Westmead EMRU PrécisForeword

As expected, we had no entries for the naming contest for the monthly research newsletter. So I have decided to drink the 1994 Bin Penfolds 389 by myself. My apologies for not mentioning the details of the prize.

Westmead EMRU Précis has been spruced up this month into a synoptic version with development of new segments. In interest of EBM, the first section DUBIUS will be dedicated to 5 questionable tests or procedures relevant to emergency medicine, these are tests and practices that have been found to lack scientific credibility but yet practiced diligently.

PRÉCIS MENSTRUA will outline the significant research articles of the month gone by or articles missed out in the recent past.

NOSTOS ALGOS will feature a significant or maybe not so significant research piece from the past.

Whilst DISPUTATIO will focus a scientific debate around a certain topic or practice!

PRIMUS will introduce you to one of the current EMRU research activity occurring at Westmead ED…

Feel free to send your articles, topics or suggestions to samit36@hotmail.com or Jennifer.Johnson@swahs.health.nsw.gov.au or margaret.murphy@swahs.health.nsw.gov.au

Further information or background data (when available) on all topics appearing on précis can also be requested for further scrutiny.

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Westmead Emergency Research Unit

Editor

Amith Shetty

Contributors

Margaret Murphy

Naren Gunja

Gopi Mann

Toby Thomas

In this month’s edition –

DUBIUS - Questionable tests and procedures – P 3

PRÉCIS MENSTRUA March 2013 – P4 – P17

NOSTOS ALGOS - Blast from the past – P18

DISPUTATIO – aggie baggie – Family presence during resuscitation – P19-21

PRIMUS – introducing – Transfusion associated Microchimerism trial - P22

CONCLUSIO – Journal club articles and department publications – P23-24.

Westmead EMRU Précis

This month’s research highlights are the Surviving Sepsis updated guidelines – nothing significantly new here. Also there have been a spate of sponsored trials trying to tell us to consider alternative drugs to warfarin… but hopefully fewer GPs follow their cue! Meanwhile, vitamin D and calcium seem to have fallen out of favour with the researchers! So maybe, just maybe the old adage: ‘eat well, drink well and live well still holds true.’ Don’t bother with the OTC supplements unless your iridologist has suggested them to you.

A meta-analysis into different β-blockers used in management of heart failure has found none of them to be superior to the other, so may be newer is not always better so the cardiologist can save some pennies for the poor patient with some generics! Meanwhile we at Westmead are a bit spoilt by availability of PCI (cathlab) facilities, but for those of us who also work elsewhere without PCI back-up; it is heartening to see a recent NEJM study pointing to early use of fibrinolytics having good outcomes for AMI.

There was also a study published on the role of Viagra as a drug for improving exercise tolerance in CCF patients – no points for guessing that the results were as good as giving a placebo. I guess you can take the horse to the water but not make him drink it! Or maybe there was no water available at the end of the walk.

It’s also great to point out that physician gestalt (gut feeling) about pulmonary embolism is better than any other scores (wells), but depends on whose gut you are looking at!

Lastly, I would like to point out that whilst this is a long newsletter, I have only attached articles which seem to

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Westmead EMRU Précishave (to me) relevance to ED practice. In most cases, I have only included the conclusions, whilst where significant some results of the study are attached as well. Where possible I have tried to include funding details of trials and I have not made any judgement calls on the trials itself. Hopefully some of you make it to the very end of the article before falling into a stupor!

Please refrain from printing this article – I don’t know what the footprint of doing that would be!

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Westmead EMRU PrécisDUBIUS

Don’t diagnose or manage asthma without spirometry. Clinicians often rely solely upon symptoms when diagnosing and managing asthma, but these symptoms may be misleading and be from alternate causes. Therefore spirometry is essential to confirm the diagnosis in those patients who can perform this procedure. Recent guidelines highlight the value of spirometry in stratifying disease severity and monitoring control. History and physical exam alone may over- or under-estimate asthma control. Beyond the increased costs of care, repercussions of misdiagnosing asthma include delaying a correct diagnosis and treatment.

Don’t do imaging for low back pain within the first six weeks, unless red flags are present. Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs. Low back pain is the fifth most common reason for all physician visits.

Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment. Numerous studies—including randomized trials—provide evidence that palliative care improves pain and symptom control, improves family satisfaction with care and reduces costs. Palliative care does not accelerate death, and may prolong life in selected populations.

Don’t prescribe oral antibiotics for uncomplicated acute external otitis. Oral antibiotics have significant adverse effects and do not provide adequate coverage of the bacteria that cause most episodes; in contrast, topically administered products do provide coverage for these organisms. Avoidance of oral antibiotics can reduce the spread of antibiotic resistance and the risk of opportunistic infections.

Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis). Although overall antibiotic prescription rates for children have fallen, they still remain alarmingly high. Unnecessary medication use for viral respiratory illnesses can lead to antibiotic resistance and contributes to higher health care costs and the risks of adverse events. 1

1 Adapted from Choosing wisely.org an initiative of American Board of Internal Medicine and involving relevant other medical specialty groups

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Westmead EMRU PrécisPRÉCIS MENSTRUA

Crit Care Med. 2013 Feb; 41(2):580-637.JUST RELEASED! Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012.Surviving Sepsis Campaign Guidelines CommitteeRESULTS: Key recommendations and suggestions, listed by category, include:

early resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); Administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of

septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; Reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); Infection source control with attention to the balance of risks and benefits of the chosen

method within 12 hrs of diagnosis (1C); Initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in

patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C);

Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C);

Fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG);

Norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥ 65 mm Hg (1B); Epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C);

Avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C);

Hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B);

Low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B);

Head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); Conservative fluid strategy for patients with established ARDS who do not have evidence of

tissue hypoperfusion (1C); Protocols for weaning and sedation (1A); minimizing use of either intermittent bolus

sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 < 150 mm Hg (2C);

Protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A);

Equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B);

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Westmead EMRU Précis Prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper

gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C); and

Addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C).

Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C).

Circulation. 2013 Jan 29; 127(4):435-41. Chest compression alone cardiopulmonary resuscitation is associated with better long-term survival compared with standard cardiopulmonary resuscitation.Dumas F, Rea TD, et al.CONCLUSIONS:The findings provide strong support for long-term mortality benefit of dispatcher CPR instruction strategy consisting of chest compression alone rather than chest compression plus rescue breathing among adult patients with cardiac arrest requiring dispatcher assistance.

N Engl J Med 2013; 368:709-718Extended Use of Dabigatran, Warfarin, or Placebo in Venous ThromboembolismSam Schulman, Clive Kearon, et al for the RE-MEDY and the RE-SONATE Trials InvestigatorsCONCLUSIONSDabigatran was effective in the extended treatment of venous thromboembolism and carried a lower risk of major or clinically relevant bleeding than warfarin but a higher risk than placebo. (Funded by Boehringer Ingelheim; RE-MEDY and RE-SONATE )

The Lancet, Early Online Publication, 13 February 2013Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trialDr Willem JM Dewilde MD , Tom Oirbans MSc et al for the WOEST study investigatorsInterpretationUse of clopidogrel without aspirin was associated with a significant reduction in bleeding complications and no increase in the rate of thrombotic events.

