November 2021

Authors

Andy Neill
Dave McCreary

Clinical Question

– should we be using helmet CPAP in the ED

Title

– Randomized clinical trial comparing helmet continuous positive airway pressure (hCPAP) to facemask continuous positive airway pressure (fCPAP) for the treatment of acute respiratory failure in the emergency department https://pubmed.ncbi.nlm.nih.gov/34271286/

Author

– Adi, AJEM 2021

Background

– We use CPAP a lot in the ED. The most common reason is heart failrue with a tendency to BiPAP in the COPD patients. These were always the traditonal patients with pneumonia typcially being something it was thought not to work well in
– Since COVID we’ve seen an explosion in CPAP use and the RECOVERY-RS trial suggests that it probably is a good thing, at least in a viral pneumonia COVID
– Over the past few years we’ve heard of trials looking at helmet CPAP which in the images alwasy looked like a diving suit out of 20000 leages under the sea. I had never seen one in practice.
– Then COVID hit and we saw lots of poor italians stuck on helmet CPAP and then we al wanted to try it
– This paper is actually of a cohort pre covid

Methods

– malaysian RCT
– non COVID
– hemlet v face mask
– change in RR following intervnetion as primary outcome (which is poor)
– inlcuded only pulm oedema and COPD but unclear how they picked those out very well.
– randomisation with sealed envelopes
– helmet was 40L flow with PEEP at 5 and Fio2 0.6 (and weirdly the FiO2 was left fixed)
– NIV was on a hamilton with flow as per patient demand with PEEP 5 and FiO2 0.6
– treatment was fairly standard on presumed diagnosis

Results

– 250 pts overall
– 80% cardiogenic pulm oedema vs 20% COPD (which would not be the usual case mix which makes me think selection is a bit off here)
– RR went down quicker in the helmet group
– symptom wise they felt better on the helmet version

Thoughts

– this is not a great paper to be honest adn there are better ones out there and from what i’ve seen they’ve had mixed results.
– i think it’s nice to have the option as patients i’ve used it with often hvae strong preferences in tterms of tolerance one way or another.

So, this month we are covering Surviving sepsis campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Published October in ICM 

This guideline is specifically to cover adult patients in the hospital setting. 

It has 92 recommendations, and we will not cover them all – so please read the guideline yourselves. We have tried to pick out points applicable to EM but there is so much gold in here it is worth a read in its entirety 

So, what does it say?

Firstly, a warning at the very start guideline states: 

We recommend against using qSOFA compared to SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock

Remember the hype about qSOFA? The guideline highlights that qSOFA is good as a predictor of poor outcome in patients with known or suspected infection, but no analysis was performed to support its use as a screening tool so it should not be used in this setting

Next a reminder… 

For adults suspected of having sepsis, we suggest measuring blood lactate

Surely this is normal practice now? You don’t get a set of bloods with us without getting a VBG so I reckon we have nailed this box… and it is useful to re measure after treatment so you can tell which direction the patient is heading. Remember that lactate alone is not sensitive or specific enough to rule in or out sepsis… sepsis is not the only condition with raised lactate!!!  

The guideline goes on to describe the initial resuscitation recommendation: 

Sepsis and septic shock are medical emergencies, and we recommend that treatment and resuscitation begin immediately

Easy to say and entirely the right thing to do but with the ambulance queues we do worry that we are not getting to these folks as quickly as we used to, and this is slipping. 

For patients with sepsis induced hypoperfusion or septic shock we suggest that at least 30 mL/kg of intravenous (IV) crystalloid fluid should be given within the first 3 h of resuscitation

I think we probably do this well… 

The 30ml /kg seems accepted now and has been shown to reduce mortality, ICU LOS, outcome etc. The guideline does point out the ARISE, PROCESS and PROMISe trials all used 30ml/kg – so can assume it is now routine practice. 

Remember its ideal body weight not actual body weight… And remember it’s not a target; don’t write up 2.5L for everyone.  Give some, see what happens, give some more.

Once this initial period of fluid resus is over, how do you measure further fluid resus? 

