I thought it prudent to give another academic update, given that there has been some big research news in terms of COVID-19 and other relevant emergency medicine studies in the last couple of weeks. If you want a general update on the state of play nationally with regards to emergency medicine research, some of the challenges we’ve faced and how the future might look, check out this recent podcast which is available via the RCEM Learning site:
I’ve mentioned the RECOVERY (Randomised Evaluation of COVid-19 thERapY) trial before. This is a large UK multicentre randomised controlled trial, led by researchers in Oxford, of possible treatments for patients admitted to hospital with COVID-19. Many of us have recruited patients to this study, which is still ongoing. As a reminder, the treatment arms are:
It has an unusual and novel adaptive design – so it changes as time goes on, and tests multiple interventions, with the ability to stop or start different treatments as the trial progresses. It makes traditional methodologists twitch. Outcome is all cause mortality at 28 days.
The first result published was hydroxychloroquine – which showed no benefit – and so that arm was discontinued. The second result, which resulted in a press release last week, was the dexamethasone arm. The pre-print of the full results paper is now available at:
They found that dexamethasone reduced deaths by one-third in patients receiving invasive mechanical ventilation (29.0% vs. 40.7%, RR 0.65 [95% CI 0.51 to 0.82]; p<0.001), and by one-fifth in patients receiving oxygen without invasive mechanical ventilation (21.5% vs. 25.0%, RR 0.80 [95% CI 0.70 to 0.92]; p=0.002). Impressive stuff from the UK medical research community, and a further illustration that academia is the new rock and roll.
More big news from an emergency medicine study that spanned half a decade in our emergency departments across the UK and indeed the world. Should we give TXA to patients with GI bleeds?
The results of the HALT-IT study have now been published:
The trial found that tranexamic acid does not reduce deaths from GI bleeding (mortality was 4% in both the intervention and control groups). Of note, it increased the risk of venous thromboembolic events (deep vein thrombosis or pulmonary embolism), although the absolute risk was low (0.8% versus 0.4%). Re-bleeding was similar in both groups.
So, an intervention that had crept into routine practice in my hospital, certainly among the admitting physicians looking after these patients because it felt like the right thing to do, is torpedoed by robust clinical evidence from a randomised controlled trial.
Stay safe and sane,
Jason Smith on behalf of the academic team
I was recently supposed to have been facilitating a session on vaginal bleeding as part of ACCS teaching so here is my attempt at a little bit of online education. Not my favourite subject on either a personal or professional level and don’t expect me to start speaking like a gynaecologist.
A little Covid humour to start:
Here goes. Everything an EM doctor needs to know on the glamorous topic of PV bleeding.
Keep it simple, stupid:
Question 1:Is the woman bleeding so heavily that they are showing signs of haemodynamic compromise? (Are they pale, ashen, sweaty? Peripherally shut down with a tachycardia? Hypotensive?). This is generally not a good sign and might make you feel a bit sweaty too. Take a deep breath, ask for some help and get the patient moved into resus.
Take another deep breath and start reciting the alphabet: A and B – pop some oxygen on, C – if you have always wanted to insert a MASSIVE cannula then now is your chance. Two would be even better. Be kind if time allows and use a little local anaesthetic. Take some bloods and send some for an urgent cross-match. If the patient is really unwell then consider activating the massive transfusion protocol and starting a balanced transfusion (PRBC, FFP, platelets).
Tranexamic acid is rarely a bad thing when people are bleeding a lot from any cause so think about it early.
If you are a bit handy with the ultrasound or can find someone who is then it is worth scanning the abdomen for free fluid (has the patient ruptured an ectopic?).
A gynaecologist is going to want to know about this patient sooner rather than later so get on the phone early.
The most likely cause of shock due to vaginal bleeding is a ruptured ectopic pregnancy in a pre-menopausal woman and fibroids in a post-menopausal woman.
Learning Bite: If the woman presents with signs of shock but with a BRADYCARDIA then you need to think about CERVICAL SHOCK. The patient will feel faint, sick and generally awful with hypotension and bradycardia. In the ED this is usually due to a miscarriage. It occurs when the products of conception pass through the cervix and cause a profound vagal response.
