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Breaking evidence: Non-Trainee Abstracts blog 4-6

Author: Govind Oliver / Codes: HAP29 & CC2O / Published: 28/08/2018

Research within Emergency Medicine (EM) is growing exponentially with a breadth as varied as the patients who present through our front doors. With increasing recognition of the importance that research has, both in terms of patient care and outcomes but also the benefits on performance of having a research active department, more and more research teams are being established. Numerous large and small trials of varying designs are being run in Emergency Departments across the globe and research within the EM community is now leading the field in areas such as trauma and decision rules.

Here we present the top scoring abstracts as presented at EUSEM 2018. Many of the key areas identified as top research priorities in the RCEM and James Lind Alliance research priority setting partnership are represented amongst these top 6-scoring abstract.

“Is prehospital blood transfusion safe and effective? A systematic review and meta-analysis”
By Tim W.H. Rijnhout (Department of Surgery section Traumasurgery, Radboud University Medical Center, Nijmegen, the Netherlands)

Prehospital haemostatic resuscitation as part of damage control resuscitation is now embedded within trauma care and forms the basis of the massive transfusion protocol in the hospital. As highlighted in the abstract, trauma remains the leading cause of death in patients <44 years of age, is the highest cause of preventable death and 40% of the mortality in trauma patients worldwide is attributable to haemorrhage. However, the efficacy in the prehospital setting of blood transfusion remains unanswered.

Through a systematic review and meta-analysis the authors aimed to ascertain whether sufficient evidence was present to recommend prehospital blood transfusion (PHBT) in trauma. The authors screened CINAHL, Cochrane, EMBASE and Pubmed from 1988 – August 2018 and following a screening process included 48 studies in their meta-analysis. Patients who received combined therapy with packed Red Blood Cells (pRBCs) and plasma showed a statistically significant reduction for 24-hour mortality (OR = 0.58; P=0.01) but no statistically significant reduction for overall mortality (OR = 0.71, P = 0.06). PHBT with pRBCs only resulted in a statistically significant increase in the odds for overall mortality (OR = 1.30, P = 0.03) but showed no statistically significant 24-hour survival benefit (OR = 0.92, P = 0.82). Patients transfused only with plasma showed no statistically significant reduction in overall mortality (OR = 0.72, P = 0.20). In a total of 6095 patients who received PHBT, ten adverse events were reported (0.16%).

The authors conclude that whilst their evidence suggests that administration of blood prehospital is safe, evidence on efficacy remains lacking due to mainly poor quality evidence. Recently published articles in the Lancet and New England Journal of Medicine provide high quality evidence regarding prehospital plasma resuscitation. But there is still need for large randomised studies assessing the efficacy of prehospital resuscitation with pRBCs and plasma. Readers may or may not be aware of the RePHILL study (randomised controlled trial of pre-hospital blood product resuscitation for trauma) being conducted within the UK at present.

The trial protocol has been published in Transfusion Medicine, PMID: 29193548. Enrolment is expected to continue until 2020 and we very much look forward to the results from this, which will hopefully help to answer many questions in this area. Other active trials include Pre-hospital Administration of Lyophilized Plasma for Post-traumatic Coagulopathy Treatment (PREHO-PLYO) NCT02736812, Rapid Administration of Blood by HEMS in Trauma (RABBIT) NCT03522636 and Prehospital Pragmatic Group O Whole Blood Early Resuscitation Trial (PPOWER) NCT03477006.

Tim’s take home message

Administering blood components in the prehospital phase is safe. However, no hard conclusion can be drawn due to the low quality of evidence from existing studies. Use of normal saline should be limited due to deleterious effect and, besides transfusion with blood components, patients with major haemorrhage should receive tranexamic acid.

Contact Tim about this work about this work: tim.rijnhout@radboudumc.nl

“Short-stay unit hospitalisation in acutely admitted older internal medicine patients”a randomised trial By Camilla Strm et al. (Specialty registrar, Department of Anaesthesia, Holbaek Hospital, University of Copenhagen, Denmark)

With the aging population, care of the elderly patient whilst in our EDs is a shared concern amongst Emergency Physicians. Whether better approaches can be developed for this cohort of patients, rather than the traditional ED, was voted the number 2 research priority in the top 10 James Lind Alliance and RCEM research priority setting partnership. The authors compared the impact of admission to an ED-based short-stay unit (SSUs) compared with standard care by the Internal (General) Medicine Department (IMD) in acutely admitted, older (>75 years) internal (general) medicine patients. The doctors on the SSUs were ED doctors with the senior clinicians having a background as general internal medicine specialists; the maximum length of stay on the SSUs is 72 hours.

