August 2020

Authors:

• Andy Neill
• Simon Laing

Question:

When do our upper GI bleed patients need their OGD?

Title:

Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding

Author:

Lau, NEJM, 2020

Background:

Upper GI bleeds are common. Most of us have pathways to risk stratify them. Most of us have some kind of urgent OP pathway. We love the blatchford score. But it’s still a little unclear when the OGD should happen. Maintaining a 24/7 OGD service is not easy and it needs used judiciously. It would be nice to know if we should be chasing an OGD at 2am or whether we can safely leave it till tomorrow morning.

Methods:

Randomised trial across several centres in Hong Kong

– Enrolled people with a blatchford of >12 but excluded the really shocked and hypotensive people in whom it was assumed immediate OGD was indicated

– Randomised to OGD within 6 hrs vs within 24 hrs (which was effectively the next morning) Results – 500 pts

– peptic ulcers in 60%, varices in ~8-10%

– ended up as 10 hrs vs 24 hrs in terms of mean timings og OGD – 9% v 6.5% mortality favouring early endoscopy but this no where near meets significance and may well be just noise.

– all the trends in the other numbers favoured early scope.

– the early group got more interventions (likely cause they were still actively bleeding) but it’s impossible to tease out if that was the causative effect of the better secondary outcomes.

– a bigger trial would be needed to tease that out.

Thoughts

– overall waiting till the next morning is almost always fine with these sick but not too sick GI bleed patients. Howerver there are undoubtedly some “stable” appearing patients amongst this group who would really benefit from an early OGD and this trial doesn’t really help us pick out who those people are.

– from a service provision point of view your hospital still needs to have an emergency endoscopy option. However it probably is still OK to only use it for the super sick.

Authors:

• Simon Laing
• Andy Neill

Clinical Question:

Is haloperidol an effective treatment for migraine?

Title:

Treatment of Headache in the Emergency Department: Haloperidol in the Acute Setting (THE-HA Study): A Randomized Clinical Trial.

Author

McCoy, Journal of Emergency Medicine, 2020

Background

Headaches are a common reason to present to the Emergency Department. Symptoms are often severe and debilitating, part of our remit in the ED is not only to tease out those with a concerning pathology underpinning their symptoms, but also to provide symptom relief. Current treatment regimes commonly include the use of paracetamol, NSAIDs, antiemetics and some opioids. This study looked to evaluate the safety and efficacy of 2.5mg haloperidol iv in the treatment of severe benign headache in the ED.

Methods:

This is a single centre prospective ED trial in the US as a randomised, double blind, placebo controlled trial. Patients were aged 13-55 years with a presentation of headache/migraine Patients were excluded if they had a BP> 200/100, sudden rapid onset, fever, acute trauma, history of a brain mass, history of stroke, history of abnormal intracranial anatomy, QT>450ms, GCS<15, any neurological abnormality on examination or any clinical concern that they would require a CT head scan Patients were assigned to receive either haloperidol 2.5mg iv or a normal saline placebo injection over 1-2 minutes.

The patients were made up of a convenience sample, with no patient recruitment between the hours of 8am-4am. The primary outcome measure was pain reduction at 60 minutes At 0, 30, 60 and 90 minutes post treatment patients had vital signs, pain score via VAS and side effects documented If the patient did not have a 50% reduction in their VAS score at 60 minutes, i.v. Ketorolac was offered. Patients requiring rescue medications were observed for a further 60 minutes prior to discharge

Results

Over 9 months 287 patients presented with headache and were assessed for eligibility, after exclusions applied 118 patients randomised to the treatment groups; 58 receiving haloperidol and 60 in the placebo group – 60% had a history of migraine – 91% had a headache classified as severe, with a VAS score>7, 1 patient had a mild headache

<4, and the rest were moderate.

– Patients in the haloperidol group reported a mean reduction on VAS of 4.77 at 60 minutes compared with 1.87 in the placebo arm which was statistically significant, a statistically significant difference was also seen at 30 minutes.

– Rescue medication was required in 31% of patients receiving haloperidol compared to 78.3% receiving placebo

– Diphenhydramine was required in 7 patients and lorazepam in 2 (9 out of 58) – Mean QT in the haloperidol group was not statistically different to the placebo group Thoughts:

– This isn’t part of my treatment strategy, so I find the paper really interesting

– Taking into account that this is a single centre study, with some convenience sampling I’ve got some scepticism about it’s applicability. IT also holds a fair amount of exclusion criteria for its use.

– The results are pretty impressive and the graphs of VAS over time pretty compelling

– But do patients want to risk those side effects requiring rescue treatment with diphenhydramine and lorazepam?

