June 2022

Author: Mark Winstanley, Becky Maxwell, Chris Connolly, Andy Neill, Dave McCreary, Rob Hirst / Codes: CAP25, CAP6, CC21, HAP23, HAP6, CP2, IP3, RespiC10, RespiP1, RespiP2, SLO1 / Published: 08/06/2022

Clinical Question

Do you have to aspirate infected olecranon bursitis or can you just treat with antibiotics?

Title of Paper

Efficacy of empiric antibiotic management of septic olecranon bursitis without bursa aspiration in emergency department patients.

Journal and Year

Academic Emergency Medicine. 2022.

Lead Author

Adrian Beyde

Background

– It’s tempting with a big juicy olecranon bursitis to get in there with a needle when you think it might be infected to get your MC&S sample and to remove the offending infected fluid
– But is it really needed? Aspiration isn’t without its reported complications including infection and chronic fistula formation.

Study Design

– Retrospective, observational cohort study in a quaternary care academic ED
– Identified patients with “Olecranon bursitis” or “bursitis” and manually reviewed the charts to confirm.
– Followed up for a period of 6 months.

Patients Studied

– Adults with olecranon bursitis
– “Suspected septic” bursitis was any patient treated with antibiotics

What They Did

– Followed identified patients up for 6 months to describe the outcomes of those treated with antibiotics, without aspiration on their initial disposition

Summary of Results

– 266 patients with olecranon bursitis included:
– Only 4 of these were aspirated in the ED
– 262 not aspirated:
– 39 admitted for abx
– 4 eventually aspirated: 1 not septic, 3 septic
– 89% of the admitted group had uncomplicated resolution without aspiration
– **147 sent home on abx (this is our group of interest)**:
– 134 followed up
– **118 (88%) had uncomplicated resolution**
– If all lost patients assumed to have complication then 80% had uncomplicated resolution
– 8 (6%) eventually got aspiration: 5 not septic, 2 MRSA, 1 inconclusive
– 9 (6.7%) admitted for IV abx
– 91% of the non-antibiotic group had uncomplicated follow up

Authors Conclusion

Our findings suggest that empiric antibiotics without bursal aspiration is a reasonable initial approach to ED management of select patients with suspected septic olecranon bursitis who have adequate follow-up care, are immunocompetent, are able to tolerate oral antibiotics, and are at low risk of antibiotic complications.

Clinical Bottom Line

This is retrospective data (albeit well collected) so this limits the strength of clinical conclusions a little. That being said, the numbers are pretty reassuring and fit with my pre-existing practice that I have to have a good reason to put a needle in something (though I do enjoy it when I get the opportunity).

Other #FOAMed Resources / References:

  1. Journal Feed
  2. SGEM

Clinical Question

Does anterior-posterior or anterior-lateral pad placement increase your chances of a successful cardioversion in AF?

Title of Paper

Anterior-Lateral Versus Anterior-Posterior Electrode Position for Cardioverting Atrial Fibrillation (The EPIC – Electrode Position In Cardioverting Atrial Fibrillation – trial)

Journal and Year

Circulation. 2021.

Lead Author

Anders Schmidt

Background

– I was always taught (and have been teaching) that AP pad placement is better for cardioversion of atrial arrhythmias (fib/flutter).
– This teaching was based on studies performed using monophasic defibrillators, rather than our modern biphasic ones.
– What’s the difference, you ask? In monophasic defibrillators, the energy discharged only travels in one direction between the electrodes; in biphasic, the current goes one way, then heads back the other way again. In theory the energy dissipates towards the distal electrode and so the myocardial cells there may not be exposed to as much energy and so are less likely to be successfully zapped. When the zap is repeated in reverse, that’ll catch those stragglers.
– Some more recent studies have at least shown trends towards favouring Ant-Lat placement for defibrillation success, but a definitive trial was needed. Queue, EPIC.

Study Design

– Multicentre, investigator-initiated, randomised, open-label, blinded outcome assessment trial

Patients Studied

– Adults with AF scheduled for elective cardioversion
– Excluded: other arrhythmias, implantable devices, haemodynamically unstable, untreated hyperthyroidism and pregnancy.

Intervention

– Anterior-lateral pad placement for cardioversion

Comparison

– Anterior-posterior pad placement for cardioversion

Outcomes

– Primary: proportion of patients in sinus rhythm 1 minute after first shock
– Secondary:
– Proportion of patients in sinus rhythm 1 minute after final shock
– Efficacy of cardioversion at discharge 2 hours post cardioversion

Summary of Results

– 467 patients: 233 A-L | 234 A-P
– Primary: A-L 54% | A-P 33%
– 22% risk difference (95%CI 13-30; p<0.001)
– NNT 5
– Secondary:
– Patients in sinus post final shock: 93% vs 85% in favour of A-L

Authors Conclusion

This study found anterior-lateral electrode positioning to be more effective than anterior-posterior electrode positioning for AF cardioversion. There were no significant differences in any safety outcome.

Clinical Bottom Line

This study was assessing stable, elective patients, largely with persistent AF and so is a different population to those we are Cardioverting in the ED. That being said, patients with persistent AF are likely more difficult to cardiovert than the new-onset patients we like to cardiovert (supported by their pretty poor first-shock success rate of 54%), so if its good enough for them then its got to be good enough for our patients.

Given either option of pad placement is safe and supported by ALS guidelines already, this study is enough for me to favour anterior-lateral placement in future cardioversions – though I’ll not be changing the pads if they already happen to be positioned A-P.

2 Comments

  1. sanjay.sinha says:

    Interesting case discussdions

  2. Ashraf Ali says:

    very good podcast and update

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