion (9.2% vs. 26.4%, risk ratio 0.35, 95% confidence interval (CI) 0.25-0.50). Based on an illustrative risk of 268 failures at first attempt per 1000 children treated using supination-flexion, this amounted to 174 fewer failures per 1000 children treated using hyperpronation (95% CI 134 to 201 fewer). This translates to a number needed to treat of 6 (95% CI 5 to 8) ; this means that six children would need to be treated with the hyperpronation method rather than the supination-flexion method to avoid one additional failure at first attempt.

 

 There is insufficient evidence to establish whether one technique is more or less painful than the other. Two (of four) studies suggested that hyperpronation may be less painful, but this evidence was of very low quality.

  

The bottom line

 

Hyperpronation appears to be much more likely to result in successful reduction of a pulled elbow than supination-flexion, though no high-quality studies exist.

 

  1. Hagroo G, Zaki H, Choudhary M, Hussain A. Pulled elbow--not the effect of hypermobility of joints. Injury [Internet] 1995;26(10):687–90. Available from: https://www.ncbi.nlm.nih.gov/pubmed/8745806
  2. Salter R, Zaltz C. Anatomic investigations of the mechanism of injury and pathologic anatomy of “pulled elbow” in young children. Clin Orthop Relat Res [Internet] 1971;77:134–43. Available from: https://www.ncbi.nlm.nih.gov/pubmed/5140442
  3. Irie T, Sono T, Hayama Y, Matsumoto T, Matsushita M. Investigation on 2331 cases of pulled elbow over the last 10 years. Pediatr Rep [Internet] 2014;6(2):5090. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24987508
  4. MAGILL H, AITKEN A. Pulled elbow. Surg Gynecol Obstet [Internet] 1954;98(6):753–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/13168841
  5. Asher M. Dislocations of the upper extremity in children. Orthop Clin North Am [Internet] 1976;7(3):583–91. Available from: https://www.ncbi.nlm.nih.gov/pubmed/958684
  6. Griffin M. Subluxation of the head of the radius in young children. Ohio State Med J [Internet] 1969;65(1):37–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/5812526
  7. Krul M, van der, Kruithof E, van S-S, Koes B. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev [Internet] 2017;7:CD007759. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28753234

 

May 28th, 2019    

Do nursing home residents get HCAP?

 

Background: Your patient has pneumonia: she is hypoxic, tachypnoeic and pyrexial. You begin oxygen and reach for a drug chart to prescribe some antibiotics. "Hold on," your colleague says, "the lady stays in a nursing home - doesn't she need different antibiotics?" You pause, uncertain. "I don't think we're doing that any more," you reply unconvincingly. But should we? Is HCAP (healthcare-associated pneumonia) still a thing?

 

 

What is HCAP? It was introduced and defined in guidelines from the American Thoracic Society / Infectious Diseases Society of America (IDSA) in 2005​[1]​. They were concerned that the following groups of patients were at higher risk of multi-drug resistant infections and should therefore be treated with broad spectrum antibiotics...

 

  • Those residing in a nursing home or extended care facility
  • Those hospitalised for 2 or more days during the preceding 90 days
  • Those receiving home infusion therapy
  • Those receiving domiciliary wound care
  • Those attending a haemodialysis centre within the preceding 30 days

 

 

It is fair to say that the concept of HCAP has been controversial from the beginning. Many studies failed to replicate the higher frequency of drug-resistant pathogens in these patient groups, and many have argued that the value of the HCAP concept varies by geographical region. I'll take a look at one representative study from each of these groups below.

 

 

Paper 1: Polverino E, Torres A, Menendez R. Microbial aetiology of healthcare associated pneumonia in Spain: a prospective, multicentre, case-control study. Thorax. 2013; 68:1007-1014​[2]​

 

 

A total of 476 patients with pneumonia were recruited over a 2-year period across 12 Spanish hospitals. Each had sputum and blood cultures, as well as urine antigen testing and nasopharyngeal swabs. They found no statistically significant differences in microbial aetiology between those meeting the IDSA definition of HCAP and those with CAP (community-acquired pneumonia). They concluded that broad spectrum antibiotics would not be helpful in the majority of HCAP cases.

