June 2017

Author: Andy Neill / Codes: / Published: 01/06/2017

Warning

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Paper Number 1

Can you make a baby wee on demand? (and why would you want to?)

Authors: Dave McCreary, Andy Neill

Codes: CC21, PAP9

Clinical Question:

  • Can you make a baby wee on demand?

Title of Paper:

Journal

  • British Medical Journal 2017

Author

  • Kaufman

Background

  • UTIs are common in kids
  • It can be bloody difficult to get a urine sample from a pre-continent infant
  • Anecdotally clinicians have noted infants tend to wee during the cleaning process for a clean catch (and parents have probably noticed that during nappy changes)
  • They reckon there is a cutaneous voiding reflex – it works in animals

Study type

  • Randomised controlled trial
  • Non-blinded
  • Superiority trial

Patients Studied

  • Infants aged 1-12 months requiring urine sample collection

Intervention

  • Gentle suprapubic cutaneous stimulation with a cold saline soaked gauze for 5 minutes (The Quick-Wee method)

Comparison

  • Standard clean catch with no stimulation for 5 minutes

Outcomes

  • Primary – voiding of urine within 5 minutes
  • Secondary – Successful collection / contamination rate / parent and clinician satisfaction

Results

  • Quick-Wee wins
    • 31% vs 12% (p<0.001) voided within 5 minutes
    • Greater satisfaction scores (2 vs 3 on Likert scale)
    • No difference found in contamination
  • NNT 4.7 to successfully collect one additional pot of wee within 5 minutes

Bottom line

  • Quick-Wee is a really simple method that significantly increases likelihood of voiding and catching it within 5 minutes
  • I imagine the novelty would wear off after my first successful attempt and suddenly 5 minutes would seem like a long time – what are the chances we can get the parents in on the action?

Further Reading

Assessing the older patient in the ED Part 1

“Whats the best way to assess the older patient in the ED?”

Author: Rosa McNamara, Andy Neill

Codes: CAP13, CC3, CC11

Acute Bacterial Prostatitis

“Are we missing acute bacterial prostatitis?”

Author: Charlotte Davies

Codes: C3AP5, C3AP9

There are four main types of prostatitis. Although not the most common, acute bacterial prostatitis is the most likely to present to the emergency department.

Acute Bacterial Prostatitis

Acute prostatitis is a common disease amongst men over 50 years of age, especially those who are immunocompromised, like in diabetes or HIV/AIDs.

It often presents with frequency, urgency and dysuria. In women, we might attribute these symptoms to a UTI, but UTI is rare in men without anatomical abnormalities, until the prostate starts to get bigger, increasing the frequency again. We should consider doing a scrotal, genital and rectal examination in any man diagnosed with a UTI, to check there isn’t something else.

There might be obstructive voiding symptoms in >80% of patients. 38% of people get perineal discomfort which may present as back or rectal pain.

Some people get systemic features. Can get fever in 60% – 86%, maybe with rigors, malaise and myalgias.

Cause

Examination

Look for signs of urinary retention. If in retention, let the most experienced person present attempt a urethral catheter. If that isnt successful, dont keep trying – contact urology for early consideration of a suprapubic catheter.

Classically described as exquisitely painful and boggy, actually you only get a painful prostate in 68%. Pain or symptom reproducability is probably the most important symptom.

Investigations

  • Urinalysis – send sample off for culture.
  • Leucocytes and nitrites have a great positive predictive value, but not a great negative predictive value.
  • Blood cultures – positive in 8 – 21% of cases
  • CRP raised in most cases
  • If there’s microhaematuria on the dip, make sure it gets repeated as it might be a sign of cancer.
  • PSA – not clear role, but has a high negative predictive value
  • PR without prostatic massage makes minimal difference to the serum PSA value and generally does not cause a clinically significant increase in PSA levels.

So how do you tell if someone has prostatitis, or just a UTI? And like many things, there’s no real answer. If they’ve got a painful or boggy mass on examination, then the answer is easy! If they haven’t…could it still be prostatitis? Generally, yes it could be. The patients are normally significantly unwell – the risk of bacteraemia is increased in severe UTIs like pyelonephritis and prostatitis. I think it’s reasonable if you have a really really sick ?urinary sepsis, to assume prostatitis until proven otherwise.

