This document contains my personal notes from the sessions I attended. A few were written up in more detail for the Bangor Conference Report; at the time of writing the full report is still in preparation. When available it will be a more comprehensive document and well worth checking out.
Two comments from the opening session. ST4 recruitment appears to be up about 50% this year after struggling for some time; the College is trying to raise awareness of exit block and its dangers, trying to get trusts to work to reduce it. The video is here.
Professor Jonathan Benger is the National Clinical Director for Urgent Care, NHS England as well as a Consultant in Emergency Medicine in Bristol. He presented an overview of some of the current challenges facing urgent care, and the work underway to address these and reconfigure the system. Some of the conclusions from the data may be (and in other sessions were) challenged; but the session offered a look at how policy is currently being shaped.
On a poll of those in the room, 63% thought that the state of Emergency Care in the UK was getting worse. Politicians were the preferred option to blame for the increasing pressure on the system, with 52% of the room selecting them as most responsible, although GPs, 111, and patients also had some votes against them.
General Practice is heading towards a recruitment crisis of its own, and may be the next major workplace challenge after Emergency Medicine. It was pointed out that reduced access to GPs correlated with increased Emergency Department use by a population – while there may be system issues, the access to a good GP helps to reduce the chance of admission.
Recent figures for the 111 service were presented. About 10% of calls end in a transfer to the 999 system; 7% are advised to attend ED; 64% go to GP or community care. However, the large number of calls received ensures that the 17% that enter the Emergency Care system are a small proportion but still a large number of patients.
While there have been large annual increases in ED attendance since the change in the GP contract in 2004, much of this has been driven by walk in centres. The increase in attendance at type 1 and 2 departments has been slower, and early indications are that it has flattened out from 2012/13 to 2013/14. It was noted that this is a national average, and contains within it a lot of variation between individual centres.
Alongside this rise, there has been a steady rise in emergency ambulance calls and emergency admissions, but the big change that has caused problems with exit block is the reduction in available acute beds. In 1988 there were close to 300 000; by 2013 less than 150 000 remained. While reducing admissions and length of stay was described as an important goal, it was maintained that the only safe way to do this was to reduce the average (and peak) occupancy, and only when this was reliably achieved to close beds – demand reduction should drive the bed reduction, not attempting to make this work the other way round.
The philosophy is to ensure that the right care is given at the right place, by those with the right skills, the first time a patient accesses care.
Ed Gold is an ED Consultant and HEMS doctor with the East Anglian Air Ambulance. To judge purely by Twitter, apnoeic oxygenation is the standard of care, but I’ve personally not seen it in routine use so was looking forward to hearing a UK proponent of the technique.
The underpinning physiology is not new – it has been recognised for over a century, and is routinely used in (among other areas) testing for brain stem death. More recently is has been gaining ground as one of a collection of measures to delay critical desaturation during intubation of critically ill patients. The aim is to ‘keep off the slope of doom’ – it takes a while for oxygen saturations to drop to 90%, but once there further desaturation to critical levels occurs rapidly.
During apnoea, around 250ml of oxygenation passes from the alveoli to the blood each minute while only 20ml of carbon dioxide passes the other way. Provided an open airway is maintained, this generates a constant flow of fresh gas into the lungs, independent of breathing. If high flow oxygen is also administered via nasal cannulae, a high oxygen concentration will be maintained in the pharynx, and will greatly delay desaturation. CO2 will accumulate but the typical rise is 1.5kPa in the first minute and 0.5kPa/minute thereafter – in the short term this is not a major issue.
Nasal oxygen is also of use during preoxygenation. As most of the oxygen reservoir is in the lung, not the circulation, the aim is to completely fill the Functional Residual Capacity (FRC) with oxygen. At the same time we want to overcome shunt, and this is where PEEP valves help a little – but by definition (‘End Expiratory’) these add no pressure during inspiration or apnoea. CPAP (Continuous Positive Airway Pressure) is needed – and with the addition of a constant oxygen flow via the nose, a PEEP valve on your BVM can maintain 8cmH2O of pressure throughout the respiratory cycle, optimising pre-oxygenation. As a note of caution, don’t overdo the PEEP – excessive pressure can impair the circulation, causing reduced capillary flow and oxygen uptake locally, and decreased venous return to the heart and systemic haemodynamic effects.
In healthy volunteers undergoing elective surgery, these techniques have maintained SpO2 above 90% for more than half an hour(!) – the hypercatabolic resus patient may not manage that, but will still do better than they would otherwise, buying time to intubate and secure the airway.
We are used to thinking about intubation as the procedure, and pre-oxygenation part of the preparation. Another recommendation is to consider pre-oxygenation a procedure in its own right, and as for any vital procedure in a distressed or agitated patient, sedating them to permit effective pre-oxygenation is a valid option. The use of 1-2mg/kg of ketamine by slow IV push will dissociate the patient enough to allow pre-oxygenation while maintaining their airway reflexes and respiratory drive.