 

Causative pathogen HCAP CAP
Streptococcus pneumoniae 62.7% 70.8%
Respiratory viruses 26.5% 15.3%
Legionella pneumophila 4.8% 11.1%
Gram-negative bacilli 7.2% 5.6%
Pseudomonas aeruginosa 4.8% 1.4%
Staphylococcus aureus 2.4% 2.8%
Haemophilus influenza 1.2% 1.4%

 

 

Paper 2: Chalmers J, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. Clin Infect Dis. 2014;58(3):330-9​[3]​

 

 

A meta-analysis of 24 studies (n=22,456). The authors searched for studies that compared the causative organisms in patients fitting the definitions of HCAP and CAP. They chose three organisms (Pseudomonas aeruginosa, Staphylococcus aureus and Gram-negative enterobacteriaceae) as being typical of hospital-acquired pathogens resistant to usual first-line antibiotics.

 

 

They found that HCAP did not perform well as a predictor of these pathogens overall. The performance was better in North America than it was in Europe or Asia, but it still fell below statistical significance, even in the USA. Conclusion: the HCAP concept does not accurately identify resistant pathogens.

 

 

The bottom line: Patients meeting the definition of HCAP are not at significantly higher risk of having drug-resistant pathogens, and should receive the same antibiotics as those with CAP.

 

 

Note: When preparing the 2016 IDSA guideline​[4]​ on hospital-acquired pneumonia, the panel unanimously decided that HCAP should not be included. HCAP is similarly absent from the British Thoracic Society guidelines of 2015​[5]​ (a change from 2009, where it is mentioned briefly).

 

 

Note: Some patients do of course contract a drug-resistant pneumonia requiring broad spectrum antibiotics. It is probably better to assess each case individually, rather than applying blanket criteria such as HCAP. Individual risk factors most likely include immunocompromise, intravenous drug use, chronic lung disease, end stage renal disease, alcoholism and malnourishment.

 

 

Other FOAMed on this topic:
PulmCCM
The Curbsiders
Pulmonary Advisor

 

  1. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. Am J Respir Crit Care Med [Internet] 2005;388–416. Available from: http://dx.doi.org/10.1164/rccm.200405-644ST
  2. Polverino E, Torres A, Menendez R, Cillóniz C, Valles JM, Capelastegui A, et al. Microbial aetiology of healthcare associated pneumonia in Spain: a prospective, multicentre, case–control study. Thorax [Internet] 2013;1007–14. Available from: http://dx.doi.org/10.1136/thoraxjnl-2013-203828
  3. Chalmers JD, Rother C, Salih W, Ewig S. Healthcare-Associated Pneumonia Does Not Accurately Identify Potentially Resistant Pathogens: A Systematic Review and Meta-Analysis. Clinical Infectious Diseases [Internet] 2013;330–9. Available from: http://dx.doi.org/10.1093/cid/cit734
  4. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, et al. Management of Adults With Hospital-acquired and Ventilator-associated          Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America          and the American Thoracic Society. Clinical Infectious Diseases [Internet] 2016;e61–111. Available from: http://dx.doi.org/10.1093/cid/ciw353
  5. Lim WS, Smith DL, Wise MP, Welham SA. British Thoracic Society community acquired pneumonia guideline and the NICE pneumonia guideline: how they fit together. Thorax [Internet] 2015;698–700. Available from: http://dx.doi.org/10.1136/thoraxjnl-2015-206881

 

May 21st, 2019    

Boxer’s fracture: does it really need a plaster cast?

Background: One fifth of hand injuries are fifth metacarpal neck fractures ('boxer's fractures'). If stable, these are traditionally treated with an ulnar gutter back slab in the first instance. Several trials have looked at buddy strapping as an alternative, but in 2005 a Cochrane review​1​ concluded that existing studies were underpowered to detect a difference in functional outcomes. Since that time, however, at least 3 trials​2–4​ have been published, each coming to the same conclusion. Here we take a look at the most recent one, which is currently only available online (it hasn't been published in written form yet).

 

 Pellatt R, Fomin I, Pienaar C, Bindra R, Thomas M, Tan E, et al. Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial. Annals of Emergency Medicine. 2019 March​4​

  

The paper: An Australian RCT that recruited 97 people with uncomplicated boxer's fractures. The fracture was classed as 'complicated' if there was a rotational deformity, an associated tendon injury, it was intra-articular or angulated more than 70 degrees (in the UK we would class this as 30 degrees angulation from the axis of the shaft on lateral view). The control arm was treated with immobilisation in an ulnar gutter plaster cast, while the intervention arm received buddy strapping of ring and little fingers. No reduction was attempted before immobilisation.

  

In terms of the primary outcome, there was no difference in reported hand function at 12 weeks (assessed using the quickDASH questionnaire). Secondary outcome measures were also identical: pain, satisfaction, days off work, return to sports and overall quality of life. The only difference found was in terms of cost, with buddy strapping costing an estimated $2 compared to $22 with plaster casting.