BMJ. 2013 Jan 16;346:f55. Benefits of β blockers in patients with heart failure and reduced ejection fraction: network meta-analysis.Chatterjee S, Biondi-Zoccai G et alCONCLUSION:The benefits of β blockers in patients with heart failure with reduced ejection fraction seem to be mainly due to a class effect, as no statistical evidence from current trials supports the superiority of any single agent (atenolol, bisoprolol, bucindolol, carvedilol, metoprolol, and nebivolol) over the others.

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Westmead EMRU PrécisBMJ 2013; 346 Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studiesLisa Te Morenga, Simonette Mallard et alConclusions Among free living people involving ad libitum diets, intake of free sugars or sugar sweetened beverages is a determinant of body weight. The change in body fatness that occurs with modifying intakes seems to be mediated via changes in energy intakes, since isoenergetic exchange of sugars with other carbohydrates was not associated with weight change.

Am J Gastroenterol 2010;105:S394The AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleedingBrian H. Hyett, Marwan S. Abougergi et alAIMS65 - Albumin less than 3.0 g/dL, INR greater than 1.5, altered Mental status, Systolic blood pressure 90 mm Hg or lower, and age older than 65 years.Criteria for Glasgow-Blatchford ScoreThe score is calculated using the table below:

Glasgow-Blatchford ScoreAdmission risk marker Score component valueBlood Urea≥6·5 <8·0 2≥8·0 <10·0 3≥10·0 <25·0 4≥25 6Haemoglobin (g/L) for men≥12.0 <13.0 1≥10.0 <12.0 3<10.0 6Haemoglobin (g/L) for women≥10.0 <12.0 1<10.0 6Systolic blood pressure (mm Hg)100–109 190–99 2<90 3Other markersPulse ≥100 (per min) 1Presentation with melaena 1Presentation with syncope 2Hepatic disease 2Cardiac failure 2

In the validation group, scores of 6 or more were associated with a greater than 50% risk of needing an intervention.ConclusionThe AIMS65 score is superior to the GBRS in predicting inpatient mortality from UGIB, whereas the GBRS is superior for predicting blood transfusion. Both scores are similar in predicting the composite clinical endpoint and other outcomes in clinical care and resource use.

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Westmead EMRU PrécisAcademic Emergency Medicine, January 2013Primary Versus Secondary Closure of Cutaneous Abscesses in the Emergency Department: A Randomized Controlled TrialAdam J. Singer , Breena R. Taira et alConclusionsThe rates of wound healing and treatment failure following I&D of simple abscesses in the ED are similar after primary or secondary closure. The authors did not detect a difference of at least 40% in healing rates between primary and secondary closure.

Ann Emerg Med 2013 Feb 1A Comparison of the GlideScope Video Laryngoscope to the C-MAC Video Laryngoscope for Intubation in the Emergency DepartmentJarrod Mosier, Stephen Chiu et alDuring the 3-year study period, there were 463 intubations, including 230 with the GlideScope video laryngoscope as the initial device and 233 with the C-MAC as the initial device.ConclusionIn this study of video laryngoscopy in the ED, the GlideScope video laryngoscope and the C-MAC were associated with similar rates of intubation success.

NEJM February 25, 2013Primary Prevention of Cardiovascular Disease with a Mediterranean DietRamón Estruch, Emilio Ros et al for the PREDIMED Study InvestigatorsThe multivariable-adjusted hazard ratios were 0.70 (95% confidence interval [CI], 0.54 to 0.92) and 0.72 (95% CI, 0.54 to 0.96) for the group assigned to a Mediterranean diet with extra-virgin olive oil (96 events) and the group assigned to a Mediterranean diet with nuts (83 events), respectively, versus the control group (109 events). No diet-related adverse effects were reported.CONCLUSIONSAmong persons at high cardiovascular risk, a Mediterranean diet supplemented with extra-virgin olive oil or nuts reduced the incidence of major cardiovascular events. (Funded by the Spanish government's Instituto de Salud Carlos III and others).

JAMA Intern Med. 2013;():1-8. doi:10.1001/jamainternmed.2013.3283.Dietary and Supplemental Calcium Intake and Cardiovascular Disease Mortality The National Institutes of Health–AARP Diet and Health StudyQian Xiao; Rachel A et alDuring a mean of 12 years of follow-up, 7904 and 3874 CVD deaths in men and women, respectively, were identified. Supplements containing calcium were used by 51% of men and 70% of women. In men, supplemental calcium intake was associated with an elevated risk of CVD death (RR>1000 vs 0 mg/d, 1.20; 95% CI, 1.05-1.36), more specifically with heart disease death (RR, 1.19; 95% CI, 1.03-1.37) but not significantly with cerebrovascular disease death (RR, 1.14; 95% CI, 0.81-1.61). In women, supplemental calcium intake was not associated with CVD death (RR, 1.06; 95% CI, 0.96-1.18), heart disease death (1.05; 0.93-1.18), or cerebrovascular disease death (1.08; 0.87-1.33). Dietary calcium intake was unrelated to CVD death in either men or women.ConclusionsFindings suggest that high intake of supplemental calcium is associated with an excess risk of CVD death in men but not in women. Additional studies are needed to investigate the effect of supplemental calcium use beyond bone health.

Ann Intern Med. 26 February 2013

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Westmead EMRU PrécisVitamin D and Calcium Supplementation to Prevent Fractures in Adults: U.S. Preventive Services Task Force Recommendation StatementVirginia A. Moyer on behalf of the U.S. Preventive Services Task Force*Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of the benefits and harms of combined vitamin D and calcium supplementation for the primary prevention of fractures in premenopausal women or in men. (I statement)The USPSTF concludes that the current evidence is insufficient to assess the balance of the benefits and harms of daily supplementation with greater than 400 IU of vitamin D3 and greater than 1000 mg of calcium for the primary prevention of fractures in noninstitutionalized postmenopausal women. (I statement)The USPSTF recommends against daily supplementation with 400 IU or less of vitamin D3 and 1000 mg or less of calcium for the primary prevention of fractures in noninstitutionalized postmenopausal women. (D recommendation)

JAMA. 2012 Dec 19;308(23):2507-16. doi: 10.1001/jama.2012.50788.Association of clopidogrel pre-treatment with mortality, cardiovascular events, and major bleeding among patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis.Bellemain-Appaix A, O'Connor SA et al ACTION Group.Of the 37 814 patients included in the meta-analysis, 8608 patients had participated in RCTs; 10,945, in observational analyses of RCTs; and 18,261, in observational studies. Analysis of RCTs showed that clopidogrel pre-treatment was not associated with a reduction of death (absolute risk, 1.54% vs 1.97%; OR, 0.80; 95% CI, 0.57-1.11; P = .17) but was associated with a lower risk of major cardiac events (9.83% vs 12.35%; OR, 0 .77; 95% CI, 0.66-0.89; P < .001). There was no significant association between pre-treatment and major bleeding overall (3 .57% vs 3.08%; OR, 1.18; 95% CI, 0.93-1.50; P = .18). CONCLUSIONS:Among patients scheduled for PCI, clopidogrel pre-treatment was not associated with a lower risk of mortality but was associated with a lower risk of major coronary events.