The only treatment is to remove the products. This is a relatively simple procedure. The cervix is visualised with a speculum and the products are gently removed with sponge forceps (see below). It is very gratifying thing to do as the woman will literally improve before your eyes. One of our own registrars did this recently with good effect. It is important to think about it as a possibility and as always ask for help.
Question 2: Is the woman pregnant?
In Emergency medicine the dogma is that we should suspect pregnancy in any woman between the ages of 10 and 50. In reality most women know or recognise the possibility that they might be pregnant so do ask the question first. Establish when their last period was. Ask about symptoms of early pregnancy (e.g. breast tenderness, tiredness, urinary frequency). Try and get a urine sample as quickly as possible.
If the pregnancy test is positive then the woman has a RUPTURED ECTOPIC until proven otherwise. Classically a ruptured pregnancy will present 6-8/52 after the woman’s last period. Pain is often more of a feature than bleeding.
If the patient is unstable then they will be managed as described above. If the patient is stable then the bottom line is that they need a trans-vaginal ultrasound as soon as possible. This can happen as an in-patient or an outpatient depending on degree of suspicion, extent of symptoms and confidence that the patient will adhere to safety netting precautions if they are allowed home. Please discuss this with a senior and then refer to the gynae team. Make sure they have had the relevant bloods sent first – don’t forget a group and save in case they deteriorate and a serum beta-HCG is helpful as a baseline for the gynae team (they may monitor this serially).
Clearly miscarriage is more common than an ectopic but is initially managed in the same way by us in the ED.
PV bleeding in late pregnancy obviously has an entirely different differential including placental abruption, placenta previa, uterine rupture and labour. It is very rare to see such patients in our ED as they usually present to labour ward. If they do appear unexpectedly resuscitate as above and seek specialist help EARLY.
Question 3: Is the woman pre or post-menopausal?
Any woman with post-menopausal bleeding has cancer until proven otherwise. At the time of writing we don’t have access to the 2WW pathways so the patient will need a letter or phone call to their GP to get this sorted.
We are now left with a pre-menopausal patient who isn’t haemodynamically compromised and isn’t pregnant. Breath. You now have time to take a bit more of a history!
Questions that will help you elucidate what is going on:
So, what can we do in ED? (assuming as always that the patient is not in need of resuscitation)
References and Further Learning
1. NICE guidance on ectopic pregnancy and miscarriage:
2. RCOG guidance on diagnosis and management of ectopic pregnancy:
3. NICE guidance on heavy PV bleeding:
4. RCEM learning module on bleeding in pregnancy:
As summer appears to have landed, all thoughts of coughs and fevers are surely receding into the background as we queue for our takeaway fish and chips. However, I thought it might be time for an academic update, to remind you that the evidence base around COVID-19 is ever-increasing, and of course there is also a raft of other emergency medicine research worthy of a mention.
“Truth: a fact or belief that is accepted as true.”
There is a danger in COVID times that we forget our evidence-based principles and assume that tests that we do for COVID-19 will give us a true answer. More in hope than expectation perhaps. We all know how to assess the performance of a diagnostic test, but of course that depends on how it compares with the gold standard for that disease. This is obviously more difficult to achieve with a new disease, where we don’t have a gold standard, or where the new test forms part of the gold standard. A recent paper in the BMJ also reminds us that the performance of diagnostic tests depends on the population in which the test is applied, and importantly the pre-test probability:
This is well worth a read, and illustrates in clear terms the impact on those who may have false negative tests, and their ongoing probability of having the disease.
In addition, for those interested in exploring in more detail how we might define a better gold standard for the diagnosis, those clever people in the centre for evidence-based medicine in Oxford, in collaboration with our own Rick Body from Manchester, have developed a composite reference standard:
Hopefully this will be utilised as a standard in future clinical trials of diagnostic accuracy.
In amongst the flurry of COVID-19 activity, you may not have noticed that the LoDED (Level of Detection of troponin in the ED) study results have been published recently in the journal Heart.This may be the signal of a paradigm shift in the way we deal with patients with chest pain in UK emergency departments, and is well worth a read:
This was an emergency medicine-led multi-centre randomised controlled trial of the clinical effectiveness of an early rule out strategy for patients with low risk chest pain, involving early discharge after a single hs-cTn test when the result was below the limit of detection. The good news is that none of the patients who were discharged using this strategy had a major adverse cardiac event within 30 days. In the words of the authors, the LoDED strategy might facilitate safe early discharge in >40% of patients with chest pain.