The guideline helps us here… 

For adults with sepsis or septic shock, we suggest using dynamic measures to guide fluid resuscitation, over physical examination or static parameters alone

This is interesting and something for me to think about in my practice… so HR, BP and CVP are poor indictors alone – it is suggested you use passive leg raising combined with cardiac output (CO) measurement, fluid challenges against stroke volume (SV), systolic pressure or pulse pressure, and increases of SV in response to changes in intrathoracic pressure… use of small boluses tailor to SV and CO if required post 30mls/kg – so what I’m reading from this is if in ED you think you need to go beyond 30mls/kg it is time to get your friendly intensivist involved who can monitor these things more closely…. 

For adults with sepsis or septic shock, we suggest guiding resuscitation to decrease serum lactate in patients with elevated lactate level, over not using serum lactate

I like this, this is what I do. VBG incredibly useful tool for many reasons and this is just one of them!

For adults with septic shock, we suggest using capillary refill time to guide resuscitation as an adjunct to other measures of perfusion

It is validated as a tool to assess tissue perfusion – cheap and easy to do, something we don’t do routinely but might be a useful number to add in to the ‘how do they look assessment’

Fluid Choice: 

Once again we are helped out here, the guideline recommends crystalloids as first line for fluid resuscitations – and then takes is a step further with the next recommendation being a suggestion to use balanced crystalloid over normal saline. There have been no studies comparing the two directly prospectively(the BASIC trial did but in ICU patients in Brazil – SGEM 347 covers it nicely) but there is an acknowledgement re the adverse effects for example hyperchloremic metabolic acidosis, renal vasoconstriction, AKI etc. from saline has sparked an interest in balanced solutions. 

However, we are reminded against using starches and gelatin – again something I hope has gone out of practice a long time before this guideline was published. 

So, what if fluids don’t work and the patient is not improving? 

There is a lot contained re vasopressors in the guideline – mostly this is critical care territory where I work but we are looking into introducing a protocol for peripheral vasopressors in the ED, which makes the following recommendation interesting 

For adults with septic shock, we suggest starting vasopressors peripherally to restore MAP rather than delaying initiation until a central venous access is secured

Reminder MAP is (SBP+[2xDBP])/3 and is the key determinant of systemic filling pressure and therefore a better measure than SBP alone.  MAP <60 are associated with poor organ perfusion.

The guideline does note that if using vasopressors peripherally, they should be administered only for a short period of time and in a vein in or proximal to the antecubital fossa. Remember this is not silo ED decision – you must develop a protocol alongside your medical and critical care colleagues. 

Of note for those patients, we are referring to intensive care it does suggest admission should be within 6 hours … 

So, onto antibiotics: 

Again, this is a large section of the guideline covering various things such as when to give, how to give, which antibiotics, MDR organisms, antifungals, when to stop – it is great but there are a few recommendations for EM physicians we have picked out: The key here is to follow your local micro guidelines and they should take into account this document.

For possible septic shock or high likelihood of sepsis – get the antibiotics in immediately and ideally within one hour

We know this is one of the most effective interventions to reduce mortality. 

So, this is for the sickest of patients – for others we have a little more time as the next recommendation states: 

For adults with possible sepsis without shock, we recommend rapid assessment of the likelihood of infectious versus non-infectious causes of acute illness – this is still time limited as it recommends you rapidly assess the patient and get antibiotics in within 3 hours if unable to rule out infectious cause. 

So the key message for us in the shocked patient if you think sepsis then give some abx asap, otherwise you have time and there’s some (observational) evidence out there that supports that approach as reasonable (bear in mind observational studies are at risk of bias) Agree this is really useful and I would try and do the same.  I think the key to doing this is documenting it well and making a forward plan for the clerking doctor if the patient is being admitted.  ‘I’ve sent XYZ, and if X then please give abx’ etc.  The guideline quotes a couple of studies that did show a 1.04 increased odds of in hospital death or a 0.4% absolute increase in death rates in non-shocked patients but also has a list of references where there was no observed association between timing and mortality. 

