Category Archives: emergency medicine

You Snooze, You Ooze: Anticoagulation and Minor Head Injury

We’re lucky to have NICE guidelines in the UK.  A couple of years ago, on a visit to the US, one of my collaborators from the US mentioned how jealous he was that we have them.  His practice was to get a CT scan for everyone with a head injury.  The NICE guidelines give us a framework for implementing evidence-based decision rules like the Canadian CT head and CHALICE rules on a widespread basis.  One area I think the NICE guideline for head injury can improve, however, is for anticoagulated patients with minor head injury.

The NICE guideline suggests that we scan head injured anticoagulated patients who have lost consciousness or have amnesia.  In the absence of other high risk features, however, the remainder of patients are potentially eligible for immediate discharge without even so much as an INR check.  This makes me worry.

Unfortunately, the Canadian CT head rule can’t really help us out here because that study excluded patients with coagulopathy.  The New Orleans rule didn’t exclude coagulopathic patients but their analysis was, shall we say, somewhat underpowered as they only had 1 patient with coagulopathy in the study!  So what is the evidence behind managing head injury in anticoagulated patients?

Fortunately, we do have some evidence, although it’s relatively limited evidence if we’re honest. A case series of 144 patients demonstrated that the incidence of clinically important intracranial injury in warfarinised patients was 7%.  For me, that’s a sufficient risk to prevent me from ruling out a bleed in this group and to make me want to request a CT brain.  Roughly 7% of patients with chest pain who have a normal ECG are having an acute myocardial infarction.  But I wouldn’t dream of ruling out AMI just because the ECG is normal.  So neither should we consider ruling out intracranial haemorrhage at that level of risk.

What’s more, anticoagulated patients who develop an intracranial haemorrhage may not meet the NICE criteria for CT (which are based on the Canadian CT head rule, incidentally).  This means that they can bleed despite being relatively asymptomatic.  And a subtherapeutic INR doesn’t mean we can relax either, as shown in this great study from John Batchelor and Simon Rendell from my own institution.

OK, so we’re going to get a CT for these patients.  I’ve sold you that, right?  But if the CT’s normal, surely we can relax.  Right?

This great small study from Annals of Emergency Medicine sheds some light on that situation.  The authors implemented a protocol to immediately CT all warfarinised head injured patients, observe them for 24 hours, then re-scan them.  Of 97 patients, 87 agreed to stay in for observation and have a repeat scan.  5 (6%) of those patients had a late bleed, not detected on the initial scan.  OK, it was minimal in 2 patients.  But 1 required craniotomy.  What’s more, only 1 of those 5 patients had showed signs of neurological deterioration in the 24 hour period between scans.  2 further patients developed late bleeds even after a normal scan at 24 hours.   So, this study definitely tells us that there’s an important incidence of late bleeding in anticoagulated patients.  Not only do we need to strongly consider scanning these patients, but we also need to consider repeating the scan 24 hours later, even in the absence of neurological deterioration.  What’s more, the symptoms reported by the patient may not be a great predictor of intracranial bleeding.  Only 1 of the 6 who bled reported a severe headache, and only 1 was vomiting.  If we rely on our patient becoming symptomatic during the period of observation, we may still miss some late bleeds.

Of course, this is just one study.  Other studies do confirm that there’s an incidence of late bleeding in anticoagulated patients, although it may not be quite as high as 6%.  However, what’s clear is that these patients ooze, and they ooze slowly.  Of course, we don’t want to miss a bleed, if present, initially.  Given the prevalence of bleeding at the time of presentation, I suggest that we should still scan these patients at presentation.  But we should also be alert to the possibility of late bleeds.

From discussions on Twitter, I know that people are doing this after 6 hours rather than 24.  There’s no evidence to definitively tell us which strategy is better.  In my practice, I’ll be strongly considering an initial scan, an INR scan, a period of observation and a repeat scan after 24 hours.  It’s not clear whether that’s the optimal strategy.  What is clear is that we must be extremely careful with these patients.  They bleed.  And they bleed late.

So, what about reversal of the anticoagulation?  Well, that’s a whole different debate – you’ll have to watch this space!…

Rick Body

Are they laughing at me?

As the world becomes smaller and our populations more multicultural (Yes I am a “Lefty” Mr Burley)… so communication in our emergency departments becomes even more crucial.

Last week whilst working in the UK, I was involved in the care of a young refugee from Eastern Europe who had not a word of English at her disposal. I’m sure everyone has had a consultation where very little in the way of effective communication has taken place – you try charades, signing, talking loudly and clearly in English and smiles…. But in the end, all that time you put in to learning history taking skills at university  – useless.