Lack of Effectiveness of Hyperbaric Oxygen Therapy for the Treatment of Diabetic Foot Ulcer and the Prevention of Amputation - A cohort studyDavid J. Margolis, Jayanta Gupta, et al.6,259 individuals with diabetes, adequate lower limb arterial perfusion, and foot ulcer extending through the dermis, representing 767,060 person-days of wound care. CONCLUSIONS Use of HBO neither improved the likelihood that a wound would heal nor prevented amputation in a cohort of patients defined by Centers for Medicare and Medicaid Services eligibility criteria. The usefulness of HBO in the treatment of diabetic foot ulcers needs to be re-evaluated.

JAMA. 2013;309(8):781-791. doi:10.1001/jama.2013.905.Effect of Spironolactone on Diastolic Function and Exercise Capacity in Patients With Heart Failure With Preserved Ejection Fraction The Aldo-DHF Randomized Controlled TrialFrank Edelmann, Rolf Wachter et al for the Aldo-DHF InvestigatorsPatients were randomly assigned to receive 25 mg of spironolactone once daily (n=213) or matching placebo (n=209) with 12 months of follow-up.Conclusions and Relevance In this randomized controlled trial, long-term aldosterone receptor blockade improved left ventricular diastolic function but did not affect maximal exercise capacity, patient symptoms, or quality of life in patients with heart failure with preserved ejection fraction.

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Westmead EMRU PrécisWhether the improved left ventricular function observed in the Aldo-DHF trial is of clinical significance requires further investigation in larger populations.

Journal of Pediatrics published online 28 January 2013. Nonsteroidal Anti-Inflammatory Drugs Are an Important Cause of Acute Kidney Injury in ChildrenJason M. Misurac, Chad A. Knoderer, et alRetrospective chart review of children diagnosed with AKI; Patients (N = 1015) were identified through International Classification of Diseases, Ninth Revision screening. Twenty-one children had clinical, laboratory, and radiographic studies suggesting NSAID-associated acute tubular necrosis and 6 had findings suggesting NSAID-associated acute interstitial nephritis, representing 2.7% (27 of 1015) of the total cohort with AKI and 6.6% when excluding complex patients with multifactorial AKI.ConclusionsNSAID-associated AKI accounted for 2.7% of AKI in this pediatric population. AKI typically occurred after the administration of correctly dosed NSAIDs. Young children with NSAID-associated AKI may have increased disease severity.N Engl J Med 2013; 368:814-823February 28, 2013DOI: 10.1056/NEJMoa1211035Ondansetron in Pregnancy and Risk of Adverse Fetal OutcomesBjörn Pasternak, Henrik Svanström, et al Investigated the risk of adverse fetal outcomes associated with ondansetron administered during pregnancy. From a historical cohort of 608,385 pregnancies in Denmark, women who were exposed to ondansetron and those who were not exposed were included, in a 1:4 ratio, in propensity-score–matched analyses of spontaneous abortion (1849 exposed women vs. 7396 unexposed women), stillbirth (1915 vs. 7660), any major birth defect (1233 vs. 4932), preterm delivery (1792 vs. 7168), and birth of infants at low birth weight and small for gestational age (1784 vs. 7136).CONCLUSIONSOndansetron taken during pregnancy was not associated with a significantly increased risk of adverse fetal outcomes. (Funded by the Danish Medical Research Council.)

JAMA Intern Med. 2013;():1-8. doi:10.1001/jamainternmed.2013.2777.Types and Origins of Diagnostic Errors in Primary Care Settings FREE ONLINE FIRSTHardeep Singh; Traber Davis Giardina et alResults In 190 cases, a total of 68 unique diagnoses were missed. Most missed diagnoses were common conditions in primary care, with pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (primary) (5.3%), and urinary tract infection or pyelonephritis (4.8%) being most common. Process breakdowns most frequently involved the patient-practitioner clinical encounter (78.9%) but were also related to referrals (19.5%), patient-related factors (16.3%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.7%). A total of 43.7% of cases involved more than one of these processes. Patient-practitioner encounter breakdowns were primarily related to problems with history-taking (56.3%), examination (47.4%), and/or ordering diagnostic tests for further workup (57.4%). Most errors were associated with potential for moderate to severe harm.

AHA/ASA GuidelineGuidelines for the Early Management of Patients with Acute Ischemic StrokeEdward C. Jauch, Jeffrey L. Saver, et al on behalf of the American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Clinical CardiologyThe American Heart Association/American Stroke Association has updated its comprehensive acute stroke care guidelines, which were previously updated in 2009. The guidelines followed the usual AHA/ASA classification of recommendations and levels of evidence. New or modified recommendations worth noting include the following:

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Westmead EMRU Précis Teleradiology networks are recommended for community hospitals that lack access to neurological expertise. (Class I, Level B) Intravenous (IV) thrombolysis is recommended in the setting of early ischemic changes, with the exception of frank hypodensity on computed tomography (CT). (Class I, Level A) A noninvasive intracranial vascular study is strongly recommended if either intra-arterial fibrinolysis or mechanical thrombectomy is being considered, but this study should not delay initiation of tissue plasminogen activator (TPA). (Class I, Level A) The target door-to-needle time for patients who receive intravenous TPA is <60 minutes. (Class I, Level A) IV TPA is recommended in the 3- to 4.5-hour time window — beyond the previously recommended 3-hour window — with additional exclusion criteria (age >80, use of oral anticoagulants, baseline NIH Stroke Scale score >25, imaging evidence of ischemic injury involving more than one third of the middle cerebral artery territory, or a history of both stroke and diabetes mellitus). (Class I, Level B) Use of IV TPA may be considered for patients with mild stroke or those with major surgery in the last 3 months, after weighing the risks and benefits. (Class IIb, Level C) Use of IV TPA is not recommended for patients taking novel anticoagulants unless clotting tests are normal or the patient has not taken medication for >2 days (with normal renal function). (Class III, Level C) When mechanical thrombectomy is considered, stent retrievers are preferred to coil retrievers. (Class I, Level A) The ability of mechanical thrombectomy devices to improve patient outcomes has not yet been established. Rescue intra-arterial thrombolysis or thrombectomy may be reasonable in patients who have failed IV thrombolysis, but additional randomized trial data are needed. (Class IIb, Level B)

Journal of Clinical Medicine Research Vol. 5, No. 2, Apr 2013Geriatric Trauma Patients with Cervical Spine Fractures due to Ground Level Fall: Five Years Experience in a Level One Trauma CenterHao Wang, Marco Coppola et alConclusion: Geriatric patients tend to sustain more upper C-spine fractures than non-geriatric patients regardless of the mechanisms. GLF or less not only can cause isolated C-spines fracture(s) but also lead to other significant injuries with ICP as the most common one in geriatric patients. Advanced age and male are two risk factors that can predict this co-injury pattern. In addition, it seems that alcohol plays no role in the cause of GLF in geriatric trauma patients.

