January 2019

Author: Andy Neill / Published: 02/01/2019

Clinical Question:

Does prehospital thawed plasma improve mortality in major trauma with haemorrhagic shock?

Title of Paper:

Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk of Hemorrhagic Shock

Journal and Year:

NEJM. July 2018.

Lead Author:

J.L. Sperry

Background:

Trauma induced coagulopathy is bad
We try to avoid that by minimising crystalloid use in resuscitation in favour of blood product based resuscitation (damage-control resuscitation)
Prehospital initiation of damage control resuscitation has potential to intervene before development of coagulopathy
There is evidence that plasma mitigates coagulopathy, alters the inflammatory response to injury, and might be glycocalyx-friendly

Study Design:

Multi-centre, cluster-randomised trial

Patients Studied:

Patients transported from scene or another department to a trauma centre
At least one episode of hypotension (SBP <90mmHg) and tachycardia (HR >108bpm) or any episode of severe hypotension (<70mmHg)

Intervention:

Administration of 2 units thawed plasma by prehospital air transport team
Group AB or A with low anti-B antibody titre
Both units infused to completion even if still going on arrival to trauma centre

Comparison:

Standard trauma resuscitation as per local protocol
Crystalloid primary resuscitation fluid
Some carried PRBCs – administered as per oral protocol

Outcomes:

Primary: 30 day mortality
Secondary: 24 hour mortality, in-hospital mortality, volume of blood products & resuscitation fluids administered in first 24 hours, incidence of multi organ failure, ALI/ARDS, TRALI, nosocomial infection, coagulopathy measurements (prothrombin time ratio & TEG)

Summary of Results:

501 patients enrolled
230 plasma group | 271 standard care group
72.7% male
82.4% blunt trauma
Median ISS 22 (IQR 13-30, range 0-75)
30 day mortality overall 29.6%
Prehospital ETT 51.1%
Prehospital PRBCs 34.7%
Operation within 24 hours 58.4%
Primary Outcome: 30 day mortality
23.2% (plasma) vs 33% (standard)
-9.8% difference [CI -18.6 to -1.0 | p=0.03]
NNT 10 to prevent one death at 30 days
Kaplan-Meier survival curve = early separation (3 hours), remained to 30 days

Secondary Outcomes:

No difference in rates of:
Multi organ failure
Acute lung injury – ARDS
Nosocomial infections
Only significant difference median INR: 1.2 (plasma) vs 1.3 (standard) p<0.001

Safety:

Allergic/transfusion reactions:
2.2% (plasma) vs 0.4% (standard)
Not statistically significant
Considered minor
“May have been related to trial treatment”

Authors Conclusion:

Prehospital administration of thawed plasma was safe and leads to lower 30 day mortality and median prothrombin time ratio compared to standard care resuscitation

Clinical Bottom Line:

Promising result for the early use of plasma but would need to be repeated in other systems to see if that survival benefit is reproducible.
Prehospital plasma isnt without logistical complications (as with any blood product).

Other #FOAMed Resources / References:

The Bottom Line have their standard, detailed and much more intelligent review

Authors:

Nikki Abela
Julia Abela
Vic Brazil

This talk was recorded at Don’t Forget the Bubbles 2018 in Australia.

You can hear more from Vic Brazil on the SimulCast Podcast

Authors:

