Authors: Dave McCreary, Andy Neill, Rob Rogers, Hugo Dowd, Iain Beardsell, / Codes: CC3, CP4, SLO10, SLO2, SLO5, SLO9 / Published: 01/07/2019

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The content you’re about to read or listen to is at least two years old, which means evidence and guidelines may have changed since it was originally published. This content item won’t be edited but there will be a newer version published if warranted. Check the new publications and curriculum map for updates

New in EM: Aromatherapy for Nauseated ED Patients

Authors:
Dave McCreary
Andy Neill

Codes: CC3, CC21, CAP1, CAP36

Clinical Question:
How does isopropyl alcohol inhalation compare to ondansetron for nausea in ED patients?

Title of Paper:

Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial

Journal and Year:

Annals of Emergency Medicine. 2018.

Lead Author:

Michael April

Background:
  • Sniffing on isopropyl alcohol (alco-wipes) has an anti-emetic effect
  • It’s use has had some medical (twitter) press previously and inspired an Academic life in the EM blog trick of the trade
  • Most evidence of its use was in post operative nausea and vomiting (just like the evidence for most of our commonly used antiemetics), and often the evidence doesn’t quite pan out when we look at ED patients with undifferentiated nausea and vomiting
  • One ED study in 2015 showed a benefit vs placebo at 10 minutes for relief of nausea
  • This study looks further at this effect compared to routine antiemetics (ondansetron)

Study Design:

  • Single-centre, placebo controlled, blinded, randomised trial or ED patients with a chief complaint of nausea or vomiting

Three arms: 

  • Inhaled isopropyl alcohol and 4mg oral ondansetron
  • Inhaled isopropyl alcohol and oral placebo
  • Inhaled saline placebo and 4mg oral ondansetron
  • Commercially prepared medical pad saturated with isopropyl alcohol or normal saline
  • Instructed to take deep nasal inhalations as frequently as required to achieve relief of nausea with pad 1-2cm from nares
  • Collected data at 10, 20, 30, 60 minutes then hourly until disposition decision
  • Allowed more sniffing of similarly prepared pad at each timepoint as needed

Patients Studied:

  • Adults presenting to ED with chief complaint of nausea or vomiting
  • Self reported nausea ≥ 3/10
  • Exclusions included:
  • Pregnancy
  • IV access

Intervention:</strong

  • Inhaled isopropyl alcohol and 4mg oral ondansetron
  • Inhaled isopropyl alcohol and oral placebo

Comparison: 

  • Inhaled saline placebo and 4mg oral ondansetron

Outcomes:

  • _Primary_: Change in nausea from baseline to 30 minutes post intervention on 0-100mm VAS
  •  _Secondary_:
  • Change in pain VAS to 30 mins | nausea scores until ED disposition | pain score at disposition | satisfaction VAS
  • Vomiting during ED stay | use of rescue anti-emetics | admission to hospital | ED LOS

Summary of Results:

  • 120 subjects (sample size met)
  • Trend to less females in Isopropyl + placebo group
  • Most common dx was infectious gastroenteritis (55.2%)

Primary:  

  • Isopropyl alcohol + ondansetron: 30mm [22 – 37mm]
  • Isopropyl alcohol + placebo: 32mm [25 – 39mm]
  • Placebo + Ondansetron: 9mm [5 – 14mm]

Secondary: 

  • Inhaled + Ondansetron:
  • Lower mean nausea scores throughout stay
  • Lower mean nausea scores at disposition
  • Better satisfaction scores
  • Greater pain reduction at disposition

Inhaled + placebo: 

  • Greater pain reduction at 30 minutes (Inh + Placebo)
  • No difference in rescue antiemetics

Authors Conclusion:

Among ED patients with acute nausea and not requiring immediate intravenous access, aromatherapy with or without oral ondansetron provides greater nausea relief than oral ondansetron alone.

Clinical Bottom Line:

Its safe, its easy, you can give the patient a stack of pads and they can do their own patient controlled antiemetic regime. Winner.

It continues to beg the question though – is ondansetron really all we make it out to be? ED patients are (generally) not chemotherapy patients.

Other #FOAMed Resources / References:

  1. Pharmacokinetics of ondansetron
  2. ALiEM blog
  3. St Emlyns

Rob Rogers at EMEC - Medutopia, Legacies and Inspiration

Rob Rogers at EMEC – Meditopia, Legacies and Inspiration

Authors:

Nikki Abela
Rob Rogers

Codes: CC15, CC23, CC24

Links:
Shift work and inflammatory markers paper mentioned by Rob

Hugo Dowd - Syncope at Belfast CPD - Part 1

Authors:

Andy Neill
Hugo Dowd

Codes: CC1, CC2, HAP5, HAP15, HAP22, HAP23, HAP35, CAP5, CAP15, CAP25, CAP32, PAP3

This interview was recorded at the RCEM CPD Event in Belfast in 2019.