Emerg Med J. 2013 Feb;30(2):91-100. doi: 10.1136/emermed-2012-201120. Epub 2012 Jun 3.Safety profile and outcome of mild therapeutic hypothermia in patients following cardiac arrest: systematic review and meta-analysis.Xiao G, Guo Q et alAbstractMEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, BIOSIS Previews and clinicaltrials.gov were searched up to June 2011. Of 1742 abstracts, 63 studies were included. Most adverse events potentially associated with therapeutic hypothermia were not significantly different between the hypothermia therapy and the normothermia groups. No significant difference was found in the in-hospital mortality, bleeding, pneumonia and bradycardia events between surface and endovascular-cooled groups in this study. Cooling device-related adverse events were generally mild. Serious adverse events potentially attributable to therapeutic hypothermia were seldom reported. MTH was associated with reduced in-hospital mortality, mortality at 1 month and at 6 months. Evidence about the safety of MTH in children has been limited. These results suggest that while it may result in some adverse events, MTH is generally safe in patients following cardiac arrest

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Westmead EMRU Précisand could improve the short-term and long-term survival of comatose patients after cardiac arrest. But awareness of these adverse events should be kept in mind in clinical practice.

This one’s for US fanatics- a new technique to try out!Br J Anaesth. 2013 Mar;110(3):368-73. doi: 10.1093/bja/aes381. Epub 2012 Nov 6.Three-step method for ultrasound-guided central vein catheterization.Tokumine J, Lefor AT et alAbstractBACKGROUND:The long-axis view and in-plane needle approach (LAX-IP) for ultrasound-guided central vein catheterization is considered ideal because of the quality of real-time imaging. We describe a novel technique, using a step-by-step procedure, to overcome the pitfalls associated with the LAX-IP. This study was undertaken to demonstrate the clinical utility of this approach.METHODS:All operators underwent training before participation in this study. One hundred patients were enrolled in this study and underwent central venous catheterization using this method. Using a portable ultrasound and vein catheterization kit, patients were appropriately positioned and a straight portion of the vein identified (Step 1). A needle guide was used (Step 2) and the vein imaged in real time in two directions (Step 3), to identify the true long axis and prevent damage to surrounding tissues.RESULTS:The overall success rate for catheterization was 100% with a median of one puncture for each patient. All catheterizations were performed within three punctures. Problems with the first puncture included difficult insertion of the guide-wire due to coiling, difficult anterior wall puncture, less experience with the procedure, and other reasons. There were no complications associated with the procedure.CONCLUSIONS:This three-step method is not dependent on an operator's ability to proceed based on spatial awareness, but rather depends on logic. This method can prevent difficulties associated with a two-dimensional ultrasound view, and may be a safer technique compared with others. Further clinical trials are needed to establish the safety of this technique.

J Emerg Med. 2013 Feb;44(2):287-91. Cervical spine injury: analysis and comparison of patients by mode of transportation.Urdaneta AE, Stroh G et alThree-hospital retrospective review of patients with CSI from January 1, 2000 to December 31, 2007. RESULTS:Of 1174 charts identified, 718 met all study criteria; 671 arrived by EMS and 47 by PV (personal vehicle). There was no difference between groups in age or gender. Ground-level fall was more likely in PV patients (32%, 95% confidence interval [CI] 20-46% vs. 6%, 95% CI 4-9%), whereas motor vehicle collision was less likely (32%, 95% CI 20-46% vs. 67%, 95% CI 63-70%). PV patients more often sustained a stable injury (66%, 95% CI 52-78% vs. 40%, 95% CI 36-44%), and were more often triaged to a lower-acuity area (25%, 95% CI 15-40% vs. 4%, 95% CI 3-6%). The incidence of neurologic deficit was similar (32%, 95% CI 20-46% vs. 24%, 95% CI 21-28%), though more PV patients had spinal cord injury without radiographic abnormality (21%, 95% CI 12-35% vs. 5%, 95% CI 4-7%).CONCLUSION:A small proportion of patients with CSI present to the ED by PV. Although most had stable injuries, a surprising number had unstable injuries with neurologic deficits, and were triaged to lower-acuity areas in the ED.

Editorial Group: Cochrane Back Group Published Online: 28 FEB 2013

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Westmead EMRU PrécisRed flags to screen for malignancy in patients with low-back painN Henschke, C G. Maher et al Included eight cohort studies (total number of patients; n = 6622) and one study was from an accident and emergency setting (n = 482). There was some evidence from individual studies that having a previous history of cancer meaningfully increases the probability of malignancy. Most "red flags" such as insidious onset, age > 50, and failure to improve after one month have high false positive rates.Authors' conclusionsFor most "red flags," there is insufficient evidence to provide recommendations regarding their diagnostic accuracy or usefulness for detecting spinal malignancy. The available evidence indicates that in patients with LBP, an indication of spinal malignancy should not be based on the results of one single "red flag" question. Further research to evaluate the performance of different combinations of tests is recommended.

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f839 (Published 15 February 2013)Hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin in patients with sepsis: systematic review with meta-analysis and trial sequential analysisConclusion In conventional meta-analyses including recent trial data, hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin increased the use of renal replacement therapy and transfusion with red blood cells, and resulted in more serious adverse events in patients with sepsis. It seems unlikely that hydroxyethyl starch 130/0.38-0.45 provides overall clinical benefit for patients with sepsis.

Annals of Emergency Medicine - Volume 61, Issue 3 (March 2013) Intravenous Dextrose for Children With Gastroenteritis and Dehydration: A Double-Blind Randomized Controlled TrialConclusionAdministration of a dextrose-containing bolus compared with normal saline did not lead to a lower rate of hospitalization for children with gastroenteritis and dehydration. There was, however, a greater reduction in serum ketone levels in patients who received 5% dextrose in normal saline solution.

Annals of Emergency Medicine - Volume 61, Issue 3 (March 2013) In Infants Younger Than 24 Months Old and With Bronchiolitis, Does Nebulized Epinephrine Improve Clinical Status?CommentaryThis Cochrane review sought to evaluate the effect of nebulized epinephrine compared with placebo and other therapies for children who were treated in the ED and released or admitted (non-ICU) to the hospital.This review concludes that nebulized epinephrine can be used for the initial ED presentation of children with acute bronchiolitis who are younger than 24 months. It was demonstrated to be more effective than placebo for decreasing hospital admissions during the first 24 hours of care. This study also examined negative outcomes for patients receiving epinephrine and concluded that few complications were associated with its use.