Lastly a note on children. They have an oxygen requirement approximately double that of adults, a fixed tidal volume (so are dependent on increasing respiratory rate to increase uptake), fatigue easily, and have a small FRC (and so desaturate rapidly). As a result any advantage to delay desaturation is vital – and 10L/min of nasal oxygenation will generate 5cmH2O of CPAP to support pre-oxygenation and maintain it.
Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Ann Emerg Med. 2012; 59(3):165-175 (Free fulltext)
(Came in towards the end of this session so only a few notes)
Feeling of ‘no news is good news’. Feedback rarely given, and when it is tends to be about errors.
‘Inherited decisions’ – getting caught between what the boss wants and policy.
Assessment as tick box exercise. Needs to include meaningful discussion. Move to SLE from WPBA nice idea, but forms virtually identical – no real change.
Kevin Mackway-Jones is Professor of Emergency Medicine at Manchester Metropolitan University, Consultant in Emergency Medicine at Manchester, and co-created the ‘BestBETS’ concept. Utilising the collective knowledge and opinions of the growing number of UK Professors in Emergency Medicine (and apologising to the anonymous recent appointee he didn’t know about at the time) he presented the top ten (eight) papers relevant to our speciality from 2013.
Kevin started by explaining his methodology. Using an accelerated two-round Delphi process, where participants were asked to nominate their personal top five papers, then vote for their preferred ten from the list produced, a selection of papers was produced, containing some predictable entries, and one or two surprises.
Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest (TTM Trial Investigators, NEJM)
Cooling after VF arrest is the standard of care – so it was something of a surprise that this trial showed that 33°C was no better than 36°C. Three times as many patients were recruited as were included in the original trials that were considered influential enough to change practice, so is it time to abandon cooling?
Probably not – both groups had active cooling techniques used, and it appears that avoiding pyrexia is probably the key. The target may change, but active temperature management is likely to stay with us.
Resus Council statement
Mechanical Chest Compressions and Simultaneous Defibrillation vs Conventional Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest: The LINC Randomized Trial (Rubertsson et al., JAMA)
2589 patients with out of hospital cardiac arrest were randomised to mechanical CPR with a LUCAS device and defibrillation with ongoing compressions, or standard CPR performed by the ambulance crew. Patients were followed up for six months, with survival and the Cerebral Performance Score recorded at four hours, ITU discharge, hospital discharge, one month, and six months.There was no significant difference found in survival or favourable outcome (CPC 1 or 2) between the groups at any time point. Most of those who survived to six months did so with a good neurological recovery. However the study was powered for superiority not equivalence; there could still be a 3% difference favouring either method.
The interpretation of the results varied dramatically between professors – comments included ‘Great! I don’t have to spend money on them!’ and ‘No problem with continuing to introduce them in our [ambulance] service.’ Apparently even a clear result doesn’t necessarily always influence practice in the same way.
Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial (3Mg research team, Lancet)
1109 adult patients with severe (but not life-threatening) asthma were randomised to 2g IV magnesium, three 500mg nebulised doses, or placebo. The power calculation indicated 1200 were needed, but a lack of funding led to an early end for the study.
IV magnesium showed a non-significant trend towards reducing hospital admission and subjective breathlessness. Nebulised doses made no difference. The authors conclude that nebulised magnesium has no role in managing acute severe asthma, and IV magnesium has a limited role at best.
The question of whether magnesium via either route has a place in treating patients with life-threatening asthma is still to be answered.
A Randomized Trial of Protocol-Based Care for Early Septic Shock (ProCESS Investigators, NEJM)
The recognition and management of sepsis is recognised as an important part of emergency care. The reduction in mortality with early goal directed therapy was startling, and there are major trials underway to replicate these findings. PROCESS is the first of these to publish, and holds both a surprise and a reassurance.
1341 patients were randomised to standard care, EGDT, or protocolised care without routine use of central line or inotropes. There was no significant difference in mortality at 60 days, 90 days, or one year. The reassuring result was that overall mortality was around 20% - far lower than in the original Rivers study. Hopefully this means we have gotten better at recognising and treating these patients, regardless of what protocol is followed.
Effect of Emergency Department Crowding on Outcomes of Admitted Patients (Sun et al., Annals of Emergency Medicine)
Retrospective study of acute hospitals in California. The model of care isn’t identical to the UK, but the findings were stark. 995379 ED attendances were in the dataset. Patients admitted to hospital on days when the ED was crowded had 5% greater odds of inpatient death, 0.8% longer hospital length of stay, and 1% greater cost of care.
The study highlights just why the College campaign to address exit block is so vital.
College video on exit block
Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism: The ADJUST-PE Study (Righini et al., JAMA)
D-dimer tends to increase with age; this study aimed to find a reliable way of increasing the cut-off level with age to improve the specificity of the test for ruling out pulmonary embolism.