Given that there is a national initiative to get us to walk and cycle everywhere to avoid public transport, should we be cycling to work? Yes, is the answer, but don’t crash your bike:
In this UK population-based study, the authors tried to determine whether bicycle commuting is associated with increased risk of injury and whether the health benefits of commuting outweigh the risk with a follow up of 10 years. They compared active and non-active mode of transport in more than 230,000 commuters. 2.5% of the cohort reported cycling as their main form of commuter transport. The study results suggest that commuting by bike is associated with a 45% higher risk of admission to hospital and a 3.4-fold higher risk of a transport-related injury.
However, if 1000 participants changed their commute to include cycling for 10 years and associations were causal, it would result in 23 more admissions to hospital (of less than a week) for first injury and three more admissions for a week or more. On the plus side, there would be 15 fewer first cancer diagnoses, four fewer cardiovascular events and three fewer deaths.
Stay safe and sane,
Jason Smith on behalf of the academic team
I hope you are all looking after yourselves in these challenging times. If, like me, you signed up for the RCEM Wellbeing app to help, but then didn’t do anything else about it because you got distracted, you will be receiving weekly emails telling you that you’ve achieved 0 out of 7 domains of wellbeing.
So, the big news this week is that we’ve found a cure for COVID-19 (if you believe the hype).. and I’m not talking about injecting disinfectant. Remdesivir is an anti-viral agent which has shown some early promise in laboratory studies, and is the subject of large randomised controlled clinical trials in China, the USA and the UK (as part of the RECOVERY trial previously mentioned). The study from China has now been reported in the Lancet, and the media coverage surrounding this has been considerable (a British understatement):
However, when I read the paper, I thought I must be reading the wrong one. This is a negative study, that was stopped early, was underpowered, and showed no significant difference in time to clinical improvement or mortality. I try not to conflate my academic leanings with politics or money, and I will therefore avoid suggesting alternative reasons for the hype over this drug and the findings of this initial study, including US presidential endorsement, but they are not based on clinical evidence. I am very prepared to alter my opinion if new evidence is published, but based on what is out there at the moment, this is much ado about nothing.
In general, if patients are sick, we know what to do; if patients are well, we also know what to do. But what about those who appear well at first, but who might deteriorate and make us look bad by coming back a lot worse a day or two down the line. We could all make use of a simple test to detect those patients who initially look ok but probably aren’t. If you have been monitoring the outputs from our Italian colleagues in particular, you may have heard of the 40 step test (or the Italian step test as the Italians have called it). This has been suggested as a useful discriminator for those patients who, if they desaturate on exertion, perhaps might be in a group that need a closer look, and potentially supplemental oxygen treatment. Older colleagues may remember a similar clinical test being employed to investigate those with pneumocystis pneumonia, common in the immunocompromised before effective treatment for HIV was available.
Helpfully, our colleagues at the Centre for Evidence Based Medicine in Oxford have produced a short cut review on the efficacy and safety of rapid exercise tests for exertional desaturation:
They’ve looked at both the 40 step test and the 1 minute sit to stand test (which is validated in patients with other conditions such as interstitial lung disease), and found that although these tests have not been validated in patients with COVID-19, they may have a role in adding to the clinical judgement of such patients. We have certainly added it to our armoury in Plymouth.
I have my own views about giving pain relief to our emergency patients (in a nutshell, we can do better) but I’ve been keeping a watching brief on articles about chronic prescription opioid use in the USA; I often wonder why this is not more of a problem in the UK. Some try to blame emergency department prescribers for this crisis in the US, by linking emergency department opiate prescriptions to long term opioid use, but I have yet to see convincing evidence that this is the case, certainly in the UK. More evidence to put in the melting pot is published in this month’s issue of Annals of Emergency Medicine:
I suspect this is a complex area which has as much to do with socio-economic factors as it does with what your ED sends you home with after you’ve broken your ankle, but in general terms, it is up to all of us to rationalise our analgesia advice and prescribing to avoid harming patients in the longer term.
