Thursday, 5 July 2018

Association of Preprocedural Fasting with Outcomes of Emergency Department Sedation in Children


Many guidelines still call for patients to be properly fasted prior to ED procedural sedation. Although this is steeped in consensus and tradition, is this really beneficial?

No.

This was a planned secondary analysis of a multicentre prospective cohort study of 6183 children who received parenteral procedural sedation in one of 6 Canadian ED’s.

They compared fasted and non-fasted children with the occurrence of pulmonary aspiration, adverse events, serious adverse events and vomiting.

Results?

Most children were very healthy at baseline. 80% of the procedures were for orthopaedic reductions and laceration repairs. Two thirds of children got ketamine alone. (This is obviously a different cohort from those patients that get treated in the operating theatre.)

How many children were not properly fasted?

About 50% for solids and 5% for liquids.

In the end, there was no association between fasting and any bad outcomes. This is concordant with all of the previous studies on this subject.

Naysayers can complain about the limitations of this study; not huge enough to make definitive claims about safety, ketamine is airway protective, conducted in tertiary centres, and it was not randomised.

The excellent accompanying editorial by Steve Green (Dr Ketamine) shreds these arguments with further evidence. In addition, he emphasises many of the potential harms of fasting.

Even before this study was published, the American Collegeof Emergency Physicians (ACEP) 2014 clinical policy recommended not to delay procedures solely on fasting time.  

Outside the USA, I would imagine most of us have quietly changed our practice anyway and don’t consider fasting to be a mandatory requirement. Perhaps is time to formally change our policies.  



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Bougie vs Endotracheal Tube with Stylet for ED Intubations: an RCT


“…use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation.”

Should we all go bougie first?

As is often the case, the devil is in the details…

This was a single centre clinical trial randomised 757 adult patients to the two arms (bougie vs. stylet) using mostly a C-MAC Macintosh blade.

The primary outcome was first-attempt success in patients with at least one difficult airway characteristics (obesity, short neck, cervical spine immobilisation etc.)

They had a ridiculously high 96% first attempt success rate with the bougie but only an 82% with the stylet. (To put this in perspective, the first attempt success rate in the ANZEDAR registry was 84%)

Before you jump on the gum elastic bougie train, consider a few things.

This study was conducted in an ED where the tradition was to use a bougie first. They would have obviously been more comfortable with this technique and the stylet was new to them.

The vast majority of the intubations were done by less experienced PGY 2 - 4 emergency residents and fellows. Emergency medicine faculty only performed 3% of the procedures.

The incidence of hypoxemia (13% vs. 14%) did not differ between the groups. This is a more relevant patient oriented outcome. This study did not report any patient harms from the lower first-attempt success of the stylet (but to be fair, was not powered for safety).

In the end, I don’t think this study will be overly practice changing. Most clinicians will stick with what they know best. But a 96% first pass success rate is extremely high and hard to ignore.

Image result for gum elastic bougie

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Wednesday, 4 July 2018

Early application of continuous femoral nerve block for neck of femur fractures: an RCT


Many patients with neck of femur fractures get some form of a nerve block in the Emergency Department. This is most often a single injection and wears off in several hours. Would a continuous block via infusion be better?

This UK single centre trial randomised patients to standard care vs. a continuous infusion of 0.2% ropivacaine at 5ml/hour for 48 hours. The medication was delivered by perineural catheter placed by experienced anaesthesia doctors.

Included patients had to be >70 years old, without cognitive impairment, live at home and independently mobilise. Yikes! This obviously limited the number of eligible patients and made this study less feasible to undertake.

The two primary outcomes were the Cumulated Ambulation Score and Dynamic Pain Score score over three days. Whatever those are...

111 patients with fractures underwent analysis.

It is no surprise no difference was found. (Other than a secondary outcome of improved pain at rest) With these small numbers, the researchers had low statistical power and could only hope to find a big difference. In addition, there were several issues that may have drawn the conclusion to the null hypothesis.

Many questions remain; did they use the right dose, did they do the correct block, were the primary outcome scores appropriate & relevant, etc.

In the end, the jury is still out. Despite the negative conclusion, the research question really remains unanswered. If there was a longer delay to theatre, one would hope a continuous infusion would be better than standard care… but who knows, there still is clinical equipois

 Image result for neck of femur fracture

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Monday, 7 May 2018

Aromatherapy for nausea? Inhaled isopropyl alcohol vs oral ondansetron for nausea in the ED; an RCT



A patient with nausea presents to your ED...

A busy triage nurse to hands a patient an isopropyl alcohol pad and says, “sniff on this.” 

Nausea magically disappears.

Believe it or not, this is not a new concept. The use of aromatherapy to reduce post-operative nausea & vomiting has been studied for decades. But it has only just just recently popped its head (nose?) into the ED.

This was a very well conducted RCT that enrolled 122 young adults with a chief complaint of nausea & vomiting >3 on a numerical rating scale. They excluded patients who had already got IV cannulation and prior antiemetic therapy.

They were randomised to one of three arms:
  • Inhaled isopropyl alcohol alone (with oral placebo)
  • Ondansetron alone (with inhaled saline placebo)
  • Both inhaled isopropyl alcohol and ondansetron

They were told to sniff on the isopropyl alcohol pad as much as they like and could get a new/fresh one about every 10 minutes.

The primary outcome was reduction in nausea as measured on a visual analog scale (VAS) at 30 minutes.