The authors conducted a pragmatic randomised clinical trial between January 2015 and October 2016, with patients randomly assigned to SSU-hospitalisation or IMD-hospitalisation if assessed to be SSU suitable. General fast-track principals were applied in the SSU; such as shorter time to tests, encouragement to mobilise with minimal assistance, early initiation of physiotherapy, and discharge planning initiated upon arrival. Their primary outcome was 90-day mortality with secondary outcome measures of: adverse events, change in Lawton Instrumental Activities of Daily Living (iADL)-score within 90 days from admission, in-hospital length of stay, and unplanned readmissions within 30 days after discharge.

430 patients were enrolled and randomised with a median age of 84 years in both groups. Ninety-day mortality was not significantly different between the SSU-group and the IMD-group at 11% and 15% respectively (OR 0.66, 95%CI). However, in the secondary outcome measures there were statistically significant differences. The SSU-group compared to the IMD-group had: fewer patients experiencing at least one adverse event (8% vs. 21%, p>0.001), lower reduction of iADL-score within 90 days from admission (p>0.001), reduction in length of stay (73 hrs. vs. 100 hrs.) and fewer readmissions (p>0.001). They also found fewer tests and treatments were applied to the SSU-group and waits for scans and physiotherapy were shorter.

This is an exciting study and highlights the potential benefit of an Emergency Department Short Stay Unit for elderly patients in having lower risk of adverse events, less functional decline, fewer readmissions, and shorter hospital stay. There are differences between how the UK and Danish system operate; their SSUs appear to overlap the role of Emergency Department and Acute Medicine/ Specialist Elderly care admissions areas. We look forward to future work in this area.

Camilla’s take home message

The hospital is a hazardous place for older patients. Optimising and minimising time spent in hospital seem to be essential in order to prevent obstacles of recovery such as functional decline or adverse events. We hypothesise that the cluster of simple fast-track principals applied in the ED-based SSU led to better outcomes in our sample of acutely admitted patients over 75 years. Sometimes, less may actually be more.

“Risk of short-term neurologic complications in children who present a post-traumatic seizure following minor head trauma: a systematic review and meta-analysis”. By Lorenzo Zanetto et al. (MD, trainee in paediatrics at the Department of Woman’s and Child’s Health, University of Padova)

Post-traumatic seizures in paediatric head injury have been associated with an increased risk of traumatic brain injury (TBI). However the risks in children with an immediate post-traumatic seizure and a normal GCS on assessment have not been rigorously evaluated. The authors therefore aimed to determine the frequency of short-term neurological complications in this group of children.

Whilst in the United Kingdom, the National Institute for Clinical Excellence (NICE) have produced guidance on paediatric head injury recommending an immediate CT scan in this group, better understanding the risks associated with an immediate post head injury seizure in a GCS 15 and well looking child are important for clinician decision making and advising parents and children.

The authors conducted a systemic literature review of PubMed, EMBASE, the Cochrane Library, Scopus, Web of Science, and ClinicalTrials.gov. Following a screening process with two independent reviewers, 7 studies met their inclusion criteria.

From these 7 studies, including over sixty-six thousand head injured children who had a GCS of 15 on assessment in the ED, 439 (0.7%) had a history of an immediate post-traumatic seizure and had undergone neuroimaging. A high proportion (13%) had abnormalities on imaging but only 2.3% required neurosurgery. Two studies reported on children with isolated post-traumatic seizures, i.e. without any other predictors of head injury (a total of 76 patients, 0.1% in both studies); TBI on neuroimaging was present in 3 patients and only one underwent neurosurgery. No children died.

The findings from this literature review support, in this group of blunt head injured children, either immediate neuroimaging (as recommended by current NICE guidance) or a prolonged period of observation due to the high frequency of abnormalities found on neuroimaging.

Lorenzo’s take home message

Immediate post-traumatic seizure is uncommon in children with normal mental status and rarely occurs in children without other signs and symptoms of head injury.

Overall the risk of TBI is significant in children with PTS and normal mental status, but lower in the absence of other predictors. Clinicians should strongly consider neuroimaging for children with PTS, but a prolonged period of observation may be performed in children with isolated PTS.

Contact Lorenzo about this work: Lorenzo.zanetto1@gmail.com

These three abstract represent how varied the research in Emergency Medicine is. They are just the tip of the iceberg of work being done to help our patients and improve our care. We congratulate all the authors on their top scoring abstracts and wish them the very best of luck in their continuing work. Let’s hope we see more from them in the near future!

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