Brigadier Tim Hodgetts is the head of the Army Medical Services and an emergency physician by background. He has published a BMJ blog outlining the elements of clinical leadership required to run a field hospital, with a summary of TEPID COIL (a military acronym outlining the key elements required for success) and how it might apply to a Nightingale facility. Well worth a look:
Brigadier Tim taught me a lesson about leadership and change management when I was a registrar at Frimley Park Hospital in the late 1990s. He was improving trauma care in the hospital at the time. He attended every trauma call, day or night, seven days a week to make it happen.
Stay safe and sane,
Jason Smith on behalf of the academic team
As I didn’t get any bottles thrown at me for my first academic update, I thought I might try a second. Do let me know if you have any suggestions for improvement or other topics that you think should be covered.
The papers are coming thick and fast, but still the quality of evidence is limited. I promised to keep an eye out for certain things; one of these is the coagulopathy and risk of thromboembolic disease associated with COVID-19, and specifically whether we should be targeting this with therapeutic rather than prophylactic anticoagulation. The short answer is that no-one yet knows – but there is a comprehensive 66-page review written by the international great and good in JACC if you want the long version:
The clinical bottom line is that if you are admitting someone to hospital with any significant illness, including COVID-19, they should be risk assessed and considered for weight-based prophylaxis to avoid the complications of thromboembolism. But then we knew that already..
What about potential treatment options for our patients with COVID-19? Self-proningis not a term I’d come across before this pandemic, but I have come across the concept while lying on a sun lounger beside a pool reading a book. I think the emergency medicine term for this is ‘lying on your front’. However, the idea really appeals to me because it’s free, almost anyone can do it, and if it helps our patients with COVID-19, then we are potentially onto a winner.
The majority of previous evidence related to proning is in intubated patients with ARDS in the ICU. This article, published a few days ago, is one of the first descriptions of proning in awake patients in the ED:
The rationale is clear, and in this series from New York a convenience sample of 50 hypoxic patients with suspected COVID-19 were recruited in the ED and underwent proning – which almost universally improved their oxygenation (the primary outcome). These were sick patients, 13 of whom ended up being intubated, but if there is a potential to avoid escalation in a group of our COVID-19 patients then we should be exploring this. Hopefully there will be more evidence to come on this topic, and in particular the potential risks associated with the technique, which haven’t been fully explored.
Exciting times for the research community involved in COVID-19 trials. The latest one that caught my eye is the proposed convalescent plasma study being coordinated by NHSBT – you may remember that in the dark days of the Ebola crisis a similar treatment was proposed and investigated. Further details can be found at:
Bottom line – if you have had COVID-19, we need your plasma to run this clinical trial.
If you are interested in academic emergency medicine and what the future holds, you might want to take a look at this editorial in the EMJ, which I hope persuades you that the future is bright, but we all have a part to play.
Another article that caught my eye in the EMJ was this paper encompassing a review and exploratory trial of methods of removing glue from the eyelids. It’s embarrassing when it happens but if you have an idea of how to manage it, then hopefully the angst around the situation can be reduced.
An interesting take on whether we as healthcare workers are more at risk of contracting COVID-19 than our neighbours is included in this episode of ‘More or Less’ from BBC Radio 4. It also includes an explanation of the infographic used to explain social isolation
Finally, given my academic role, I will always encourage you to read high quality research articles, and apply the principles of critical appraisal to what you read. In these strange times, however, I would urge you all to read a non-evidence based book, “The Boy, the Mole, the Fox and the Horse” by Charlie Mackesy; a fable for our times, equally relevant to young and old. In the words of the horse, “Everyone is a bit scared”, “But we are less scared together.”
Stay safe and sane,
Jason Smith on behalf of the academic team
These are extraordinary times. In the medical literature, fast-tracked articles relating to COVID-19 are appearing in journals on a daily basis, and I for one am finding it difficult to keep up, and to sort the wheat from the chaff.