Now, in the ED we are used to a lack of information…. (Indeed I think if I have more than 70% of information on which to base a decision I fall into a apoplexy of indecision)…and that is OK; if you know that’s all you’ve got. But it becomes incredibly frustrating when you want to do the best you can for a vulnerable patient and you know your missing vital information because you just can’t get the message through a language barrier.

Back to the patient…There are not many people who can effectively communicate in Baltic state languages in our department so I attempted (for the first time) using “Language Line”. For those that don’t know – this is a telephone service that allows you to contact a translator for any language in the world (except perhaps some dialects in the North-east of the UK!). Once you have you have your translator you then spend an incredibly long time passing the phone between yourself and the patient whilst the person on the other end translates ever more personal information (all in complete confidence – so we are told – and with patient consent).

This is great, a revolution. Instant understanding. Verbatim translation…..Except… those moments when – and you’ve no doubt know it – the patient and translator have an incredibly long conversation and perhaps share a laugh…… and you get a classic one word translation in response.

You wonder… What were they talking about? Were they laughing at me? Have I got some food left around my mouth? And you start to get a bit uncomfortable….

Probably more important you think –  have I missed something?

So, the translator and the patient have a rapport, they share a laugh (perhaps at my expense) but you get a history to write down and everyone’s happy…. Except the real history is often hidden in the nuance of communication – the way something is said, the unspoken words, the carefully selected words, the language.

And we do miss vital information….

A very interesting paper from South Africa by Penn et al. has attempted to characterise the information we miss in translation. But, hold onto your hats it’s Qualitative Research.

From the outset I will say that its not specific to the ED, but the findings are interesting and can be related to translation of all sorts.

What the authors did was record healthcare interviews performed “pas de trois” (their French term not mine), i.e. doctor-patient-translator. Using the interview transcripts they have then decided selected what they term “asides” – times when the translator and patient communicated between themselves and not involved the doctor. They have then taken these asides and classified them as “big talk” (topics like patient beliefs about illness, relationship issues, disclosure issues) or “small talk” (topics such as transport, weather, clarification requests).

Asides were rarely translated for the doctor (even when directly asked)…. And here’s the thing – these nuanced conversation pieces were judged to contained vital health related cues that were never triggered by the doctor in the rest of the consultation. For example, in one consultation a patient discloses information  regarding who has knowledge of her HIV status – and the fact that a partner might not know, which was never relayed to the doctor.

These were issues that gave insight into the patient’s true agenda but weren’t brought out in direct conversation only these non-interpreted “asides”. The treating doctor was left none-the-wiser. Being qualitative there are no hard outcome measures – just developing of these themes…however, this is all interesting stuff because it gives us 2 useful insights:

  1. That we must beware of the translated consultation – we are missing the point!!
  2. History taking (even in your mother tongue) is more than just about asking textbook questions – patients are constantly giving us social cues and clinically important information from each and every aside…. We had better be listen carefully.

So next time you’re in a translated consultation and the patient and translator laugh at you… They probably are laughing at you… But be sure to ask why…

@tombartram

Croup: Riding the Dex Express

Sooooo….this paper turned up at JC last week (thanks to Nicola P) and whilst I’m not sure that it meets all three of our criteria for a top JC paper it is relevant as a week barely seems to go by without someone questioning the dose/route/brand/colour/size/ethnicity of medicine for croup.
Rule of thumb chaps and chapesses ‘The greater the dogma, the greater the ignorance’. Someone cleverer than I said that, but I’m happy to plagiarise ‘cos it’s true.
Anyway, Croup arrives as a question once again in the journal Emergency Medicine Australia, but this time the question relates to speed of onset in mild to moderate croup.

 STOP! If you are in exam mode at this point you should read the paper. See what you think about it and give it a mark out of 10.

We’ve talked about this paper and it’s a tricky one. The first question is why has this paper been done (which we cannot answer, but can surmise privately). The use of steroids in the management of croup is very well established and is something we led on here in Virchester many years ago. It was even one of the very first BETs back in 2004 (amazing to think that we are still talking about this 8 years later).
I’ve also seen the Cochrane review and even examined some CTRs for FCEM on the subject. So, it pretty much seems to me that the question of whether we give steroids for croup is well made. The research that remains is, I suppose, about refining and polishing what is surely a well established fact.

STEROIDS WORK IN CROUP Click the link and read the Cochrane review.