– This is one for joint decision making with the patient, and whilst I won’t be reaching for it immediately, I might be keeping the option in my proverbial back pocket

Authors:

– Andy Neill
– Simon Laing

Clinical Question

– should we pursue DCC for new AF in the ED

Title

– Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial
Author
– Stiell, Lancet July 2020

Background

– Many of us have pathways and protocols in our EDs for DCC of new A fib. This is generally those in late middle age who are clinically well but symptomatic with a very clear onset of symtpoms. There might be some hypertension in the background but generally no intercurrent illness.
– It remains unclear how valuable the cardioverson is. Overall in the long run rate control probably is in the lead by a nose in overall outcomes but rememember that that is long term AF management and antiarrhythmic use and even ablation. I tihnk the rate v rhythm control debate is different from the rate v rhythm control debate in cardiology.

– There was a nice little trial (RACE, Plumayers, 2019, NEJM – Pluymaekers, N., Dudink, E., Luermans, J., Meeder, J., Lenderink, T., Widdershoven, J., Bucx, J., Rienstra, M., Kamp, O., Opstal, J., Alings, M., Oomen, A., Kirchhof, C., Dijk, V., Ramanna, H., Liem, A., Dekker, L., Essers, B., Tijssen, J., Gelder, I., Crijns, H. (2019). Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation New England Journal of Medicine) that reminded us that lots of AF will cardiovert itself if you just give it 48 hrs.
– this group has done a lot of stuff on AF before and consistently deliver high quality practice changing research

Methods

– this is a “partial factorial study”
– 1) Procain and DCC vs Placebo and DCC
– 2) for those getting DCC they were then randomised again to AP v anterolateral
– Included what appear to be what i consider typical for ED cardioversion
– if not coverted 30 mins after the infusion then sent for DCC (and again randomised for pad placeement)
– powered for a 10% improvement in conversion with the drug shock group (assuming 85% conversion for shock only)

Results

– 11 EDs over 5 years
– screened a lot of patients (which i think is fair as we see so much AF and not that many who are DCC candidates)
– 400 pts
– Age 60
– mainly palpitations as symptoms, half had had a previous DCC
– 1/3 were anticoagulated
– 97% v 92% conversion favouring drug/shock rather than shock only.
– no difference in the pad position group.
– one patient in the shock group had a brief arrest when they forgot to press the sync button (!)
– ~10% return to ED for recurrent AF

Thoughts

– this trial assumes that rhythm control is the way to go. Which is fine. But it gives us good insight into how to do it well. I have always been a shock first type of doctor. Partly because i’m impatient and the procedure is fun and effective. But also partly because procain is hard to come by i’ve found in the UK and Ireland. I’ve seen a few protcols advocating amio as the chemical strategy but i’ve never quite liked that.
– I have been doing AP pad positioning but it seems the benefit i saw in that was largely anecdotal.
– I will continue to cardiovert appropriate patients with AF and skip the drugs. However it is perfectly reasonable to offer the patient a chemical option if the idea of having large amounts of electricity directed through major organs causes them some anxiety. Feel free to put the pads where you want cause both work. Though bi tempiral placement is probably not ideal.

References:

– Rebel EM covers this lovely

This month Chris and Becky turn their attention to the RCEM guideline on suspected internal drug traffickers published in May 2020….

Definitions:

Body packers (mules)swallow well wrapped drug packages, most commonly cocaine the packages are subsequently passed and sold on the street.

Body Stuffers Drug dealers/street users may conceal drugs wrapped in cling film in their mouth. The packages are swallowed or spat out to avoid detection by the police

Pushers conceal drugs, usually in containers such as “Kinder eggs” or objects such as mobile phones or sim cards, in their rectum or vagina, to avoid detection.

“County lines” describes tactics by drug dealers who use juveniles/vulnerable adult to transport drugs to suburban areas in this manner. Consider the possibility the patient trafficking drugs may themselves be a victim.

Parachuting is a technique of recreational drug use in which medications or illicit drugs are ingested by wrapping them in a covering that is expected to dissolve or unravel in the gastrointestinal tract and release the drug for later absorption.

The legal bit…..

Drugs Act 2005 and the Authorised Professional Practice (APP) from the College of Policing state by LAW patient who police suspect of concealment MUST be taken to ED

The police will stay with patient under close observation but the patient has right to speak to you confidentially

Police can use the Modern Slavery Act 2015 to charge drug dealers if using under 18s as county lines ‘mules’.

Risk factors for complications of concealed drugs:

• Abdominal pain
• Vomiting
• Abnormal vital signs
• Improvised/home made packaging
• 50 packets ingested
• Large packet size
• Delayed passage (>48hours0)
• Poisoning in a co-transporter
• Passing fragments of packaging in the stools.
• Previous abdominal surgery
• Concomitant use of constipating agents

Routine drugs screening and blood tests are not useful in guiding your management in the ED!!! (make this bold!!)

References

www.rcem.ac.uk