Treatment

  • Broad spectrum (cephalosporin) plus gentamycin if patient is systemically unwell.
  • If oral antibiotics are appropriate, use
    • Ciprofloxacin 500mg BD for 28 days or
    • Ofloxacin 200mg BD for 28 days
  • If patient is allergic to quinolones, consider trimethoprim (200mg BD for 28days) as an alternative. It needs to be for a long time because the prostate has quite a poor blood supply.
  • Laxatives – if defacation uncomfortable
  • Rest
  • NSAIDs
  • It is possible to add on an alpha blocker such as tamsulosin which has been proven as an beneficial adjunct for symptom relief.
  • Hydration

If fails to respond, arrange trans-rectal USS or CT of the prostate to R/U prostate abscess. Prostatic abscesses are relatively uncommon due to clinical practice due antibiotic therapy. Like prostatitis, common presenting features are dysuria, fever, suprapubic pain +/- urinary retention. Urine examination usually reveals pus cells. The organisms usually involved include:

  • Escherichia coli
  • Staphylococcus spp
  • Gonococcus spp: rare

References

  • RCEM Learning – Acute Urinary Retention
  • Radiopaedia
  • WikiEM – Prostatitis
  • BMJ Learning
  • Best Bets
  • Etienne M, Pestel-Caron M, Chapuzet C, Bourgeois I, Chavanet P, Caron F.
    Should blood cultures be performed for patients with acute prostatitis? J Clin
    Microbiol. 2010 May;48(5):1935-8. doi: 10.1128/JCM.00425-10. Epub 2010 Mar 17.
    PubMed PMID: 20237098
  • Etienne M, Pestel-Caron M, Chavanet P, Caron F. Performance of the urine
    leukocyte esterase and nitrite dipstick test for the diagnosis of acute
    prostatitis. Clin Infect Dis. 2008 Mar 15;46(6):951-3; author reply 953. doi:
    10.1086/528873. PubMed PMID: 18288905 [Free full text]
  • Sneezing during Micturition: A Possible Trigger of Acute Bacterial Prostatitis [Free full text]
  • Mosharafa AA, Torky MH, El Said WM, Meshref A. Rising incidence of acute
    prostatitis following prostate biopsy: fluoroquinolone resistance and exposure is
    a significant risk factor. Urology. 2011 Sep;78(3):511-4. doi:
    10.1016/j.urology.2011.04.064. Epub 2011 Jul 22. PubMed PMID: 21782225.
  • Kim SJ, Kim SI, Ahn HS, Choi JB, Kim YS, Kim SJ. Risk factors for acute
    prostatitis after transrectal biopsy of the prostate. Korean J Urol. 2010
    Jun;51(6):426-30. doi: 10.4111/kju.2010.51.6.426. Epub 2010 Jun 21. PubMed PMID:
    20577611; PubMed Central PMCID: PMC2890061.

Stoica G, Cariou G, Colau A, Cortesse A, Hoffmann P, Schaetz A, Sellam R.
[Epidemiology and treatment of acute prostatitis after prostatic biopsy]. Prog
Urol. 2007 Sep;17(5):960-3. French. PubMed PMID: 17969797

NICE Trauma Guideline: Pelvic Injuries Part 1

“What does NICE suggest about suspected pelvic injuries?”

Authors: Becky Maxwell, Chris Connolly

Codes: HMP3

Suspected Pelvic injuries

  • Use CT as first line imaging if high energy injury in adults and you suspect a pelvic fracture.
  • In kids use CT if high energy injury and assessing the abdomen for other injury with CT. RCR guidance says do a CT with contrast if its indicated as imaging modality.
  • It also states pelvic fractures are rare in kids. But I guess that covers the whole spectrum 1 year old to 16 year old.

Pelvic binders

  • I dont know about you but they seem to be on everyone.
  • The guideline suggests suspected isolated pelvic fracture can go to the local TU.
  • Remember they should ideally go binder to skin.
  • Remove the binder after d/w ortho if a stable fracture or if the binder isnt controlling the mechanical stability. If your patient becomes unstable after removal put the thing back on and consider re-imaging.
  • If unstable due to pelvic bleeding then IR is the future its now affectionately known as the circle of life rather than the donut of death in Sheffield.

Paper Number 2

“Is RV dilation on PoCUS useful to diagnose PE during a cardiac arrest”

Authors: Dave McCreary, Andy Neill

Codes: CC21,U8, HMP2

Clinical Question:

  • Is RV dilation on PoCUS useful to diagnose PE during a cardiac arrest

Title of Paper:

Journal

  • Critical Care Medicine, 2017

Author

  • Aagaard

Background

  • PE is on everyones list of Hs and Ts during a cardiac arrest. If the patient is in arrest from a PE then they probably should received thrombolytics and we probably should continue CPR long enough for those lytics to take effect
  • A potential tool for this is PoCUS. We know big PEs cause RV dilation in shocked patients so why not big RVs in dead people?