February 8, 2013DOI: 10.1056/NEJMoa1212793A Trial of Imaging Selection and Endovascular Treatment for Ischemic StrokeChelsea S. Kidwell, Reza Jahan, M.D et al for the MR RESCUE InvestigatorsCONCLUSIONSA favorable penumbral pattern on neuroimaging did not identify patients who would differentially benefit from endovascular therapy for acute ischemic stroke, nor was embolectomy shown to be

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Westmead EMRU Précissuperior to standard care. (Funded by the National Institute of Neurological Disorders and Stroke; MR RESCUE ClinicalTrials.gov number)

February 7, 2013DOI: 10.1056/NEJMoa1214300Endovascular Therapy after Intravenous t-PA versus t-PA Alone for StrokeJoseph P. Broderick, Yuko Y. Palesch for the Interventional Management of Stroke (IMS) III InvestigatorsCONCLUSIONSThe trial showed similar safety outcomes and no significant difference in functional independence with endovascular therapy after intravenous t-PA, as compared with intravenous t-PA alone. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number)

March 10, 2013DOI: 10.1056/NEJMoa1214865Treatment of Anemia with Darbepoetin Alfa in Systolic Heart FailureKarl Swedberg, James B. Young et al for the RED-HF Committees and InvestigatorsRandomized, double-blind trial, we assigned 2278 patients with systolic heart failure and mild-to-moderate anemia (hemoglobin level, 9.0 to 12.0 g per deciliter) to receive either darbepoetin alfa (to achieve a hemoglobin target of 13 g per deciliter) or placebo.Fatal or nonfatal stroke occurred in 42 patients (3.7%) in the darbepoetin alfa group and 31 patients (2.7%) in the placebo group (P=0.23). Thromboembolic adverse events were reported in 153 patients (13.5%) in the darbepoetin alfa group and 114 patients (10.0%) in the placebo group (P=0.01). Cancer-related adverse events were similar in the two study groups.CONCLUSIONSTreatment with darbepoetin alfa did not improve clinical outcomes in patients with systolic heart failure and mild-to-moderate anemia. Our findings do not support the use of darbepoetin alfa in these patients. (Funded by Amgen; RED-HF)

March 10, 2013DOI: 10.1056/NEJMoa1301092Fibrinolysis or Primary PCI in ST-Segment Elevation Myocardial InfarctionPaul W. Armstrong, Anthony H. Gershlick et al for the STREAM Investigative TeamAmong 1892 patients with STEMI who presented within 3 hours after symptom onset and who were unable to undergo primary PCI within 1 hour, patients were randomly assigned to undergo either primary PCI or fibrinolytic therapy with bolus tenecteplase (amended to half dose in patients ≥75 years of age), clopidogrel, and enoxaparin before transport to a PCI-capable hospital. Emergency coronary angiography was performed if fibrinolysis failed; otherwise, angiography was performed 6 to 24 hours after randomization. The primary end point was a composite of death, shock, congestive heart failure, or reinfarction up to 30 days.More intracranial hemorrhages occurred in the fibrinolysis group than in the primary PCI group (1.0% vs. 0.2%, P=0.04; after protocol amendment, 0.5% vs. 0.3%, P=0.45). The rates of nonintracranial bleeding were similar in the two groups.CONCLUSIONPrehospital fibrinolysis with timely coronary angiography resulted in effective reperfusion in patients with early STEMI who could not undergo primary PCI within 1 hour after the first medical contact. However, fibrinolysis was associated with a slightly increased risk of intracranial bleeding. (Funded by Boehringer Ingelheim)

Radiology. 2013 Mar;266(3):783-90. doi: 10.1148/radiol.12120732. Epub 2012 Nov 30.Head CT for Nontrauma Patients in the Emergency Department: Clinical Predictors of Abnormal Findings.Wang X, You JJ.

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Westmead EMRU PrécisThis study was a retrospective review of consecutive unenhanced head CT examinations in patients aged 18 years or older who did not have trauma or known intracranial pathologic processes in ED from January 2004 through June 2006. Results: Six independent clinical predictors of important abnormal findings on head CT were identified: age (adjusted OR per 10-year increase: 1.17; 95% CI: 1.08, 1.28), focal neurologic deficit (adjusted OR: 5.39; 95% CI: 3.90, 7.47), altered mental status (adjusted OR: 2.32; 95% CI: 1.66, 3.25), history of malignancy (adjusted OR: 4.11; 95% CI: 2.28, 7.42), nausea and/or vomiting (adjusted OR: 2.22; 95% CI: 1.14, 4.33), and derangements in coagulation profile (adjusted OR: 1.91; 95% CI: 1.07, 3.41). Conclusion: This study identified several potential clinical predictors of abnormal head CT findings in ED patients who did not sustain trauma. Prospective validation of a clinical prediction rule in this population is warranted. Performing CT only in patients with any of the five non-age predictors would have detected 94% of abnormalities and lowered CT scanning by 30%. Including all older patients (age, >70), plus younger patients with any of the other five predictors, would have increased sensitivity to 96%, and 21% of scans would have been avoided. Although seizure was not an independent predictor, adding seizure as an indication to scan would have increased sensitivity to 99%, and 14% of scans would have been avoided.

JAMA. 2013;():1-10. doi:10.1001/jama.2013.2024.Effect of Phosphodiesterase-5 Inhibition on Exercise Capacity and Clinical Status in Heart Failure With Preserved Ejection Fraction - A Randomized Clinical Trial (VIAGRA)Margaret M. Redfield, Horng H. Chen et al for the RELAX TrialConclusion and Relevance Among patients with HFPEF, phosphodiesterase-5 inhibition with administration of sildenafil for 24 weeks, compared with placebo, did not result in significant improvement in exercise capacity or clinical status.

Resuscitation Volume 84, Issue 3 , Pages 292-297, March 2013Emergency department factors associated with survival after sudden cardiac arrestNicholas J. Johnson, Rama A. Salhi et al, Study identified 38,593 cases of cardiac arrest representing an estimated 174,982 cases nationally. Overall ED SCA survival to hospital admission was 26.2% and survival to discharge was 15.7%. Greater survival to admission was seen in teaching hospitals (OR 1.3 95% CI 1.1–1.5, p = 0.001), hospitals with ≥20,000 annual ED visits (OR 1.3 95% CI 1.1–1.6, p = 0.003), and hospitals with percutaneous coronary intervention capability (OR 1.6 95% CI 1.4–1.8, p < 0.001). ConclusionsAn estimated 175,000 cases of SCA present to or occur in US EDs each year. Percutaneous coronary intervention capability, ED volume, and teaching status were associated with higher survival to hospital admission.