  

There are several limitations to this study. No strictly objective assessments were included as outcome measures: in particular, grip strength, range of motion and radiographic angulation. However, one could argue that the outcomes chosen were more patient-centred than these surrogate markers. Also, cosmetic appearance was not directly assessed and some studies​2​ suggest that loss of the knuckle is commoner with conservative management.

  

The bottom line: Buddy strapping is a viable alternative to cast immobilisation for uncomplicated boxer's fractures. This study found no difference in functional outcome, and there is a considerable saving in terms ED resources.

 

Note: Why is there a cut off for the degree of acceptable angulation? Simply that as the angle increases the distance between the origin and insertion of flexor digiti minimi decreases, which creates slack and reduces grip strength. A study from 1999​5​ provided the evidence that led to the 30 degrees cut off.

  

Expert commentary:
"I've always put them in a POP as I thought it was more comfortable for the patient. If there's no difference in outcome then I think this could change practice. The only thing to be wary of is managing 'complicated' fractures in this way. We need to keep the above features in mind to ensure we are selecting the right group of patients for this intervention."
Dr Dwynwen Roberts, ED Consultant

 

Other FOAMed on this topic:
emDocs
Life in the Fast Lane

  

References

  1. Poolman RW, Goslings JC, Lee J, Statius Muller M, Steller EP, Struijs PA. Conservative treatment for closed fifth (small finger) metacarpal neck fractures. Cochrane Database of Systematic Reviews [Internet]. 2005 Jul 20; Available from: http://dx.doi.org/10.1002/14651858.CD003210.pub3
  2. van Aaken J, Fusetti C, Luchina S, Brunetti S, Beaulieu J-Y, Gayet-Ageron A, et al. Fifth metacarpal neck fractures treated with soft wrap/buddy taping compared to reduction and casting: results of a prospective, multicenter, randomized trial. Arch Orthop Trauma Surg [Internet]. 2015 Nov 11;135–42. Available from: http://dx.doi.org/10.1007/s00402-015-2361-0
  3. Dunn JC, Kusnezov N, Orr JD, Pallis M, Mitchell JS. The Boxer’s Fracture: Splint Immobilization Is Not Necessary. Orthopedics [Internet]. 2016 Mar 29;188–92. Available from: http://dx.doi.org/10.3928/01477447-20160315-05
  4. Pellatt R, Fomin I, Pienaar C, Bindra R, Thomas M, Tan E, et al. Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial. Annals of Emergency Medicine [Internet]. 2019 Mar; Available from: http://dx.doi.org/10.1016/j.annemergmed.2019.01.032
  5. Ali A, Hamman J, Mass D. The biomechanical effects of angulated boxer’s fractures. J Hand Surg Am [Internet]. 1999 Jul 1;24(4):835–44. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10447177

May 16th, 2019    

Introducing the modified Sgarbossa criteria

 

Background: I saw a patient last month who had chest pain and an ECG showing an acute MI in the context of LBBB. The ECG did not meet the original Sgarbossa criteria but did when the modified rule was applied. I was suitably thrilled by this. No one else was. In fact, most of my colleagues were not familiar with the original Sgarbossa, let alone the modified version...

 

 

Warning: you can probably tell already that this post is going to be a little more nerdy and detailed than you're used to. Bear with me - Sgarbossa is not really difficult and it can really help when confronted with ECGs showing LBBB or ventricular pacing. The in-built ECG computer usually reports paced ECGs as: "no further analysis attempted". Be better than the machine! You can analyse them and, in particular, you can spot a STEMI with 80% sensitivity if you use the rule described below.

 

 

Dr Elena Sgarbossa proposed a clinical prediction rule for diagnosing acute myocardial infarction in the presence of LBBB way back in 1996 (in this paper). It consisted of 3 simple ECG criteria, and was later found to be equally helpful for diagnosing MI in the presence of a paced rhythm (see this post from The BREACH and the ESC guidelines on the management of STEMI here). What you may not know is that Dr Stephen Smith modified the Sgarbossa criteria in 2012 to make them more sensitive (this paper). Here we consider the proposed changes, and review a validation study that was published 3 years later.

 

 

Myers HP, Limkakeng T, Jaffa EJ, et al. Validation of the modified Sgarbossa criteria for acute coronary occlusion in the setting of left bundle branch block: a retrospective case-control study. Am Heart J. 2015 Dec;170(6):1255-64

 

 

The paper: A retrospective case-control study performed by chart review. Over 3 years every patient with LBBB and cardiac-sounding chest pain was included (294 in total - 45 STEMIs and 249 controls). The modified Sgarbossa criteria performed significantly better than the original weighted Sgarbossa criteria: 80% vs 49% sensitivity, and 99% vs 100% specificity. Against the unweighted criteria, modified Sgarbossa was again significantly better: 80% vs 56% sensitivity, and 99% vs 94% specificity.