With 3346 patients recreuited and PE prevalence of 19%, they found that an age-adjusted cut-off (10 x age, measured in µg/L) would permit 29.7% of patients with low Wells score to have PE ruled out without CT, compared to 6.4% using the standard cut-off level.
MAGNEsium Trial In Children (MAGNETIC): a randomised, placebo controlled trial and economic evaluation of nebulised magnesium sulphate in acute severe asthma in children (Powell et al., Health Technol Assess)
Another paper looking at nebulised magnesium in severe asthma, this time in children. The results were published in the Lancet, but this paper also included an economic evaluation. 508 children were randomised to standard care with three salbutamol and ipratropium nebulisers at twenty minute intervals, or the same nebulisers with the addition of 151mg of nebulised magnesium.
There was no overall benefit seen, but subgroup analysis of the most severe cases and those with duration under six hours did show a benefit. At the £20000 per QALY gained threshold, magnesium was calculated to have a 60% chance of being cost effective.
Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomised controlled trial (Bateman et al., Lancet)
Patients needing treatment for paracetamol overdose were randomised to the standard NAC regime or a modified 12 hour infusion (with or without Ondansetron pre-treatment). Total dose was the same, but the maximum infusion rate was 50mg/kg/hour.
There were significant reductions in the incidence of vomiting, anaphylactod reactions, and need for pauses in treatment with the modified group. The proportion of patients with >50% rise in ALT did not significantly differ between groups.
While this is promising, it was noted that the trial was not powered to detect non-inferiority of efficacy – so while no significant difference was found, it’s not yet certain that the modified protocol works as well.
It was noted that four of the top five papers were essentially negative – they showed no benefit to previously used treatments – but the investigation of conventional wisdom is clearly just as important as investigating new ground.
A lot of work put in by College ahead of time seems to have paid off. Total of 25 queries to office - compare RCGP with 5 queries a day!
Patient/public surveys still under debate. Existing tools do not work well for Emergency Medicine (or anaesthetics, and others). Note dearth of evidence to show validity of any tool for this purpose.
James Hickman (OBE for his efforts!) on the M5 crash, November 2011
Tony Hudson on the Exeter bomber, 2008
John Heyworth on medical cover at Glastonbury
Dr Lennard Funk is a Consultant shoulder surgeon from Wrightington. He thoroughly debunked all the orthopaedic stereotypes with an engaging talk about common shoulder injuries that present to the ED on a regular basis, with advice on the immediate management and longer-term assessment.
Proximal Humerus Fractures
This section was removed from the talk to allow more time on the other topics. He did offer a brief summary of how to appropriately manage these patients in the ED – ‘Put them in a sling and send them to the should clinic’ covers almost all scenarios safely!
Starting with two pleas:
Surgical and conservative approaches both have their place. The aim is to achieve union for better function and less pain. Early union is less likely in displaced or comminuted fractures, and more likely in younger, male patients. Mid-shaft fractures do better than those in the lateral third. A calculator is available based on work by Robinson et al. that will give the likelihood of persisting non-union at 6, 12, and 24 weeks; this is useful to discuss options and agree a plan with each patient. Early rigid fixation is the best option for many of these patients – while the decision might not be made in the ED, it may help us to discuss what is likely to happen to them in the future.
Acromioclavicular joint injuries
Grading systems are not particularly helpful with these injuries. X-rays should be done but have limited sensitivity and specificity. Clinical judgement is more important, and the key question to ask is ‘how is this patient coping with the injury?’
Leaving aside open injuries and neurovascular deficits, the vast majority can be treated with broad arm sling and analgesia, then reviewed at three weeks and three months. Those that are improving and coping well can be left alone; those that are struggling (more likely in athletes and those who do a lot of overhead work) can be offered surgical repair. Repair has a relatively high complication rate, so is rarely the preferred early option.
Differentiate the first time, high energy dislocation from the frequent recurrence, low or no trauma patient. There are many described techniques to reduce the former – most have a success rate between 80 and 100%, with little to choose between them. Earlier reduction is better for reducing pain.
Chronic, recurrent dislocations can be difficult to manage, and reduction is less of a priority as many will have unstable, hyperlax joints. Indeed it may be appropriate to discharge them with the shoulder dislocated for outpatient review by a shoulder specialist. Previous records, physiotherapy, and discussion with a shoulder surgeon are also useful in decision making.
Links and references
Shoulderdoc.co.uk – Wealth of information from Dr Funk and colleagues, for patients and clinicians.
Robinson’s prognostic index calculator, based on Robinson et al., Estimating the Risk of Nonunion Following Nonoperative Treatment of a Clavicular Fracture, J Bone Joint Surg Am. 2004 Jul;86-A(7):1359-65.