Resuscitation Volume 84, Issue 3 , Pages 298-303, March 2013A clinical observational study analysing the factors associated with hyperventilation during actual cardiopulmonary resuscitation in the emergency departmentSang O Park, Dong Hyuk Shin et alConclusionsHyperventilation during CPR was associated with inexperienced or uncertified ACLS provider, auscultation to confirm intubation, and night time or weekend CPR. And to deliver proper ventilation, comments by the team leader should be given regardless of providers’ expert level.

Resuscitation Volume 84, Issue 3 , Pages 304-308, March 2013

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Westmead EMRU PrécisResuscitation of the pregnant patient: What is the effect of patient positioning on inferior vena cava diameter?J. Matthew Fields, Katherine Catallo et alA total of 26 patients were enrolled with one excluded from data analysis due to inability to obtain IVC measurements. The median IVC maximum diameter was 1.26 cm (95% confidence interval [CI] 1.13–1.55) in LLT compared to 1.13 cm (95% CI 0.89–1.41) in supine, p = 0.01. When comparing each individual patient's LLT to supine measurement, LLT lead to an increase in maximum IVC diameter in 76% (19/25) of patients with the average LLT measurement 29% (95% confidence interval 10–48%) larger. Six patients had the largest maximum IVC measurement in the supine position.ConclusionIVC ultrasound is feasible in late pregnancy and demonstrates an increase in diameter with LLT positioning. However, a quarter of patients had a decrease in IVC diameter with tilting and, instead, had the largest IVC diameter in the supine position suggesting that uterine compression of the IVC may not occur universally. IVC assessment at the bedside may be a useful adjunct in determining optimal positioning for resuscitation of third trimester patients.PLoS One. 2013;8(2):e57873. doi: 10.1371/journal.pone.0057873. The relationship of sugar to population-level diabetes prevalence: an econometric analysis of repeated cross-sectional data.Basu S, Yoffe P et alUsing econometric models of repeated cross-sectional data on diabetes and nutritional components of food from 175 countries, we found that every 150 kcal/person/day increase in sugar availability (about one can of soda/day) was associated with increased diabetes prevalence by 1.1% (p <0.001) after testing for potential selection biases and controlling for other food types (including fibers, meats, fruits, oils, cereals), total calories, overweight and obesity, period-effects, and several socioeconomic variables such as aging, urbanization and income. No other food types yielded significant individual associations with diabetes prevalence after controlling for obesity and other confounders. The impact of sugar on diabetes was independent of sedentary behavior and alcohol use, and the effect was modified but not confounded by obesity or overweight.

Emerg Radiol. 2013 Jan;20(1):45-9. doi: 10.1007/s10140-012-1071-y. Utility of head CT in the evaluation of vertigo/dizziness in the emergency department.Lawhn-Heath C, Buckle C et al.The diagnostic yield for head CT ordered in the ER for acute dizziness is low (2.2 %; 1.6 % for emergent findings), but MRI changes the diagnosis up to 16 % of the time, acutely in 8 % of cases. Consistent with the American College of Radiology appropriateness criteria and the literature, this study suggests a low diagnostic yield for CT in the evaluation of acute dizziness but an important role for MRI in appropriately selected cases.

Annals of Emergency Medicine – Article in PressIdentifying Children at Very Low Risk of Clinically Important Blunt Abdominal InjuriesJames F. Holmes, Kathleen Lillis, et al, Pediatric Emergency Care Applied Research Network (PECARN) The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15).Conclusion

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Westmead EMRU PrécisA prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention.

J Emerg Med. 2013 Feb;44(2):306-12. doi: 10.1016/j.jemermed.2012.07.048.Utility of observation units for young emergency department chest pain patients.Ely S, Chandra A et al.CONCLUSION:Routine observation of symptomatic young adults for ACS had low yield. This suggests that observation and stress testing should not be routinely performed in this demographic absent other high-risk features.

Prehosp Emerg Care 2013 Apr; 17:203. Paramedic ability to recognize ST-segment elevation myocardial infarction on prehospital electrocardiograms. Mencl F et al.Conclusions. Despite training and a high level of confidence, the paramedics in our study were only able to identify an inferior STEMI and two normal ECGs. Given the paramedics’ low sensitivity and specificity, we cannot rely solely on their ECG interpretation to activate the cardiac catheterization laboratory. Future research should involve the evaluation of training programs that include assessment, initial training, testing, feedback, and repeat training.

Annals of Emergency Medicine - Article in PressComparison of the Unstructured Clinician Gestalt, the Wells Score, and the Revised Geneva Score to Estimate Pretest Probability for Suspected Pulmonary EmbolismAndrea Penaloza, Franck Verschuren, et al ResultsThe study population was 1,038 patients, with a pulmonary embolism prevalence of 31.3%. AUC differed significantly between the 3 methods and was 0.81 (95% confidence interval [CI] 0.78 to 0.84) for gestalt assessment, 0.71 (95% CI 0.68 to 0.75) for Wells, and 0.66 (95% CI 0.63 to 0.70) for the revised Geneva score. ConclusionIn our retrospective study, gestalt assessment seems to perform better than clinical decision rules because of better selection of patients with low and high clinical probability.

Annals of Emergency Medicine Volume 61, Issue 3 , Pages 330-338, March 2013Prognostic Value of Plasma Lactate Levels Among Patients With Acute Pulmonary Embolism: The Thrombo-Embolism Lactate Outcome StudySimone Vanni, Gabriele Viviani et alResultsOf the 270 patients included in the study, the mean age was 73 years (SD 12.7 years) and 151 (55.9%) were women. Twelve patients (4.4%) showed shock or hypotension (shock or systolic arterial pressure <100 mm Hg) at presentation, 109 (40.4%) had right-sided ventricular dysfunction, 93 (34.4%) showed troponin I level greater than or equal to 0.10 ng/mL, and 81 (30%) showed lactate level greater than or equal to 2 mmol/L. Seventeen patients (6.3%) died, 12 (4.4%) because of pulmonary embolism, and 37 (13.7%) reached the composite endpoint. Patients with lactate level greater than or equal to 2 mmol/L showed higher mortality (17.3%; 95% confidence interval [CI] 11.9% to 20%) than patients with a lower level (1.6%; 95% CI 0.8% to 1.9%).Conclusion

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Westmead EMRU PrécisPatients with pulmonary embolism and elevated plasma lactate level are at high risk of death and adverse outcome, independent of shock or hypotension, or right-sided ventricular dysfunction or injury markers.JAMA: Issue: Volume 309(11), 20 March 2013, p 1145–1153Comparison of Presenting Complaint vs. Discharge Diagnosis for Identifying “ Nonemergency” Emergency Department VisitsRaven, Maria C. Lowe, Robert A. et alConclusions and Relevance: Among ED visits with the same presenting complaint as those ultimately given a primary care–treatable diagnosis based on ED discharge diagnosis, a substantial proportion required immediate emergency care or hospital admission. The limited concordance between presenting complaints and ED discharge diagnoses suggests that these discharge diagnoses are unable to accurately identify nonemergency ED visits.

