June 2016: New in EM

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Author: Andy Neill / Code: CAP2, CAP35, CC21, CMP2, HAP21, HMP2 / Published: 01/06/2016

Summer is coming which means it’s time to sit in a dark room while the sun blazes staring at your computer screen reading the latest literature…

Clinical Question to be answered

  • Does lactate predict survival in patients in OOHCA?

Title of paper

  • Use of serum lactate levels to predict survival for patients with out of hospital cardiac arrest – a cohort study [PubMed]

Journal and year

  • Emergency Medicine Australasia 2016

Lead Author

  • Williams T

Patients studied

  • Adult patients over 5 year period 2007 – 12 transported by SJA-WA to 2 of the 3 Teritary centres in Perth. 934 pts had OHCA of which 518 had lactate measured.

Comparison

  • there is no gold standard test for this other than time.

Primary outcome

  • Survival to hospital discharge, secondary outcomes CPC (1+2 deemed good)

Summary of results

  • 518 pts with lactate recorded. 24% survival (126), of this 94% had CPC 1 or 2! VF/VT were the most common primary rhythm in survivors (76%). for each increase of serum lactate by 1mmol/L there is an 18% decrease in the odds of survival.
  • Median lactate levels in survivor 5.7 and 2.2 (at 0-2h and 2-4h), vs 11.1 and 4.6 in the non survivors group.
  • Of note other factors with good OR of survival were 1) ROSC at arrival to ED 21.53 (8.8 – 52.7) and shockable rhythm 9.0 (4.13-19.6) although 95% CI are broad

Strengths

  • Exclusions: traumatic OHCA, ROSC prior to ambulance arrival.
  • large population size.
  • Post hoc analysis of those without lactate measured – 416 with 31 survivors and 385 non survivors – does this confer some bias into those in whom lactate was measured in the first place?
  • looked at lactate clearance as a secondary marker: in survivors found median values cleared quicker in 69% of pts. this part of the analysis is confusing in the write up – med values to 1.6 and 6.5 in the two groups.

Weaknesses

  • no clear delineation of what they consider to be a significant lactate level ie: if lactate is >8 does that predict ‘badness’, rather they just seem to have looked at all the lactate levels in the cohort and then its clearance.
  • No power calculation done.

Clinical Bottom Line

  • There appears to be an association between higher presenting lactate level and failure lactate clearance with mortality amongst adult patients suffering OOHCA

Any other FOAM sites where you found it or who have discussed it already so that we can be sure to give kudos

Clinical Question to be answered

  • If you are following the new DAS guidelines and are looking to stock your airway trolley with a video laryngoscope-which ones have the best sucess for intubation

Title of paper

  • Comparison of seven videolaryngoscopes with the Macintosh laryngoscope in manikins by experienced and novice personnel [PubMed]

Journal and year

  • Anaesthesia 2016

Lead Author

  • B. M. A. Pieters

Patients studied

  • Manikin based

Intervention (if therapeutic)

  • Intubation

Comparison

Primary outcome

  • Time to intubation and proportion of successful intubation

Summary of results

  • Devices with a standard MAC style blade were quickest to intubation and scored highest in the user satisfaction

Strengths

  • Variety of specialities studied, randomised order of trial

Weaknesses

  • Manikin based, time to best glottic view used rather than passage of the tube through the cord (we know with some devices that the dispatch of the tube through the cords can be tricky even with a good view).

Clinical Bottom Line

  • Being given a device that you are unfamiliar with can make for added complexity and difficulty in a stressful situation. More work needed in this area but may influence some peoples choice of VDL and most importantly prompt everyone to go and check out the kit on their difficult airway trolley

Clinical Question to be answered

  • In renal colic does an USS predict surgical intervention for calculi? Therefore preventing the need for CT KUB scans in some patients

Title of paper

  • Ultrasonography for the prediction of urological surgical intervention in patients with renal colic [PubMed]

Journal and year

  • Emergency Medicine Journal 2016

Lead Author

  • Mark Taylor

Patients studied

  • Retrospective cohort study of 500 consecutive ED patients with a diagnosis of renal colic that had Ultrasonography either during or within 24 hours of their ED visit

Primary outcome

  • To determine surgical outcomes of the patients who had an USS within 24 hours of ED admission. Evaluated the specificity and sensitivity of USS to assess the need for surgical intervention

Summary of results

  • Positive Ultrasound findings is 97% sensitive and 28% specific in determining the need for surgery (positive meaning – at least one stone identified or moderate to severe hydronephrosis

Strengths

  • relevant topic and the first step towards devising a clinical scoring system which could be used alongside USS for deciding this in the future. Of particular interest to me as a colleague does POCUS plus checks renal function whilst observing young women prior to thinking about CT. I am currently auditing CT KUBs. Good number of patients identified and looked at. Reasonable period of FU to allow surgical intervention 16 weeks. Clear inclusion/exclusion criteria. Clearly defined outcome. Sensitivity very impressive!

Weaknesses

  • Not really POCUS – done by radiologists not ED physicians – how easy is it to get USS on all your renal colics? USS skill which is operator dependant
  • Did not directly compare with CT scans – RCT or non inferiority trial may have been better
  • Depends on referral process of your ED and urology service – we can’t refer until proven stone.
  • Looked only at those who required surgical intervention, need a study which looks at those patients we need to refer

Clinical Bottom Line

  • We probably do too many CT KUBs as they are readily accessible in UK EDs. Could use as a useful tool in young women who we are reluctant to CT – but only using radiologists. However, I’m unlikely to change my practice immediately as need further studies on what the sensitivity/specificity is in the hands of an ED physician rather than radiologist.

Clinical Question to be answered

  • Should we avoid venepuncture on the same side as prior breast surgery and lymph node removal?

Title of paper

  • “Impact of Ipsilateral Blood Draws, Injections, Blood Pressure Measurements, and Air Travel on the Risk of Lymphedema for Patients Treated for Breast Cancer” [PubMed]

Journal and year

  • Journal of clinical onocolgy, March 2016

Lead Author

  • Ferguson

Patients studied

  • Prospective data on patients following diagnosis and treatment for Breast Ca. Surgery and radio included. All were followed at a special clinic monitoring for lymphedema using a fancy machine and a clear definition of lymphoedema. Filled in surveys at each visit to report air travel, venpuncture, cellulitis etc in the arm

Intervention (if therapeutic)

Comparison

  • they compare those who had venepuncture etc with those who didn’t

Primary outcome

  • Development of lymphoedema

Summary of results

  • No association between ipsilateral venepuncture or air travel or BP measurements with the later development of lymphoedema. Predictors of lymphoedema were high BMI at diagnosis and cellulitis

Strengths

  • Prospective data with good follow up and objective outcomes.

Weaknesses

  • potential for recall bias, low incidence of index events (eg only 8% had venepuncture)

Clinical Bottom Line

  • Checking BP and taking blood from the ipsilateral arm is unlikely to cause lymphoedema

Any other FOAM sites where you found it or who have discussed it already so that we can be sure to give kudos

  • via @sean9n (a geris reg) on twitter

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