May 2019 Podcast

This month we have an awesome selection of interviews from the Belfast CPD event themed around major trauma, another awesome selection of New in EM for you ranging from airways to scribes in the ED and we have Becky talking research and the launch of the new TERN TIRED study.

If you want to hear the best minds in digital education talk FOAMed and its future the come to London on 9th May we still have tickets available for the first RCEM Digital Education day.

To go with this months trauma theme we have the latest in our series of iBooks published on trauma – thanks as always to the contributors!

trauma ibook an introduction

Authors:

– Andy Neill
– Dave McCreary

Clinical question

– Do scribes improve efficiency in the ED

Title

– Impact of scribes on emergency medicine doctors productivity and patient throughput: multicentre randomised trial https://www.bmj.com/content/364/bmj.l121

Author

– Walker, BMJ, 2019

Background

– This is not a new idea though this is the first multicentre randomised trial on it
– There’s a box in the paper that lists “tasks that can be done by scribes” is basically most of what i do all day everyday though it didn’t seem to include dipping the urine and doing the pregnancy test which is eem to do daily as alll our nurses are looking after admitted patients.
– This was planned as scribes were being introduced into Australia (lead site was a private ED but even there they were salaried not paid per patient)
– Consenting docs were randomised to have scribe or not during their shifts
– Consultants only (which makes sense) to begin with but rolled out to some senior trainees later in the trial
– Scribes had a brief but formal training period and competency assessment before beginning work
– Looked at the patients the docs were primarily responsible for (rather than those they were advising on) This makes it less relevant to some UK EDs where the ED physician is the captain of the ship but not seeing that many patients directly.
– Primary outcome was “productivity” on shift. By this they seem to mean patients per hour. They needed a 15% increase in this to justify the cost so this is how they did their sample size needing a 1000 shifts total.

Results

– 88 docs and 12 scribes
– Went from 1.13 to 1.31 patients per hour (meeting their 15% goal)
– 3900 shifts (630 scribed and 3300 not) – i could not find out why this was so unbalanced but either way it met their power calculation

Definite potential for hawthorne effect and this may overestimate the benefit. But I definitely like it and it was interesting to note that it had the most benefit in areas like senior doc at triage where the throughput is big and limited by how quick you can write and how quick you can order tests.

Authors:

– Andy Neill
– Dave McCreary

Clinical question

– What do pneumothoraces and haemothoraces mean clinically these days?

Title

– Pneumothorax and Hemothorax in the Era of Frequent Chest Computed Tomography for the Evaluation of Adult Patients With Blunt Trauma

Author

– Rob Rodriguez, Annals EM, 2018

Background

– Back in the day… any PTX or hemothorax meant a big dirty great tube. But times have changed. Now the majority we find on CT and most of us are only getting excited when we really think we need to.
– This is a big data set that helps us know what all these CT findings mean

Methods

– This is a sub study of the NEXUS chest study (yes there’s a NEXUS chest study and clinical decision instrument… spoiler alert it’s not as useful as the C-spine one)
– The NEXUS chest studies were both prospective observational including 22000 blunt trauma patients
– They look at 8600 patients who have both CXR and CT and they look to see what it means when the injury is isolated or only visible on CT
– CT was reference standard here

Results

– In the 8600 with both CXR and CT, 9% had a PTX and 2.5% had a haemothorax (and some had both)
– 67% of PTX were only on CT, 80% of haemothorax were only visible on CT
– There were few isolated injuries
– Lots of these injuries were managed with observation and many were even discharged
– 30% of CT only PTX got a tube v 65% when visible on CXR, similar for haemothorax

Thoughts

– This is purely descriptive data and can’t tell us if it’s right not to drain these small CT only pleural injuries but it confirms that most of us have already changed proactive (this data is greater than 10 years old) and you’re not mad when you’re simply observing some of these.

Authors:

– Dave McCreary
– Andy Neill

Clinical Question:

Does Roc rock and Sux suck? How does Rocuronium compare to Suxamethonium for first pass success in ED RSI?

Title of Paper:

Emergency Department Intubation Success With Succinylcholine Versus Rocuronium: A National Emergency Airway Registry Study
PMID: [29747958](https://www.ncbi.nlm.nih.gov/pubmed/29747958)

Journal and Year:

Annals of Emergency Medicine. 2018.

Lead Author:

Michael April

Background:

– Roc or sux, sux or rocRoc rocks and Sux sucks and all that”
– There has been a trend in recent years towards the use of rocuronium for ED (and prehospital) RSI
– Suxamethonium is a depolarising muscle relaxant and causes a transient increase in serum potassium which could be unpopular in patients with conditions such as:
– Rhabdomyolysis
– Pre-existing hyperkalaemia
– MS
– MND
– MD
– Denervating injury, burns or crush injury >72 hours old
– Tetanus
– Immobilisation
– In the ED were are pretty information-light, particularly for patients unwell enough to require intubation
– Suxamethonium can also cause:
– Raised ICP (secondary to fasciculations)
– Masseter spasm (which could lead to a surgical airway)
– But the sux lovers and roc haters (Im looking at you anaestheticsok not all of you, but you know who you are) still argue we should be using it because:
1. Quicker onset for ideal intubating conditions
2. Shorter half life – helpful in event of failed airway/cant intubate, cant oxygenate – as if we can wait for the minimum 5 minutes apnoea time and let them wake up in an ED RSI

Study Design:

– Observational study with data analysis from the National Emergency Airway Registry (NEAR), a prospective registry of ED intubations in the USA

Patients Studied:

– ED patients >14 years old receiving either rocuronium or suxamethonium for first intubation attempt
Intervention:
– Rocuronium vs suxamethonium

Outcomes:

– Primary: first pass intubation success
– Secondary:
– Adverse events
– Best Cormack-Lehane view
– Lowest peri-intubation oxygen saturation
Summary of Results:
– 5071 intubation encounters reported out of 5244 at participating sites
– 2275 suxamethonium – mean dose 1.8mg/kg
– 1800 Rocuronium – mean dose 1.2mg/kg
– Primary: First pass success
– Suxamethonium 87.0%
– Rocuronium 87.5%
– difference 0.5% [95%CI 1.6-2.6%]
– Multivariate analysis – 1st pass success similar after adjusting for difficult airway, indication for intubation, patient demographics, airway characteristics, intubation position, device, sedative agent and incubator experience
– On significant difference on subgroup analysis was higher first pass success in non-difficult airway patients given 1.2mg/kg roc compared to <1.2mg/kg (OR 2.2; 95%CI 1.2-3.4)
– Adverse events:
– 14.7% suxamethonium
– 14.8% rocuronium

Authors Conclusion:

In this large observational series, we did not detect an association between paralytic choice and first-pass RSI success or peri-intubation adverse events.

Clinical Bottom Line:

– There doesnt seem to be a difference in first pass success with rocuronium, yay!
– If your a sucker for sux, I doubt this is going to change your mind, but it provides some evidence to support rockers.
– The authors are very conservative and considered in their conclusions, clearly stating that their study doesnt make any inferences about causal relationships or the non-superiority of suxamethonium. A randomised clinical trial is needed to really put this to bed.

Other #FOAMed Resources / References:

– Josh at Pulmcrit has [this blog](https://emcrit.org/pulmcrit/pulmcrit-rocketamine-vs-keturonium-rapid-sequence-intubation/) on rocketamine vs keturonium – how do you give yours? (After reading this Im team rocketamine)
– LITFL – [Does Roc Rock and Sux Suck?](https://litfl.com/does-roc-rock-does-sux-suck/) (Includes a great video from Reuben Strayer on the evils of suxamethonium)