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Westmead EMRU PrécisNOSTOS ALGOS - Blast from the past

Prevention of Thrombosis in Patients on Hemodialysis by Low-Dose AspirinHerschel R. Harter, John W. Burch et alN Engl J Med 1979; 301:577-579September 13, 1979DOI: 10.1056/NEJM197909133011103Share:AbstractSince platelet cyclooxygenase is much more sensitive to inactivation by aspirin than is the enzyme in the arterial wall and low doses of aspirin may prevent thrombosis by blocking thromboxane synthesis, we conducted a randomized, double-blind trial of aspirin (160 mg per day) vs. placebo in 44 patients on chronic hemodialysis. The study was continued until there were 24 patients with thrombi and both groups had been under observation for a mean of nearly five months. Thrombi occurred in 18 of 25 (72 per cent) of patients given placebo and 16 of 19 (32 per cent) of those given aspirin (P<0.01). The incidence of thrombosis was reduced from 0.46 thrombi per patient month in the placebo group to 0.16 thrombi per patient month in the aspirin group (P<0.005). A dose of 160 mg of aspirin per day is an effective, nontoxic antithrombotic regimen in patients on hemodialysis.

This article seems to be one of the first to point towards aspirin’s capabilities (in a controlled trial). Some of us were just born then and only a few of us were studying or practising medicine then!

We all know where aspirin (off-patent drug) now stands and there are a lot more aspects of aspirin and the cyclooxygenase system we are still learning about (role in carcinoma pathogenesis and prevention).

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Westmead EMRU PrécisDISPUTATIO

Family Presence during Resuscitation

This month New England Journal of Medicine (NEJM) posted a great article for discussion – here I present to you the evidence for each side of the argument (not all) and let you make an informed decision around your opinion on this sensitive matter.

There are various issues here to consider – effects on medical teams and team perceptions of their actions and effects on viewers and long-term implications. Remember, neither option may be right or wrong, but it would be interesting to receive your responses – email them to samit36@hotmail.com

N Engl J Med 2013; 368:1008Family Presence during Cardiopulmonary ResuscitationPatricia Jabre, Vanessa Belpomme, et alIn the intervention group, 211 of 266 relatives (79%) witnessed CPR, as compared with 131 of 304 relatives (43%) in the control group. In the intention-to-treat analysis, the frequency of PTSD-related symptoms was significantly higher in the control group than in the intervention group (adjusted odds ratio, 1.7; 95% confidence interval [CI], 1.2 to 2.5; P=0.004) and among family members who did not witness CPR than among those who did (adjusted odds ratio, 1.6; 95% CI, 1.1 to 2.5; P=0.02). Relatives who did not witness CPR had symptoms of anxiety and depression more frequently than those who did witness CPR. Family-witnessed CPR did not affect resuscitation characteristics, patient survival, or the level of emotional stress in the medical team and did not result in medicolegal claims.CONCLUSIONSFamily presence during CPR was associated with positive results on psychological variables and did not interfere with medical efforts, increase stress in the health care team, or result in medicolegal conflicts.

J Adv Nurs. 2012 Sep;68(9):1967-77.Reactions of staff members and lay people to family presence during resuscitation: the effect of visible bleeding, resuscitation outcome and gender.Itzhaki M, Bar-Tal Y et al.FINDINGS:Overall, both staff and lay people perceived family presence during resuscitation negatively. Visible bleeding and an unsuccessful outcome significantly influenced both staff's and lay people's perceptions. Female physicians and nurses reacted more negatively to family presence than did male physicians and nurses; laymen responded more negatively than lay women.CONCLUSIONS:Changing the current negative perceptions of family presence at resuscitation requires (a) establishing a new national policy, (b) educating healthcare staff to the benefits of the presence of close relatives and (c) training staff to support relatives who want to be present.

J Palliat Med. 2011 Jun;14(6):715-21. Family-witnessed resuscitation: bereavement outcomes in an urban environment.Compton S, Levy P et al.RESULTS:Sixty-five family members (24 FWR and 41 Non-FWR) were included. There were no differences between groups in relationship to the patient (35% spouse/significant other), mean age (overall, 56 years), or race (75% African American). Patients in each group did not differ in need for assistance in

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Westmead EMRU Précisany activities of daily living (overall, 44% needed assistance) prior to cardiac arrest. However, more FWR were female (83% versus 59%), and had higher levels of overall social support available. There were no differences between FWR and Non-FWR on overall PTSD scores (11.7 versus 11.4; mean difference = 0.3 [95 confidence interval (CI): -5.5; 6.1]) or depression scores (16.0 versus 20.6; mean difference = -4.5 [95CI: -12.0; 3.0]).CONCLUSION:Bereavement related depression and PTSD symptoms are commonly seen in family members of cardiac arrest victims, however, the magnitude of the effect is not impacted by witnessing or not-witnessing CPR in the ED.

Ann Emerg Med. 2009 Jun;53(6):777-84.e3. The effect of family presence on the efficiency of pediatric trauma resuscitations.Dudley NC, Hansen KW et al.RESULTS:Of 1,229 pediatric trauma activations, 705 patients were included in the study protocol, 283 with family presence on even days, and 422 without family presence on odd days. Median times to CT scan (21 minutes; IQR 16 to 29 minutes) and median resuscitation times (15 minutes; IQR 10 to 20 minutes) were similar with and without family presence. There was no clinically relevant difference in CT time (hazard ratio 1.04; 95% confidence interval [CI] 0.83 to 1.30) or resuscitation time (hazard ratio 0.98; 95% CI 0.83 to 1.15). Families believed that family presence was helpful both to their child and themselves.CONCLUSION:This prospective trial shows that family presence does not prolong time to CT imaging or to resuscitation completion for pediatric trauma patients. Family presence does not negatively affect the time efficiency of the pediatric trauma resuscitation.

Pediatrics. 2007 Sep;120(3):e565-74.Family presence during pediatric trauma team activation: an assessment of a structured program.O'Connell KJ, Farah MM et al.RESULTS:A total of 197 family members participated in family presence. There were no cases of interference with medical care by family members. Seven family members were asked to leave the trauma area by staff after initiation of family presence for various reasons. Times to completion of key components of the trauma evaluation did not differ significantly between enrolled patients with family presence and those without family presence. Surveys were completed for 136 cases, and the majority of providers reported that family presence either had no effect on or improved medical decision-making (97%), institution of patient care (94%), communication among providers (92%), and communication with family members (98%).CONCLUSIONS:This prospective study suggests that there is an overall low prevalence of negative outcomes associated with family presence during pediatric trauma team evaluation after implementation of a structured family presence program. Excluding family members as a routine because of provider concerns about negative impact on clinical care does not seem to be indicated.