We thought it might be useful to provide an occasional update on the evidence related to COVID-19, as well as a reminder that there is still a clinical world outside febrile respiratory illness, and a pointer towards other non-clinical articles that might be of interest. In other words, to act as a filter and sanity check.
The main issue at the moment is that although evidence is emerging in front of us, we are in danger of drawing conclusions from incomplete or poor-quality data. We are all trained in critical appraisal and now, more than ever, is the time to use those skills. Some of the articles related to COVID-19 that are being published in the most prestigious medical journals are.. less than high quality evidence (a British understatement).
One COVID-19 article that might be of interest, but (spoiler alert) doesn’t give us all the answers, is by Wynants et al, published recently in the BMJ. It can be found at https://www.bmj.com/content/bmj/369/bmj.m1328.full.pdf
This is a systematic review and critical appraisal of prediction models for the diagnosis and prognosis of COVID-19. After all, it would be great to know who has the disease, who needs to be admitted, and of those, who is going to need critical care support and who might be suitable for a more accelerated ambulatory pathway.
It is worth a look, and it elegantly collects and summarises a lot of references in one place, but as it points out, “proposed models are poorly reported, at high risk of bias, and their reported performance is probably optimistic” – so more work to be done.
Hot topics that I will keep a watching brief on are (in no particular order):
It is worth noting that there are a few clinical studies starting up in the UK which you may become involved with in your hospitals if not already. One to highlight is the PRIEST (Pandemic Respiratory Infection Emergency System Triage) study - which was the PAINTED study, but it had to change its name as coronavirus isn’t spelled the same as influenza - this is an observational cohort study collecting data on potential and confirmed COVID-19 patients. It hopes to identify the most accurate method of predicting severe illness among patients who attend the ED with suspected COVID-19.
Another to highlight is the RECOVERY trial, which is a multi-centre RCT of multiple potential treatments for COVID-19, including lopinavir-ritonavir; low-dose dexamethasone; hydroxychloroquine; and azithromycin – more details can be found at https://www.recoverytrial.net.
Other non-COVID clinical evidence
I don’t know about you, but pregnant women who present with breathlessness or pleuritic pain always make me pause for thought before deciding on the best management strategy. This is an area where this is constantly evolving evidence. You may, for example, have seen recent European Society for Cardiology and European Respiratory Society guidelines suggesting that a combination of clinical probability assessment and D-dimer result could rule out PE in pregnancy. You may want to think again if you read Steve Goodacre’s paper in the EMJ (https://emj.bmj.com/content/early/2020/04/09/emermed-2019-209213). This is a secondary analysis of his DiPEP study data, and the conclusions are that some patients with PE would have been missed using this strategy, although the clinical significance of this is not clear. Listen to this man and read his work – he may not inhabit social media, but he is a Jedi.
Non-clinical article to read
You might want to take a look at the attached commentary from Chatham House on some of the biases and limitations of the complex modelling that sits at the very heart of our reality currently; https://www.chathamhouse.org/expert/comment/predictions-and-policymaking-complex-modelling-beyond-covid-19
Thank you for reading to the end. If this has been useful or interesting, let us know. If not, you know how to use the delete button.
Stay safe and sane,
Jason Smith on behalf of the academic team
2020 04 16
As a result of the extraordinary rota changes required to provide resilience during the COVID pandemic, unfortunately teaching has been cancelled this month. I didn't want you to miss out though! So here is a collated list of resources which will cover these curriculum elements for your delectation and delight.
Skin appearance in meningococcal disease
I'm not going to teach you to suck eggs here...
There are multiple resources available for meningococcal sepsis, but here are a couple you could complete for CPD/link to your portfolio.
Drug reactions involving the skin
There is an excellent BMJ Best Practice article covering this topic, if you don't have a personal log in you can access via OpenAthens.
And BMJ Best Practice for this one.
Rashes in kids
There is a NICE Clinical Knowledge summary available here.
Again, I found this US public facing website provided a good basic overview of this condition.
This is a UK based dermatology website for primary care, and therefore handy for EM dealing with primary care type presentations.
