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 27th, 2019    

Eye trauma: could you manage a retrobulbar haemorrhage?

 

Background

 

Patients with head injuries sometimes present with a closed, swollen eye. We rightly worry about intracranial bleeding in these cases, but there are some important eye injuries to consider too. Dr Anna MacDonald​[1]​ suggests that the following four time-critical, sight-threatening diagnoses should be foremost in our minds when assessing a patient with blunt ocular trauma...

 

  1. Retrobulbar haemorrhage with orbital compartment syndrome
  2. Globe rupture
  3. Retinal detachment
  4. High grade ('8-ball') hyphema with acute glaucoma

 

The first of these, retrobulbar haemorrhage (RBH), is a fairly rare condition and many of us will be unfamiliar with its features and recommended management. A recent paper in the EMJ tried to assess the competency of UK ED docs in treating RBH, and identified some issues...

 

The paper

 

Edmunds MR, Haridas AS, Morris DS, Jamalapuram K. Management of acute retrobulbar haemorrhage: a survey of non-ophthalmic emergency department physicians. Emerg Med J 2019;36(4):245-247 ​[2]​

 

 

For detailed show notes please visit our website: https://the-breach.com

 

June 21st, 2019    

What is the risk of AKI following contrast CT in septic patients?

 

Background

 

The concept of contrast-induced nephropathy (CIN) came from a 1954 paper​[1]​ and has been widely taught over the last 60 years. However, recent studies have questioned the true incidence of CIN, and even whether it exists at all. There are in fact many robust RCTs​[2,3]​ now showing no association between contrast administration and acute kidney injury (AKI). The earlier confusion seems to have arisen for several reasons:​[4]​

 

  • Older contrast dyes had a higher osmolarity than modern ones and possibly were nephrotoxic. They were also used in larger volumes
  • Older studies rarely used control groups, so although some patients developed an AKI after contrast CT, it is impossible to know whether this would have happened anyway (without the CT)
  • Many studies take small fluctuations in creatinine as evidence of 'kidney injury' but it is debatable whether these equate to actual patient-centred outcomes like need for dialysis

 

 

The paper

 

Hinson JS, Al Jalbout N, Ehmann MR, Klein EY. Acute kidney injury following contrast media administration in the septic patient: a retrospective propensity-matched analysis. J Crit Care. 2019;51:111-116​[5]​

 

 

For detailed show notes please visit our website: https://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]​

 

For detailed show notes please visit our website: https://the-breach.com

 

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]​

 

For detailed show notes please visit our website: https://the-breach.com

 

 

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]​

 

 

For detailed show notes please visit our website: https://the-breach.com

 

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]​

 

 For detailed show notes please visit our website: https://the-breach.com

 

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​

 

For detailed show notes please visit our website: https://the-breach.com

 

 

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

 

 

For detailed show notes please visit our website: https://the-breach.com

 

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)

 

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