Author: Rob Hirst, Becky Maxwell, Chris Connolly, Andy Neill, Dave McCreary / Codes: SLO4, TC2, TP7 / Published: 01/08/2022

New in EM - Mid lines vs PICC

Authors:

– Andy Neill
– Dave McCreary

Clinical Questions:

– Are PICC lines or mid lines safer for short term indications?

Author:

– Lakshmi Swaminathna, JAMA Int Med 2021

Background:

– OK, this is a bit of a stretch to make this immediately relevant to UK EM practice but stay with me. We all know IV access is a crucial part of the journey for most of our patients. Many of our most crucial treatments hinge on having secure IV access. Cannulas fail at the most inopportune moments and patients frequently end up missing crucial treatments like antibiotics for example.
– In EM we have embraced the US guided peripheral cannula and we’re generally pretty good at it. However we all know that those stumpy little 32mm pink and green cannulas usually only last an hour or so and next thing the medical team are coming back to you asking for another line.
– PICC lines are generally the reserve of the interventional radiologist and are largely an inpatient procedure.
– Enter the midline. Effectively this is a PICC line cut really short so that it’s only 10-15cm and can be placed with US at the bedside without an image intensifier or an x-ray.
– (imagine in an A Team intro voice) So when you need access and you don’t want or need to commit to a CVC and your crappy peripheral cannula is tissued and if no one else can help, and if you can find them….maybe you can put in a mid line.

Methods:

– Review of a huge US data set collected as part of quality improvement project as part of 48 hospitals.
– This is all hospitalised in patients so i acknowledge this isn’t ED patients here
– They included patients who for the lines for short term uses like fluids and antibiotics rather than home TPN for example.
– They compared PICC lines (tip in the SVC) vs shorter lines (basilic, brachial). It seems the short ones could include
– They were primarily interested in complications (eg infection or DVT)

Results:

– 5000 PICCs, 5000 mid lines
– 10% major complication compared to 4% in the midline (commonest being blockage), 1.5% infection in PICCs and 0.5 in midlines. DVT similar in both
– Median length in mid line group was 14cm vs 42 in the PICC group
– Median duration of placement was 6 days for the mid line and 14 days for the PICC (far longer than your crappy peripheral IV)
– They quantify their co morbidities with a Charlston comorbidity index suggesting they were somewhat similarly sick but of course there could be lots of confounders here.

Thoughts:

– OK this is basic data and obviously there is potential for bias in observational data.
– That being said, I have thrown this in given the disappointing results we’re seeing with US guided peripheral IVs in the upper arm – where they typically don’t last the way we want.
– I’m trying to make the argument that any time you’re pulling out the US to place a tricky cannula you should probably be doing a mid line. The same applies for the person that you’re putting a CVC in purely for tricky access – a mid line is probably all you need.
– As usual, this is not something to go out and do tomorrow. there needs to be some thought in what particular lines you might use and what your level of sterility might be. I have often used the commonly used arterial lines for this purpose in a pinch – they’re 18G with 8cm length and Seldinger placement. People often freak out as it’s an art line but it literally says on the packet “for IV or art use”.

1. Swaminathan, L. _et al._ Safety and Outcomes of Midline Catheters vs Peripherally Inserted Central Catheters for Patients With Short-term Indications. _Jama Intern Med_ **182**, 50–58 (2022).

New in EM - The FORCE study

notion.so

Clinical Question:

Do Torus fractures need immobilisation and follow up or can they be discharged immediately with an optional bandage?

Title of Paper:

Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK

Journal and Year:

Lancet. 2022.

Lead Author:

Dan Perry

Background:

– Buckle/Torus fractures are really common. I see them all the time in our mixed department and I even had one recently in one of the couple of kids a day that make it into our adult-only department.
– They are minor injuries, with pain being the main clinical feature.
– Despite how common, and how minor they are, there is a lot of practice variation nationally and internationally on whether these need to be immobilised and whether or not they need formal follow up.
– A Cochrane review concluded that recovery appeared similar regardless of approach, but that the evidence quality was low or very low leading to some uncertainty.
– It’s pretty common for parents to expect that “fracture” (”or is it a break?”) = “plaster”

Study Design

– Multicentre, randomised, controlled, equivalence trial (aiming to prove the intervention is neither better, nor worse than the comparator)

Patients Studied

– Children aged 4-15 with torus fractures
– Exclusions:
– Injuries >36h old
– Cortical disruption (greenstick)
– Additional fractures outside the wrist

Intervention:

– Simple bandage such as gauze roller
– Decision to use and discontinue at the families’ discretion
– No planned follow up
– Return to activity as comfort allows
– Bandage not to be worn for >3 weeks

Comparison:

– Rigid immobilisation: rigid wrist splint (futura) or moulded cast (backslab/POP)
– Treatment advice and follow up as per protocol at each centre
– Follow up by SMS or email, questionnaires at 1, 3, 7 days, 3 and 6 weeks.

Outcomes:

– Primary: Pain at 3 days on Wong-Baker FACES pain scale
– Decided in association with parent and carers forum, children and young people from GenerationR Young Persons Advisory Group.
– Secondary:
– Functional recovery
– Analgesia use & type
– Days off school/childcare
– Complications (mainly representation)
– Satisfaction

Summary of Results:

– 965 randomised
– 94% follow up to primary outcome
– Primary endpoint (pain at 3 days): equivalence demonstrated

– No functional difference at any stage

Authors Conclusion:

This trial supports the strategy of the offer of a bandage and immediate discharge from the emergency department for children with torus fractures of the distal radius.

Clinical Bottom Line:

– This confirms what I’m sure a lot of us have thought for a while now. I think I’ve placed my last splint for Torus fractures. I’ll offer the bandage and tell parents if they are concerned re pain they can get a Futura splint from the chemist as needed.
– Why the bandage, and not nothing? Well the authors were going to study just that, but when they discussed the study with patient/parent interest groups they found that parents wouldn’t find this acceptable and would prefer a bandage.
– Kudos to my good friend and Orthoflow partner, James Widnall (who’s nickname isn’t sharable on a public forum) for getting his name as one of the et al. on a Lancet paper…
– Further kudos to his wife, and my even older friend (she likes to remind us she claimed me first), and Orthoflow illustrator, Cat Widnall for some lovely

Other #FOAMed Resources / References:

– This site from the study team has patient information leaflets, infographics and the FORCE pathway to download