So, what about the paper this week? Is there anything we can draw from it and learn? Well, the authors have done an RCT (good) on mild/moderate croup patients. Interesting this as for the mild ones would you give steroids or just let nature take its course? (Ed – depends on how mild as croup score 1-3 is mild) I’m not sure so there maybe an element of over-treatment in comparison to other practices. Whatever, the authors tell us that there is an effect of giving steroids that they can define and detect at  30 minutes following administration of steroid and that this counteracts the information given through Cochrane about a delayed effect taking up to 6 hours.

I have major concerns with this paper and I just don’t see how this is going to make a significant difference to our practice in PEM.  I don’t think a paper like this would appear in an exam, but if it did I would be pulling holes in it along the following lines.

1. What is the clinically important question here? It seems that we are looking to see the speed of onset of steroid meds in mild/moderate croup. The clinical importance of this is perhaps unclear except in logistical (admission) terms. What defines a significant difference in this low acuity group? Mild croup is not admitted anyway so what is the issue we are addressing?

2. Sample size. OK. An interest of mine, and if you share that interest (you sad person) then hop over to the podcast to hear more about how to understand and interpret sample size calculations. In this paper they appear to be using tests for continuous data for data which is unlikely to be so. Honestly, it seems as though these are the wrong tests for this data, but there is insufficient information in the paper for us to tell. Where is the clue? Well, the Wesley croup score is a categorical score (at best ordinal). It’s not continuous and is unlikely to be normally distributed, so a t-test is rarely going to be the right test. So hmm, not enough information to know but questions are there to be asked. If you want to know more about stats for Critical Appraisal then click here and here. Apart from anything else, a study of just 70 patients would have to show a massive effect if it is be valid and I don’t see that here. Similarly the graph shows average scores only, and I’m not sure that I’m just interested in the change in average score amongst 35 patients. I want to see the distribution as well. This is a common problem in papers as the mean score reporting removes the depth and character of the data.

3. Right, so we are unsure of the validity of the question and also of the sample size what else? Well,  do applaud the authors for defining the numbers of patients that they ‘could’ have recruited and the difference between that number (828) and the number recruited (70) is huge. This suggests a degree of patient selection which may well affect the results. Now, I don’t want to put a massive downer on this as it is an inevitable problem with EM research, but this ratio really asks questions as to whether this is a representative sample, or whether the results will be heavily skewed because it is a sample of convenience.

So, it sounds as though we were pretty down on this paper from a methodological point of view. We gave it a 3/10 to be honest which is clearly not high, but just wait is there ANYTHING we can take away from this piece of work at all. Well, it’s tricky to be honest. It’s likely (but I’m finding it difficult to tell) that oral dex starts working fairly quickly, but that was never a clinical dilemma for me before I read this paper so I’m not going to change practice. However, it’s a useful to use this as a vehicle to discuss Croup (again), to review the relevant BETs and to talk about how to spot flaws in papers.

 bw

Simon C

PS. If you are still in exam mode try answering the following questions…

1. What is meant by the term ‘double-blinded’ and why is it important in a trial like this?

2. Four patients in the placebo group worsened during the initial phase of the trial and were then given steroids. They were analysed in the placebo group despite getting steroids. What is this type of analysis called and is it the right approach?

Journals are dead: Long live the Journal Club

“The report of my death was an exaggeration”

Mark Twain

Just a quicky and a link out to our guide on Emergency Medicine Journal Clubs. Despite the rumours of the imminent demise of all medical journals, we at @stemlyns strongly believe that this will not lead to the death of journal clubs. Even if paper publication wanes (and it probably will) it will be even more important for clinicians to have the skills and abilities to be wary of what ‘evidence’ is out there.

For example anyone can now set up a Blog (Er, not sure that’s the right message here – Ed) and say what they like. How do you know it’s fair comment and good enough to change practice?

You do need, and you will always need to be a sceptic with the skills to critically appraise and critique the evidence and we think that a Journal Club is a great way to learn.

Read more here on our top tips for making your Emergency Medicine Journal Club effective, productive and worthwhile.

Our Journal Club runs on a Friday lunchtime in the ED. We’ll review, debate and then blog on the papers we discuss. Watch the blog for the latest in EM Critical Appraisal.

vb

Simon C

PS: We’ll be keeping a log of papers reviewed in our Journal Club from now on. If it works then we should have a rolling program of the best, most current and most relevant papers for Emergency Medicine. If you’re coming up to an exam….it’s a good place to visit.