Nicky Moore
Charlotte Kennedy

Assessing the impact of introducing S100B biomarker into the UK head injury guidelines. By Nicholas Moore et al. (ST3 Emergency Medicine in North East London)
Most of the head injuries that we see in our EDs on a day-to-day basis are mild, yet we still conduct neuroimaging in a large cohort of these patients. In the UK, NICE has defined a set of criteria which guide clinicians on the need for neuroimaging based on features from the history and examination. But other countries have gone one step further than this in their decision algorithms and in 2013 the Scandinavian Neurotrauma Committee introduced the use of the blood biomarker S100B into their guidelines. The authors of this paper wanted to determine what effect introducing S100B in the UK might have on neuroimaging rates were we to consider adopting it.
The study was run over a 28 day period and captured data on all patients aged 18-65 attending with a head injury to the ED of a large teaching hospital in England. Cases were reviewed retrospectively as to whether the patient underwent neuroimaging and whether they would have qualified for S100B measurement under the Scandinavian guidelines (GCS14-15, presenting within 6 hours of injury, with no high risk features except vomiting or syncope). In total 238 patients were identified as having attended with a head injury, of which 212 had a GCS of 14-15 on assessment. 114 (48%) of these patients underwent neuroimaging, with no abnormalities found on any of the CT scans. Of those that had a CT, 96 would have potentially qualified for S100B measurement. Previous studies conducted on S100B allowed the authors to estimate that 32% of patients qualifying for measurement would have had values low enough to avoid further investigation, which would translate to a reduction in neuroimaging in this study of approximately 25%. Scaling this up to the UK population as a whole, it has the potential to avoid over 75,000 CT scans per year. However, the use of S100B in the UK needs further validation in our population before it is adopted into clinical decision rules and we hope to see more along these lines from the authors in due course.

Nicholas’ take home message about this work: The S100B biomarker has convincing potential to reduce CT scans, admissions and perhaps presentations to emergency departments in patients with mild head injuries in the UK. A validation study is warranted.

Authors:

Suzanne Ablard
Govind Oliver

Pathways of care for adult mental health emergency department attendances – Analysis of routine data. By Suzanne Ablard et al. (Research Associate, Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), The University of Sheffield)

Many of us will have experienced the frustration of trying to deliver care to mental health patients within an Emergency Department (ED) environment and with recourses suboptimal to their needs. Optimising the care of mental health patients in the ED is a shared concern amongst Emergency Physicians and was voted number 3 in the top 10 James Lind Alliance and RCEM research priority setting partnership. The authors highlight the limitations of the current evidence in this area and sought to characterise when, why and how mental health patients use the ED in order to better target interventions.

They performed a large multi-site retrospective analysis of routine NHS patient level data for adult attendances across 18 EDs in Yorkshire and Humber in 2014. They categorised mental health attendances into 1) Psychiatric, 2) Overdose/ Self-harm and 3) Anxiety and analysed these alongside non-mental health patients against age, mode and time of arrival, number of investigations and treatments and length of stay.

They found that 3.1% (n=39,594) of over 1.3 million ED attendances were mental health related. The majority of these were self-harm/overdose (56%) followed by psychiatric (32%) and anxiety (12%). Unsurprisingly, mental health patients are more likely to arrive by ambulance (OR 3.25, 95% CI 3.18-3.32), more likely to arrive out-of-hours (OR 1.95, 95% CI 1.90-1.99) and are more likely to leave ED before treatment or to refuse it (OR 2.94, 95% CI 2.85-304). Once in the ED they have a significantly longer length of stay (Median 178 mins vs. 139 mins, p>0.001). Their data on investigations and treatment or advice highlight that a high proportion of mental health patients, particularly in the psychiatric sub-group, do not receive investigations (72.7%) or any advice or treatment (51.2%).

The authors highlight from their evidence the burden these patients place on the Emergency Care Services. They stress the need for better training and referral pathways and alternative mental health services in the community, particularly during the out-of-hours period. The need for change has likely only increased with mounting pressures over recent years and we look forward to further work in this area.

Suzanne’s take home message: “Mental health patients are placing a small but significant demand on emergency care services, particularly in the out of hours period. There is also evidence they are receiving poorer levels of care than other patients in the ED. While a proportion of these attendances will be necessary, for example in instances of genuine emergency such as drug overdoses, high rates of ambulance transportation for conditions such as anxiety identified in our study may be less urgent and amenable to a pre-hospital intervention to reduce an ED attendance.”

Authors:

Satveer Nijjar
Andy Neill

This podcast was recorded at EuSEM18 in Glasgow.