Am J Respir Crit Care Med. 2012 Dec 1;186(11):1133-9. Parent presence during invasive procedures and resuscitation: evaluating a clinical practice change.Curley MA, Meyer EC et al.MEASUREMENTS AND MAIN RESULTS:

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Westmead EMRU PrécisMore than 70% of clinicians participated in the perception surveys (n = 782) and 538 clinicians and 274 parents participated in the practice surveys. After the intervention, clinicians reported that parents were present during more invasive procedures and reported higher levels of comfort with the practice of providing options to parents during resuscitative events. Levels of comfort were higher in clinicians who had practiced skills in a simulated learning environment. During both phases, few clinicians reported that parent presence affected their technical performance (4%), therapeutic decision-making (5%), or ability to teach (9%). During the post phase, clinicians reported more active parent behaviors during procedures. Parents who reported receiving information to help them prepare for their children's procedures reported higher levels of procedural understanding and emotional support.CONCLUSIONS:Implementation of practice guidelines and interprofessional education had a positive impact on clinicians' perceptions and practice when providing parents with options and support during their children's invasive procedures and/or resuscitation.

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Westmead EMRU PrécisPRIMUS

Transfusion associated Microchimerism study

Plain language summary:Microchimerism (abbreviated Mc) is the presence of a small number of cells that originate from another individual and are therefore genetically distinct from the cells of the host individual. Mc due to blood transfusion can be transient, but can also persist for years. Leucoreduction is a process of filtration used to remove leucocytes (WBC) from blood units. Leucoreduction has been shown to reduce the potential for graft versus host and autoimmune diseases following transfusion. The Australian Red Cross blood service (ARCBS) is undertaking this study to determine the effectiveness of Leucoreduction and to provide a baseline for future blood processing technologies. ARCBS wants to analyse samples from massively transfused trauma patients from participating hospitals to determine the incidence, duration and biological kinetics of potential chimerism when patients are transfused with leucoreduced blood products.Patient inclusion criteria:

Male and female patients over the age of 18 All category 1 (major trauma) admissions

Patient exclusion criteria: Females who are pregnant at time of admission Patients who do not obviously require blood transfusion Minors under the age of 18 Patients who receive any blood products immediately prior to transfer to Westmead

HospitalWhen in doubt about any trauma patient – please collect samples and send it across in any case where the need for blood transfusion or pink tube collection is felt necessary!If the above criteria are fulfilled:Please collect study blood sample:

Collect at the same time as standard-of-care baseline blood collection Use 2 green capped (sodium heparin) 6mL blood tubes. PLEASE FILL to 6mL volume Label the tubes with minimum; full name and date-of-birth and MRN (by hand or sticky

label) Send blood tubes to Pathology at Westmead Hospital Consent will occur retrospectively by Trauma Service staff once other inclusion criteria have

been examinedAny questions about the trial can be directed to Amith Shetty/ Margaret Murphy or Julie Seggie from the trauma service.

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Westmead EMRU PrécisCONCLUSIO

This month’s ED journal club featuredAnnals of Emergency Medicine Volume 61, Issue 1, Pages 72-81, January 2013Intravenous Droperidol or Olanzapine as an Adjunct to Midazolam for the Acutely Agitated Patient: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Clinical TrialEsther W. Chan, David M. Taylor et alCritically appraised by Dr Faryal WaqarThis article raised significant discussions surrounding the issues of consent and mentally ill patients. The ethical validity of the trial was also questioned as there are existing practices in place for management of agitated patients and thus the role of using placebos was questionable. Also the three groups in the study were considered unequal on the basis of availability of therapy i.e. whilst one group received a lower dose of midazolam and other groups received midazolam plus olanzapine/Droperidol. Thus the time to sedation results reduction by 4 and 6 minutes is probably a simple reflection of more drug dose used! Also noted was that at the end of 60 minutes all three groups had received similar amounts of midazolam so the use of multiple drugs is still questionable though there were reduced incidences of respiratory side effects in the dual drug groups.

In February, the ED journal club featuredBMJ, doi:10.1136/bmj.38181.482222.55 (published 2 August 2004)Corticosteroids for severe sepsis and septic shock: a systematic review and meta-analysisDjillali Annane, Eric Bellissant et alCritically appraised by Dr Richard McNultyThe conclusion from the critical appraisal involving attending doctors and nurses was “to give steroids as a last resort only unless the patient has a known steroid dependence and that long courses of low dose steroids (100mg tds hydrocortisone for 5 days) are better than short courses of high dose steroids.”

Toxicology journal clubThis month’s topic – role of haemodialysis in Toxicology – excerpt follows – by Dr Gopi Mann / Dr Naren Gunja

Dialysis considerationSignificant signs/symptoms, haemodynamic instabilityMulti/end-organ dysfunction (e.g. Renal failure with reduced clearance)Acidosis (pH < 7.3)Rising drug levels (before systemic toxicity)

HD in Toxicology - consider in:Acute massive (>500mg/kg) salicylate ingestion (levels>4.4)Acute massive Lithium (> 10) & chronic lithium (>4 with symptoms)Toxic Alcohols (anion gap metabolic acidosis & osmolar gap)Carbamazepine (levels> 200)Metformin-associated lactic acidosisSodium valproate - massive ingestion (level>6000)Massive KCL ingestionsTheophyllineRenal-cleared Beta blockers (sotalol, atenolol)Others (MCPA, early paraquat, dabigatran, glyphosate-induced renal failure

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Westmead EMRU PrécisCharacteristics of Xenobiotic That Are Cleared by ECR

Low volume of distribution (Vd; <1 L/kg), that is, not in tissue Single-compartment kineticsLow endogenous clearance (<4 mL/min per kilogram)For hemodialysisMW <500 Da (little data on high-flux membranes) Water solubleLow plasma protein bindingFor Charcoal hemoperfusionMust be adsorbed by activated charcoalFor CRRTHigher MW, 1000 to 4000 Da, depending on the membrane(ECR extracorporeal removal; MW molecular weight; CRRT continuous renal replacement therapy)

In brief,HaemodialysisPros - traditional gold standard allowing high flow rates for speedy clearanceCons - Intermittent 4-8hrs (may need to be repeated when drug levels rebound), contraindicated in hypotensive critically ill patients, need for dialysis nurse/renal team for set up

CRRTPro - continuous (rebound in drug levels is less likely), easily set up & run by ICU staff, used in hypotensive patientsCons - slower clearance rate, insufficient evidence at this stage (despite widespread use)

Charcoal HemoperfusionPro - Binds carbamazepine Con - Activated charcoal cartridge is expensive, lack of availability (less likely to be stocked)

Westmead ED publications this month

Gunja N. The Clinical and Forensic Toxicology of Z-drugs. J Med Toxicol, 2013; doi: 10.1007/s13181-013-0292-0http://www.ncbi.nlm.nih.gov/pubmed/23404347

Gunja N. In the Zzz Zone: The Effects of Z-Drugs on Human Performance and Driving. J Med Toxicol, 2013; doi: 10.1007/s13181-013-0294-yhttp://www.ncbi.nlm.nih.gov/pubmed/23456542

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