 

Next find the course and deal with it if possible: 

For adults with sepsis or septic shock, we recommend rapidly identifying or excluding a specific anatomical diagnosis of infection that requires emergent source control and implementing any required source control intervention as soon as medically and logistically practical

There is a large section on ventilation in the Guideline  – I have picked out two important points for us from this: 

There is insufficient evidence to make a recommendation on the use of conservative oxygen targets in adults with sepsis-induced hypoxemic respiratory failure

And most interestingly 

For adults with sepsis-induced hypoxemic respiratory failure, we suggest the use of high flow nasal oxygen over non-invasive ventilation

Paediatrics have done this for some time but it’s something that is not in my adult practice…. the quality of evidence for this is low, therefore it is a ‘weak recommendation’ but something worth think about esp. when considering the complications of NIV versus HFNC BUT be cautious – the recommendation is based on a sub group analysis of a single RCT where the primary outcome measure was 28 day intubation rate.  However practically speaking it makes sense – try something else non-invasive before intubating a person…..

What about glycaemic control?  Item 69 – Recommends insulin therapy at glucose levels >10 in patients with sepsis or septic shock and then having targets of 8-10.  I don’t think we currently routinely do this but again something for me to take away.  The target is the higher end of the scale due to the risk of hypoglycaemia at lower targets.  Do you do this?

Finally, there is a section in the guideline about goals of care, although most not applicable to ED the one thread throughout is to talk to the patient and family, shared decision making is extremely important and supporting the family through this journey begins at the front door… 

Clinical Question

Back pain – is there an app for that?

Title of Paper

Effectiveness of App-Delivered, Tailored Self-management Support for Adults With Lower Back Pain–Related Disability A SELFBACK Randomized Clinical Trial

Journal and Year

JAMA Internal Medicine

Lead Author

Louise Sandal

Background

– You’ve probably assessed a lower back pain or two if you’ve ever done an ED shift
– A large part of the management of LBP is the communication with patients, educating them on exercises and setting expectations for duration of symptoms etc.
– Can some of that be outsourced to an app?

Study Design

– RCT
– Denmark & Norway
– Assessing the effectiveness of App-Delivered, Tailored Self-Management support for adults with lower back pain-related disability.

The system they were testing, the SELFBACK self-management support system is an AI-powered, evidence-based app that is installed on the patient’s smart phone that provides weekly, individually tailored self-management recommendations for 1) physical activity (steps), 2) strength and flexibility exercises and 3) daily educational messages.

Patients Studied

They randomised adults with non-specific lower back pain in the preceding 8 weeks to have usual care or usual care plus the app (with their very own step counter).

Pain related disability was measured at baseline, 6 weeks, 3 months, 6 months and 9 months using the [Rolan-Morris Disability Questionnaire](https://www.physio-pedia.com/Roland%E2%80%90Morris_Disability_Questionnaire) which is a selection of questions which gives a score of 0-24, with higher score signifying more pain-related disability.

Outcomes

The primary outcome was the difference in mean improvement in this score at 3 months and they decided that a clinically relevant difference what somewhere in the 2-4 point range so they also looked at percentage of patients achieving at least 2 or 4 point improvement.

Summary of Results

Difference in mean improvement between the groups was -0.79 points (in favour of the intervention – control = 3 pt ↓, intervention = 3.7 pt ↓) but that 13% more patients in the intervention group showed an improvement of 4 or more giving OR for improvement of 1.76 or a NNT of 7.3.

Authors Conclusion

They concluded this is difference was small and of uncertain significance – and I’d certainly agree with that in this population.

Clinical Bottom Line

There are some differences between the population studied here and the cohort of back pains that we see in the ED:

– Only 15% of these patients were recruited in a GP office, the rest were physio, chiro or a back pain clinic so this population is not our usual punter.
– Are they more health literate and that’s why they are being seen in appropriate clinics rather than ED?
– Are they in less pain than those we see in ED and therefore there are less gains to be made?
– 58% of the patients had pain for over 12 weeks already. Again different to those we generally see acutely:
– Maybe the more acute back pain patients would benefit more from this kind of app?

So my conclusion – I think there could be potential for this kind of system in acute patients, though this particular app is likely to be pretty expensive once they commercialise it. I know that I always teach acute back pain as being as much a patient communication exercise as it is a medical one, teaching patients what to expect and exercises to do etc. So we probably need an RCT of its use in the true *acute* LBP patients…once we’ve excluded CES, of course.

Authors:

Dr Mark Winstanley
Dr Michelle Tipping

References:

Taming the SRU: scleritis-and-episcleritis
Ophthalmology training.com episcleritis-and-scleritis
NICE CKS: red-eye
Lagina A, Ramphul K. Scleritis. [Updated 2021 Jul 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.