Patients studied

  • Female crossbred Landrace/Yorkshire/Duroc pigs (27 32 kg) So not people then…
  • This is pure animal work
    • Lab setting
    • Anaesthetised pigs with a nice model of cardiac from PE and other causes. They created the PE by taking some of the pigs own blood into a glass jar, letting it clot and then injecting it back in.
    • Lots of monitoring

What they did

  • Compared 3 different models of porcine cardiac arrest
    • PE
    • Hypoxia
    • VF
  • Took lots of pre and intra arrest transthoracic echocardiograms (they actually had to remove part of rectus abdominus to get the view and cant recommend that in humans)
  • They then compared them all to see if RV dilation during a pulse check reliably predicted PE

What they found

  • 24 pigs, 8 in each of the 3 groups
  • All groups had RV dilation and it was slightly more in the PE group but not enough to be in any way meaningful
  • (they actually had a sub study where they showed a bunch of docs the images and asked them to distinguish between moderate and severe RV dilation and they couldnt do it suggesting that any differences in the amount of RV dilation are not clinically meaningful

Bottom line

  • In pigs (and probably in humans) during cardiac arrest the RV tends to dilate no matter what the cause. PEs make it a little bigger but not in any clinically useful manner. Dont get too trigger happy with your tPA just cause the RV looks a bit big in a dead patient. If theyre shocked but not dead, whole different story

Paeds A-Z: Sam Thenabadu Part 1

“Paeds A-Z with Sam Thenabadu”

Authors: Sam Thenabadu, Andy Neill

RCEM Reference: Vertigo

“How do we know if its BPPV or something more serious?”

Authors: Simon Laing

Codes: CAP12

The presentation of vertigo to the Emergency Department is one that we are likely to see most shifts. Being able to differentiate between symptoms and causes is key to the ED assessment. RCEMLearning has a superb reference section on vertigo.

In this podcast we run through just a small part of the article, focussing mainly in the different parts to assess with regards nystagmus and which features of nystagmus are more likely to be resultant of a central or peripheral cause.

Make sure you have a look at the reference section itself which can be found here.

Further Reading:

Assessing the older patient in the ED Part 2

“Whats the best way to assess the older patient in the ED?”

Author: Rosa McNamara, Andy Neill

Codes: CAP13, CC3, CC11

NICE Trauma Guideline: Pelvic Injuries Part 2

“What does NICE suggest about suspected pelvic injuries?”

Authors: Becky Maxwell, Chris Connolly

Codes: HMP3

The prehospital environment

  • Chris and Becky are not pre-hospitalists as EM is better when warm, dry and surrounded by walls.

Splinting

  • A traction splint should be applied if suspected fracture above the knee
  • Vacuum splint for others. There still seems to be a lot of the orange box splints about but the vacuum ones seem to be better as they really look like they support the limb.

Open fractures

  • Advice is to transfer to MTC or specialist ortho-plastic centre if fracture is to a long bone, hind foot or midfoot. I dont think this is part of our trauma divert package in South Yorkshire yet and I wonder what additional strain this would put on the MTCs.
  • Guidance states not to irrigate the open fracture in ED or in the prehospital setting.
  • Remember to give prophylactic antibiotics!

Paeds A-Z: Sam Thenabadu Part 2

“Paeds A-Z with Sam Thenabadu”

Authors: Sam Thenabadu, Andy Neill

Paper Number 3

“Do minor ankle sprains need physiotherapy?”

Authors: Dave McCreary, Andy Neill

Codes: CC21,CAP 33

Clinical Question:

  • Do minor ankle sprains need physiotherapy?

Title of paper:

Journal

  • British Medical Journal 2016

Author

  • Robert Brison

Background

  • We see lots of low grade sprains in the ED
  • Clinical standards for the treatment of them arent well defined
  • Physiotherapy is a great but finite resource so we need to know if they add anything to these injuries

Study type

  • Parallel group RCT

Patients

  • 16 years
  • Simple grade I & II ankle sprain
    • Included clinically unimportant avulsion fracture (<3mm displacement)
    • Within 72 hours of injury
  • Excluded: multiple injury, other condition limiting mobility, ankle injury requiring immobilisation, unable to accommodate time consuming protocol

Intervention

  • Supervised program of physiotherapy plus usual care

Comparison

  • Usual care
    • Written instructions for RICE, graduated weight bearing activities

Outcomes

  • Primary – proportion of participants reporting excellent recovery
    • Assessed with foot and ankle outcome score (FAOS)
    • Defined as 450/500 at 3 months
    • Difference of 15% increase in absolute proportion of participants with excellent recovery deemed clinically important.
  • Secondary:
    • Assessment of excellent recovery at one and six months
    • Change from baseline using continuous scores at 1, 3, 6 months
    • Clinical and biomechanical measures of ankle function at 1, 3, 6 months

Results

  • 504 patients randomised
  • No significant difference in excellent recovery at 3 months
    • 43% PT group vs 37% usual care
    • Absolute difference 6%, CI 3-15%
  • Trend towards benefit PT did not increase in the per protocol analysis and was in opposite direction at 6 months

Bottom Line

  • There is no clinically important improvement in functional recovery when providing supervised physiotherapy in addition to standard care for grade I/II sprains presenting within 72 hours of injury.
  • I suppose it depends on your institution whether this is something you do anyway, but based on this Ill probably be less inclined to consider it.
  • Obviously this doesnt go for the potentially higher grade sprains or the ones you cant assess for stability on initial assessment…and I suppose for professional footy players unless youre really brave…

Further Reading

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