Hugo is a Paediatric and Adult Emergency Physician working in Antrim Area Hospital in Northern Ireland.

Show notes – Useful Links

Timed Up and Go Test
Timed Up and Go predicts functional decline in older patients presenting to the emergency department following minor trauma

Conclusion

In community dwelling elders presenting to the ED following minor trauma, TUG scores were associated with frailty and strongly associated with functional decline at 3 and 6 months post injury. TUG scores were not associated with self-reported falls. Use of the TUG in the ED will help identify frail patients at risk of functional decline.

San Francisco Syncope Rule

Iain Beardsell - Diagnostics at Belfast CPD

Authors:

Dr Mark Winstanley
Dr Ian Beardsell @docib

Codes: CC1, CC2, CC5, C12

Links:

broomedocs.com
stemlynsblog.org im-bayes-bout-bayes-no-treble
stemlynspodcast.org
Stemlynsblog.org induction

Hugo Dowd - Syncope at Belfast CPD - Part 2

Authors:

Andy Neill
Hugo Dowd

This interview was recorded at the RCEM CPD Event in Belfast in 2019.

Hugo is a Paediatric and Adult Emergency Physician working in Antrim Area Hospital in Northern Ireland.

Show notes – Useful Links

Timed Up and Go Test
Timed Up and Go predicts functional decline in older patients presenting to the emergency department following minor trauma

Conclusion

In community dwelling elders presenting to the ED following minor trauma, TUG scores were associated with frailty and strongly associated with functional decline at 3 and 6 months post injury. TUG scores were not associated with self-reported falls. Use of the TUG in the ED will help identify frail patients at risk of functional decline.

San Francisco Syncope Rule

New in EM Cardioversion for A Fib

Should we be cardioverting all the A fib in ED?

Paper

– Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation

Author

– Pluymaekers, NEJM 2019

Codes: CC21, HAP23, HAP8, CAP7, CAP25

Background

– we love procedures. I feel like we started converting a fib in the ED about 10-12 years ago so it seems fairly recent innovation for ED practice. It’s fun and patients seem to be impressed by the drama of the intervention and they still get to home afterwards
– this of course has nothing to do with whether or not it benefits patients or not
– there’s proabbly a 70% chance a new a fib patient will cardiovert spontaneously within 72 hrs (http://www.onlinejacc.org/content/31/3/588)
– there is a lot of data from Canada on the safety of ED cardioversion and OPD management of new A fib but i still don’t think it’s clear if we’re really adding much value.
– for a fib overall a rate control strategy seems to be equally as good as an aggressive rhythm control strategy

Methods

– Dutch trial, multi centre non inferiority trial
– Randomised reccent onset a fib patients to “wait and see” (beta blocker etc to get HR<110 then discharge and review at 24-48 hrs to see if they were still in A fib. If they were they got cardioversion at that stage) versus “cardioversion” (preferably chemical with flecanide or DCC if drugs not suitable)
– used CHADS VASC in both groups to determine need for anticoagulation
– primary end point was sinus rhythm at 4 weeks
– they set their non inferiority margin at 10% which seems generous. (the margin is how close the “inferior” treament as to get to the fancy one to be considered “non inferior” this is investigator determined and is open to massive fudging. this also determines their sample size
– 90% were in in sinus rhythm in both groups easily meeting “non inferiority”
– these guys confirm the previous numbers that 70% had converted to sinus at 48 hours
– those that were still in a fib got electrical cardioversion in the main

Results

– 440 patients
– under half were first episode of a fib
– 65% had a CHADS-VASC 2 or higher (meaning anticoagulation)
– 40% were already on anticoagulation and 30% had it started

Thoughts

– first off remember that everyone here got a cardioversion strategy so this isn’t the rate vs rhythm control debate – this is simply asking should you delay the cardioversion a day or two to see if you need it
– primary end point here is not ideal as we don’t so much care about rhythm as we do stroke or even impact on the patient’s life
– of note in the wait and see group it looks like some of the people still in a fib would have been getting cardioversions at beyond the magical 48 hr window and that didn’t seem to be an issue
– this has potential to change my practice. why not wait a day or two? The major stumbling block is somewhere to bring them back to. In our place we have great cardiac nurse specialists and a cardiac advanced nurse practitioner. Theoretically we could have clinic in the ED to bring them back to. But the old issue of follow up and ownership will be the main sticking point.

Further reading

  1. Since recording this I see st emlyns have covered it too
  2. Check out the breach blog too