 

 

'Weighted', by the way, refers to the system where each criterion receives a certain number of points, which are then totalled to give a final result. When Sgarbossa is used 'unweighted' (any one criterion gives a positive result), the sensitivity increases while the specificity reduces. With the modified criteria however, the sensitivity is pretty good already, so there is no need to bother with a points system. This makes it much easier to remember and use in practice.

 

 

The bottom line: The modified Sgarbossa criteria are superior to the original criteria for identifying acute STEMI in the context of LBBB

 

 

 

Original criteria:
1. Concordant ST elevation >1mm in leads with a positive QRS
2. Concordant ST depression >1mm in leads with a negative QRS (V1-3)
3. Excessively discordant ST elevation >5mm in leads with a negative QRS (V1-3)

 

 

 

Modified criteria:
1. Unchanged
2. Unchanged
3. ST elevation >25% of the depth of the S wave in leads with a negative QRS (V1-3)
i.e. the new criteria make the degree of ST elevation proportional: dependent on the amplitude of the preceding QRS rather than being an absolute figure

 

 

Note: Dr Smith's modified criteria were referenced and accepted by Dr Sgarbossa herself in this 2013 paper.

 

 

Expert commentary:
"This is interesting, especially if it was validated by Dr Sgarbossa. I think there needs to be more education on this for our department (and for EM trainees in general) as it is not widely known."
Dr Dwynwen Roberts, ED Consultant

 

May 11th, 2019    

New guidelines on lower GI bleeding

 

Background: Lower GI bleeding (LGIB) is a fairly common ED presentation, but it may surprise you to learn that there are no UK national guidelines on the acute management of this condition. Who can go home? Who needs admission? What is the best initial management? Thankfully, the British Society of Gastroenterology has recently published a paper covering all of this, and it's a big one: stakeholders include the Association of Coloproctology of Great Britain and Ireland, the British Society of Interventional Radiology, the Royal College of Radiologists and NHS Blood and Transplant.

 

 

Oakland K, Chadwick G, East J, et al. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut. 2019 Jan;0:1-14

 

 

Summary of recommendations

 

 

Diagnosis:

 

  • The Oakland score is recommended to risk-stratify patients
  • Patients with a minor self-limiting bleed (Oakland 8 points or less) can be discharged for urgent outpatient investigation
  • Patients with a major bleed (Oakland >8 points) should be admitted for colonoscopy on the next available list
  • Patients who are haemodynamically unstable (shock index >1 after initial resuscitation) should be admitted for urgent CT angiography (CTA)

 

 

Management:

 

  • Colonoscopy is the preferred initial investigation in most cases of major LGIB as it has the potential for diagnosis and treatment
  • CTA is preferred over colonoscopy in unstable patients, as it can localise a bleeding source in the upper and lower GI tract and has no requirement for bowel preparation
  • If no source is identified on CTA, patients should undergo an upper endoscopy (OGD)
  • Some unstable patients should proceed directly to OGD following senior discussion, as shock is more commonly found in UGIB than LGIB
  • No patient should proceed to emergency laparotomy unless every effort has been made to localise bleeding by radiological or endoscopic modalities

 

 

Blood transfusion:

 

  • Patients should be transfused if haemoglobin level is less than 70g/L
  • Patients with a history of cardiovascular disease should be transfused if haemoglobin is less than 80g/L

 

 

Expert commentary:
"This article is really interesting: a useful summary for ourselves and the admitting speciality. The Oakland score looks promising, as it seems to have fairly standard criteria on it."
(Dr Robert Tan, ED Consultant)

 

 

More on the Oakland score:
The score can be found on MDCalc. It predicts the probability of safe discharge, specifically the absence of rebleeding, transfusion, interventions, readmission or death at 28 days. It is based on 7 variables: age, sex, history of LGIB, blood on PR, heart rate, blood pressure and haemoglobin level. A score of 8 or less corresponds to a 95% probability of safe discharge. The score was derived in a large UK-based multi-centre study (The Lancet, 2017) involving around 2,300 patients. It has not been internationally validated yet.

 

May 6th, 2019    

Should we cardiovert everyone with recent-onset fast AF?

 

Background: Cardioverting a patient who presents with recent-onset fast AF is great. You consent them, sedate them, shock them, and they wake up feeling better and (often) go home. You feel awesome - quick action, visible result, everyone happy. But how necessary is it to get these patients back into sinus rhythm on their initial visit? And how many will cardiovert without any intervention? The RACE-7 trial can help us answer these questions.