Results?

Both arms using isopropyl alcohol had reductions in nausea by about 30mm. The ondansetron alone arm only had reduction by 9mm. This was statistically significant and the authors made the expected conclusions.

Despite elegant methods, this study did have some important limitations.
  • It is difficult to blind alcohol. (but you can get blind with alcohol… sorry). This could have introduced bias.
  • Persistence and duration of effect is difficult to gage. What about the repeat customer who states, “you’re not going to try to get me to sniff on that alcohol pad again?”
  • These were low risk patients who didn’t need IV’s.
  • Small studies reporting large treatment effect are often disproven

In the discussion, the authors state the mechanism of action remains unclear but could be “related to olfactory distraction.” Perhaps a nausea voodoo dance would have met with the same effect? Who knows…

What should we conclude?

Inhaled isopropyl alcohol might help some low risk patients in the ED with nausea. It is very unlikely to cause harm. But I still like the idea of a voodoo macarena.


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Sunday, 6 May 2018

Unsuspected Critical Illness Among ED Patients Presenting for Acute Alcohol Intoxication


During my ED training, I was taught the maxim; nobody is ever "just drunk." Of course, this was meant to emphasize caution in recklessly labelling patients as such. Some may have subdurals, infections or other bad illness.

These authors attempted to quantify the proportion of patients who were thought to be just drunk but who ended up requiring critical care resources. In addition, they sought to find clinical features that might be associated with the need for these resources.

Enter Minneapolis, Minnesota. (Evidently, a lot of people resort to drinking here.) Their ED has a “dedicated intoxication unit” where these presumed low risk patients are grouped.

Over five years, they put over 35,000 patients through this area. One patient was readmitted 227 times!

Of these low risk patients, what proportion of them ended up requiring critical care resources?

1%

Abnormal vital signs, hypoglycaemia and parenteral sedation were associated with this outcome. This has face validity i.e. makes sense.

However, this study had substantial limitations.

It was a retrospective review of EHR data which we know to be rather unreliable. It also rested on subjectivity in the definition of their study population and other assumptions.

At best the 1% estimate is a ballpark figure.

But the accuracy doesn’t matter. The overall message has not changed; a small proportion of patients who you suspect to be “just drunk” will really have something bad. Pay attention to vital signs and overall be cautious.

Where have I heard this before?


Covering:

Klein LR, Cole JB, Driver BE, et al. Unsuspected CriticalIllness Among Emergency Department Patients Presenting for Acute AlcoholIntoxication. Ann Emerg Med 2018;71:279-288.
Image result for just drunk




Haloperidol for cannabinoid hyperemesis syndrome; why not…



It seems “Vitamin H” is pretty good for lots of things.

Add it to the list for cannabinoid hyperemesis syndrome (CHS)!

Ok, this “study” if far from high science (forgive the pun). It’s a retrospective chart review reporting a case series of 4 with lots of limitations.

All included patients were thought to have CHS. Perhaps they were diagnosed in the hot shower? They seemed to all have refractory vomiting until they were given haloperidol 5mg IV.

The authors provide some physiologic reasons why this might be efficacious and appropriately temper their conclusion by stating their success “warrants further investigation.”

In summary, this study is arguably a level of evidence just above anecdote. But who cares… did I say I love vitamin H?



Covering:

Witsil JC, Mycyk MB. Haloperidol, A Novel Treatment for Cannabinoid Hyperemesis Syndrome. Am J Therap. 2017;24:e64-7.




Saturday, 5 May 2018

Intralipid emulsion treatment as an antidote in lipophilic drug intoxications- Worst paper of the decade?


This case series from Turkey published in the American Journal of Emergency Medicine is a fabulous example of intoxicated peer review (perhaps they needed the intralipid?)

It is awful from the first sentence.

Intravenous lipid emulsion (ILE) is a lifesaving treatment of lipophilic drug intoxications.

Of course, this is not referenced.  

There is no definitive high-quality evidence demonstrating a reduction in mortality from intralipid. There best evidence is mostly case series. (Although I did find an RCT of 34 cats poisoned by permethrin!)

So, getting past the first sentence is problematic… but I’ll continue.

The authors report a case series of 10 patients admitted to their ED who had allegedly taken overdoses of mostly amitriptyline but also some metoprolol, nifedipine, quetiapine, lamotrigine, sertraline, fluoxetine, alprazolam and of course Bonsai.

Bonsai?

This term is not explained in the manuscript. Gut if you google Bonsai, you get some beautiful images of small trees. If you dig a bit further, you come to discover it is a popular synthetic cannabinoid in Turkey. Who would have known?

Another tangent… back to the paper.

The authors describe each patient in some detail, but don’t really mention if any standard treatment was given. It looks like only one of the patients with TCA overdose ever got sodium bicarbonate except one who (I think) died.

She did not answer cardiopulmonary resuscitation, and she was admitted as exitus.

What should we conclude?

In the end they gave intralipid to 10 patients who may or may not have needed it. They may or may not have derived benefit or harm from this therapy. We’re not sure…

The authors conclude

According to these results, it was found that ILE treatment is a lifesaving agent in lipophilic drug intoxications and can be used in unconscious patients who have cardiac and/or neurologic symptoms, but no history of a specific drug ingestion.

I conclude the authors and the peer reviewers were probably on the bonsai… and I’m not talking small trees.


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Image result for bonsai