Bites & infestations
Presented by Molly Jones, ENT PA
Painful ear conditions
Outer ear infections (otitis externa): infection of the ear canal, mostly bacterial but can be due to fungus or yeast. More common in swimmers. Present with pain (pre/post auricular), dizziness, hearing loss and discharge. If canal too swollen may need wick. Best treatment is aural toilet and topical steroid drops. Note - may well have mastoid tenderness but does not need mastoiditis.
Necrotising otitis externa is a chronic osteomyelitis of the ear canal is typically seen in diabetic/immunocompromised, elderly, overweight. Requires long course of IV abx.
Middle ear infections (otitis media): most common is acute otitis media, often presents with otalgia and high fever in children. Rupture of tympanic membrane results in relief of otalgia. Mostly viral. Needs urgent ENT involvement if any facial weakness. May progress to mastoiditis.
Mastoiditis: infection of the mastoid one, most common in toddlers. Requires IV abs and sometimes surgical intervention. Patient will be unwell with boggy, posterior auricular swelling, protruding pinna and loss of sulcus. Needs urgent ENT referral.
Inner ear infections: less common, usually viral, and can cause sudden hearing loss and dizziness
Cerumen (ear wax) impaction: Shouldn't require emergency intervention. Otax ear drops and olive oil.
Eardrum perforation: caused by infection or injury. Traumatic perforation may be caused by insertion of objects into the ear canal or direct impact to side of head, also sudden negative pressure. Will usually heal itself in about 6 weeks. Advised to see GP for examination in 6-8 weeks and if still present refer to ENT. Advise to keep dry for this period. May need surgical repair.
Cholesteatoma: a cyst or sac of skin that is growing backwards behind the ear drum into the middle ear and mastoid. Appears as small pearlescent object behind the tympanic membrane. Results in chronic, smelly discharge, and may cause damage to structures by erosion through local structures -> neurological features. May present acutely with pain/discharge. Require ENT referral as may need surgical excision.
Pinna cellulitis: Can be secondary to otitis externa. Presents with hot, swollen ear that may spread down to the cheek. Managed with aural toilet and antibiotics (flucloxacillin, oral may be sufficient).
Perichondritis: Infection of the cartilage in the ear. Involves the pinna and does not spread to the lobe. Managed with IV abx (tazocin). There is also a relapsing/remitting condition which is non-infective.
Pinna haematoma: Blood collects in the perichondrium after trauma. Requires drainage (aspiration or incision) to prevent avascular necrosis of the perichondrium, and compression dressings. May lead to longstanding deformity. Refer to ENT.
Pinna laceration: vary in degree, need good washout and closure. Consider regional block.
Other ear conditions
Surfers ear: bony exostoses within ear canal
Foreign body removal
Button battery: immediate ENT involvement
Organic material: urgent removal
Insects: if still alive, drown them with warm water
Inorganic material: if sharp then more urgent, smooth can be done routinely
Embedded earring: may need GA if child distressed or non-compliant.
Children should have as few attempts to remove as possible. If save to wait then review in SHO clinic probably best.
Post grommet insertion: blood/discharge from ear. May need drops (cipro) if infection but normally settles. ENT should be informed
Post major ear surgery: Will have posterior auricular wound and often the external auditory meatus with be packed with ribbon gauze and plugged with cotton wool at the entrance. Do not remove the packs, call ENT.
Sudden onset hearing loss (24 hours - 1 week)
May present to ED but usually referred directly by GP. Not usually painful.
Rule out infection, cerumen impaction or other blockage
Tuning fork tests, check ear for vesicles, check for CN VII palsy (i.e. Ramsay Hunt)
Sudden onset sensorineural hearing loss, needs treatment with steroids +/- acyclovir and ENT review
Learning opportunities - email Molly!
I came across this gem of a talk by Cliff Reid (resus.me), and thought it is too valuable not to share.
Spend 15 minutes watching this video, I promise you will not be disappointed.
This 6 year old girl presented to a local MIU complaining of a sore forearm after falling off a climbing frame. It was difficult to elicit the site of maximal tenderness and the following X-ray was performed:
What does the X-ray show and how would you manage it?
The Derrifoam Blog
Welcome to the Derrifoam blog - interesting pictures, numbers, pitfalls and learning points from the last few weeks. Qualityish CPD made quick and easy.....