 

 

Pluymaekers NAHA, Dudink EAMP, Luermans JGLM, et al. Early or delayed cardioversion in recent-onset atrial fibrillation. N Engl J Med 2019 Apr;380(16):1499-1508

 

 

The paper: A total of 437 patients were randomised over a 4-year period across 15 EDs in the Netherlands. Each presented with recent-onset (within the last 36 hours) stable AF and were randomised to immediate or delayed cardioversion. Those in the delayed group received rate-controlling medication in the ED and were followed up at 48 hours. If they were still in AF, they were cardioverted at this time. In the immediate cardioversion group, sinus rhythm was restored in 94% of cases (16% spontaneous, 38% chemical, 40% electrical). In the delayed group, 69% had spontaneously cardioverted by the time of follow up, and the remaining 28% were successfully cardioverted at this time (4% chemical, 24% electrical). There was no significant difference in the authors' primary endpoint (the presence of sinus rhythm after 4 weeks), but for me the interesting part of this study is the rate of spontaneous cardioversion in both groups.

 

 

The bottom line: These data suggest that the majority of patients presenting with recent-onset stable AF will spontaneously cardiovert by 48 hours. Maybe we should give them a chance before reaching for the defib pads.

 

 

Expert commentary:
"I think this backs up our usual practice: most get rate control or IV fluids and they often slow down/convert. I'm not always convinced that the change in rate/rhythm is anything to do with what we've done to the patient but that they just slow down/convert on their own! This study lends support to this practice."
(Dr Dwynwen Roberts, ED Consultant)

 

May 1st, 2019    

Upside-down position for SVT in children

Background: Supraventricular tachycardia (SVT) is the commonest arrhythmia in children, having two peaks – one in the first year of life and another around age 6. We generally attempt vagal manoeuvres before medication or electricity to restore sinus rhythm. The commonest techniques are the ‘mammalian dive reflex’ (submerge the face of an infant in freezing water) and the Valsalva method (forced expiration against a closed glottis). There is, however, a new kid on the block – the imaginatively-named upside-down position. This is the first pilot study of this technique. The authors are currently conducting a larger RCT.

 

Bronzetti G, Brighenti M, Mariucci E, et al. Upside-down position for the out of hospital management of children with supraventricular tachycardia. Int J Cardiol 2018;252:106-109

 

The paper: A single-centre study of 24 children with known paroxysmal SVT. The parents were taught to identify SVT using palpation of the brachial or carotid pulse and with a stethoscope. Each family was randomly assigned to standard vagal manoeuvre (VM – blowing into a 10ml syringe for 15 seconds) or upside-down manoeuvre (UD – manually flipping children weighing less than 30kg or helping heavier children to do a handstand for 30 seconds). If this was unsuccessful, the other manoeuvre was attempted. The rate of cardioversion at the first attempt was 33% (VM), compared to 67% (UD). Of those in whom the attempted manoeuvre was unsuccessful, 50% subsequently cardioverted with UD, whereas none cardioverted with VM. In addition to these results, parents reported that their children enjoyed the upside-down position more than syringe-blowing.

 

The bottom line: This is a tiny pilot study, but the results are very much in favour of the upside-down position for the treatment of SVT in children.

 

Note: It is well-known that vagal manoeuvres work better if they are carried out before adrenergic tone rises, which is why they work better when performed soon after the onset of SVT, and at home rather than in the ED

 

Expert commentary:
“Interesting… to be honest I have never tried this technique. However, it seems very promising and I’m glad that further research is happening. The British Heart Foundation leaflet for parents on SVT actually recommends the upside-down method so it’s certainly becoming well-established.”
(Mohsin Jafri, Paediatric Consultant)

April 27th, 2019    

New tetanus guidelines

 

Background: Have you ever seen a case of tetanus? Don't feel bad if you haven't - there were only four in the whole of England during 2016. The disease is admittedly terrible: the muscle spasms can be so severe they cause fractures, and serious complications loss of airway and respiratory arrest. Thankfully, vaccination has made the condition extremely rare in the developed world. But it often feels as though confusion reigns over the best approach to vaccination in the ED... Who needs a booster? Who needs immunoglobulin? What kind of patient? What kind of wound? The Department of Health recently updated their guidance on tetanus immunisation, replacing the 2013 recommendations. Here is the bite-sized BREACH summary of the document...

 

 

Department of Health (2018). Tetanus: The Green Book, chapter 30

 

See www.the-breach.com for summary tables

 

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