The Olympics and the ED physician

It’s a great week to be British. Bradley Wiggins wins the tour and we are just a few short days away from the greatest show on Earth – the Olympics I mean.

(Ed – don’t mention the Cricket, & don’t send this to any South Africans)

So, Virchester is hosting some of the Olympic events and as a result the local EDs have been put on standby to receive athletes and their support teams as patients. We have some experience in this as a few years ago the Commonwealth games were held here and it was interesting to think back to that time and reflect on how it affected us in the ED. Virchester also hosts many elite sporting teams so we are used to famous and/or talented sportsmen and women turning up on our doorstep.

Teams form the large, wealthy countries invariably bring their own team of healthcare staff with them ranging from docs to physios. It’s likely that most problems will be dealt with by these people and therefore they won’t come to you that often. If they do then the athlete/support staff are usually accompanied by one of their physicians. These are usually fairly easy consults as a result.

Athletes and staff from the less well off nations present different problems. They may not have their own supporting staff and as a result it is possible that they may end up in your ED. Now, LOCOG and other major sporting organisations put on fantastic facilities and teams of staff to deal with this issue, but still they may slip through the net. In previous events we have had all sorts of things turning up in the ED, from acute trauma, right through to long term health problems presenting to the ED for treatment (for conditions where treatment might be tricky to get back home).

So, despite the best laid plans, if you are near an Olympic venue you might get Olympic participants through the door. So, what are you going to do about it and where are the dilemmas? These are not the thoughts of a sports physician and I know that many ED docs know more about sports medicine than I do, rather what should we be thinking about as non-sports medicine experts faced with the prospect of high profile, high maintenance, high risk athletes turning up in our EDs over the next few weeks.

  • 1. Who should they see? This is the age old chestnut of how to manage VIPs in the ED. Should anyone be prioritised in terms of time or in the seniority of clinician who sees them? Rightly or wrongly I would suggest ensuring that elite athletes are reviewed by a senior physician. These are high risk (legally and clinically) patients and it makes sense to get the best opinion possible.
  • 2. Costs? All participants in the Olympics are entitled to free health care so there are no concerns here. The NHS committed to “Provide free comprehensive healthcare to Olympic and Paralympic family members throughout their stay for the Games whilst still providing healthcare for our local residents”. Treat them as NHS patients and don’t worry about it.
  • 3. Clinical Vigilance? This is a tricky concept for me to explain, but it’s something along the lines of balancing between delivering normal care (which should be the best you can) with an appreciation that sports medicine is different. It’s different clinically as there are a host of conditions that are sports specific, but also the psychological elements around the relationship between athlete, coach and physician (team and you). Complex factors such as the injury being made public, desire to compete, potential risk etc. may all be at play in the consultation and you may find it difficult to understand everything that’s going on. So close to an Olympics such conflicts are likely to rear their heads. I have found this aspect of treating athletes the most complex and difficult.
  • 4. Expertise? You’re a great emergency physician I know, but don’t step outside your comfort zone. By all means diagnose the undisplaced metacarpal fracture in the water polo player, but think long and hard before you advise them on whether they can play with it strapped up in 5 days time. I have been asked all sorts of stuff about prognosis, therapy etc. Remember that time to healing to sit behind a desk is somewhat different to time to be able to compete at elite level. Similarly, you don’t want to say something is OK to compete on if it then results in more serious injury. If you are going to give advice beyond your competency phone your medical protection organisation soon (see note below).
  • 5. Drugs? This is not about you detecting  the performance enhancing kind, but rather that little stock of drugs in the cupboard that might result in an athlete testing positive. The WADA (World Anti Doping Association) lists can be found here. I guess analgesics and B2 agonists are the areas where the typical ED doc might make an error. That could be rather embarrassing so best avoided.
  • 6. Refer appropriately. LOCOG has a number of health centres specifically for athletes. If in doubt give them a call they probably know more than you (and me). London 2012 Olympic Games Healthcare Guide – December 2011-1

So, hopefully everything will go swimmingly well (the Ozzy swimmers are in Virchester this week), and we won’t see any athletes or staff at all……., but somehow I don’t think so.

vb

Simon Carley
NB. Sports medicine and EM. I actually think they make really great bedfellows as much of what we do is transferable to the sporting arena. I once attended a Cricket match at Old Trafford when a chap collapsed in front of us. Within minutes there were 2 ED consultants, an ICU consultant, a Cardiology consultant and a Rheumatology consultant in attendance. We sorted the chap out and handed him over to the site doctor…..an SHO in pathology who’s domain knowledge was thankfully not required.