Satveer has worked before with the Royal College of Psychiatry and RCEM. She works training health professionals and others in awareness of self harm.

satveernijjar.com

Phenytoin is a sodium channel blocker with slow and erratic oral absorption.

Peak levels are delayed by 24 48 hours and it is 90% protein bound, so dialysis is ineffective. It is metabolised in the liver, importantly this metabolism is saturable and plasma levels can rise dramatically with only a slight increase in daily dosing.

Elimination half-lives in a poisoned patient can vary between 24 to 230 hours.

In Overdose…

Acute overdose has

  • cardiovascular side effects as the biggest problem. Because of the poor oral absorption, these are only really likely with IV – bradycardia, hypotension, vf, asystole, wide QRS.
  • Neurological signs are the most common with nystagmus (initially on forced lateral gaze only, later becomes spontaneous), ataxia, decreased consciousness.
  • Can also cause Nausea and vomiting
  • “Purple glove syndrome” and Stevens Johnson can also occur
  • Anticonvulsant hypersensitivity syndrome

Toxicity symptoms by phenytoin level

Level Sypmtoms

>10 Usually no symptoms

10-20 Occasional mild nystagmus

20-30 Nystagmus

30-40 Ataxia, slurred speech, Nausea/vomiting

40-50 Lethargy, confusion

>50 Coma, seizure (rare)

Correct the phenytoin level for albumin = Observed phenytoin (mg/L) (O.2 x albumin [g/dL]) + 0.1. If possible, take a trough level (ie just before next dose), but if you suspect toxicity or need to treat status, just take a level – treat the patient not the numbers.

Management

Supportive care

avoid lidocaine (same antidysrhythmic properties as phenytoin)

Activated charcoal PO

Falls risk

References

rcemlearning.co.uk – dystonia

wikem.org Phenytoin toxicity

emdocs.net phenytoin-toxicity

lifeinthefastlane toxicant anticonvulsants phenytoin

journals.sagepub.com –> this one is really good for levels!

Authors:

Andy Neill
Dave McCreary

Clinical Question

What’s the best way to secure an IV cannula

Paper Title

Dressings and securements for the prevention of peripheral intravenous catheter failure in adults (SAVE): a pragmatic, randomised controlled, superiority trial

Author:

Rickard, The Lancet, 2018

Background

  • we do this a lot. An awful lot, a “probably more than we should” lot
  • Most of us know that they don’t last very long. They commonly get infected, dislodged or blocked. (they quote 70% failure rate in the paper)
  • There are a whole variety of methods and dressings for securing them from sticky tape to dressings to tissue glue. This is a very unstudied area for such a ubiquitous part of the job

Methods

  • RCT in Oz.
  • Included patients who needed a cannula estimated to be for at least 24 hrs
  • Ward patients and no ultrasound used (so not our typical population…)
  • Groups (picture in the paper is much more descriptive!!)
    1) tissue adhesive and clear dressing
    2) bordered clear dressing (clear in the middle, white gauzey bit round the outside)
    3) clear sticky with a little plastic clip on the cannula
    4) simple clear sticky dressing (control group)
  • mix of winged and non winged cannulas used
  • all had a short extension set attached that was secured with some simple white mepore
  • all patients had a daily review of the line site
  • Primary outcome was a composite of different forms of IV line failure
  • Powered assuming a 40% failure and that any of the 3 intervention arms would have a 10% reduction in failure

Results

  • 1800 patients
  • 70% were 22G cannulas
  • 85% were done by an “expert nurse inserter” Presumably as part of a roving hospital IV team
  • clear dressing with glue was best at 38% failure with simple clear dressing the worst at 43%
  • commonest reasons for “failure” were phelbitis, followed by occlusion, followed by dislodgement
  • any of the intervention dressings were significantly more expensive than the control

Thoughts

  • this group did the other trial on this topic that I was familiar with (www.ncbi.nlm.nih.gov and covered beautifully by St Emlyns here ) which found a pretty decent benefit (10%) to gluing cannulas down.
    – This is their more substantial follow up which is disappointingly statistically negative.

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