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?
I attended a recent study day, and one of the speakers was from the GMC. The GMC has numerous publications, and it can be challenging to keep up with all the guidance. We discussed 2 topics, one which I knew nothing about and thought I'd share.
Patients recording NHS staff in health and social care settings
Doctors' use of social media
This is an important guide to be aware of, as social media is increasingly becoming more and more part of our daily practice. The use of social media is not limited to Facebook! There are very few teams now that do not make use of a messaging app, and we should make sure we maintain patient confidentiality.
There are many new apps available marketing themselves as "NHS compliant", "GMC compliant" for communication use between clinical teams. They may well replace the bleep / referral system one day!
Have a look:
These may well be a better option than WhatsApp...
I started this morning innocently reading a recent blog post by the St Emlyn's Team with the intention of screening large numbers of recent blog posts as part of my weekly CPD update. Low and behold, it is 5pm and I am still stuck on this one post and topic: ATRIAL FIBRILLATION. I should have known reading something about AF would not be a simple task!
I am sure I am not the only person who feels a little overwhelmed from time to time when faced with decision making in the management of AF. I guess it is because it does not fit in a neat box of a single answer for every event.
I thought I would summarise a few key points I have reviewed today:
2. Aim of treatment
RATE CONTROL vs RHYTHM control
MEDICATIONS FOR RATE CONTROL
NICE: Offer a beta-blocker or a rate-limiting calcium-channel blocker (diltiazem [off-label use] or verapamil). The choice between a beta-blocker and a calcium-channel blocker will depend largely on the person's comorbidities.
IS TROPONIN NECESSARY FOR ALL ACUTE AF PATIENTS IN THE ED?
AF WITH WIDE QRS
A 78 year old man with history of Type 2 diabetes mellitus and hypertension presents to the emergency department with Right shoulder pain. The paramedics are concerned as they have found a Left bundle branch block on his ECG.
On arrival he appears to be in pain but he has a normal complexion and is not diaphoretic. His vital signs are:
HR 98, BP 145/80, RR 18, Sats 97% on air, temp 37.2
On further questioning his GP has been treating him conservatively for a pain in his right shoulder for the last month following its sudden development after “jolting” it whilst cleaning the car.
He has been otherwise well but the pain in his shoulder has been getting progressively worse and is now debilitating. It is worse with movement but he hasn’t noticed any change with exertion per se.
Examination reveals a clear chest, dual heart sounds with no murmurs and a soft non tender abdomen. Examination of the right shoulder reveals a fullness at the sterno-clavicular joint which is painful to palpation, this has been present since cleaning the car. There is no bony tenderness elsewhere. He has full range of movement of the shoulder but all range of motion is painful. His right limb is neuro-vascularly intact.
As part of the work up an ECG is undertaken which confirms a LBBB, serial troponin tests are negative and the Chest X-ray can be seen below:
With a keen eye you may notice the calcific deposit in a rotator cuff tendon above the greater tuberosity of the humerus concerning for calcific tendonitis, but did you notice anything abnormal about the clavicle?
On closer inspection the proximal half of the clavicle is missing.
A CT scan was conducted which demonstrated a soft tissue density mass overlying the medial aspect of the right clavicle which had been eroded with extension into the antero-superior mediastinum. The cause of this mass was a right lower lobe pulmonary primary tumour.
This initial Xray finding was sadly missed by the treating doctor and the reporting radiologist, and only when the patient returned due to increasing analgesia requirements a week later was it spotted. Although diagnosis at the first attendance wouldn't have changed the clinical course, admission for symptom control would have been beneficial; the patient required large doses of intravenous opiates to control his pain.
This case highlights many challenges in patient diagnostic strategies in todays busy emergency departments. Firstly there had been an emphasis on ruling out myocardial ischaemia as a cause of chest pain, and although this is clearly an important consideration it is also important to keep a broad differential when assessing patients in the emergency department. The harmful effects of cognitive bias and heuristics are important in emergency medicine especially when we are making quick decisions in a busy environment. Be aware of anchoring bias which occurs when the clinician prematurely settles on a diagnosis due to important initial features of the presentation and failing to adjust the diagnostic workup when new information is obtained. This can lead to diagnostic momentum bias which leads the clinician down a diagnostic path, failing to acknowledge other potential causes. In this case the potential for myocardial ischaemia as a cause of the chest pain was given a lot of weight due to the paramedics concern for ACS and the LBBB on ECG.
There was also an element of premature closure in this case as once the serial troponins were negative it was thought safe to send the patient home with analgesia and safety netting without consideration for whether there was another rare, life threatening cause.
When reviewing X-rays it is important to look at the whole image each time. When its busy we naturally rely on pattern recognition and probability of abnormality from the history and examination. Make sure you have a systematic approach to reviewing all X-rays to ensure that you don't miss rare and not so obvious findings.
This patient had a primary diagnosis of lung cancer presenting as a metastatic clavicular mass which is clearly very rare, but it is our job in the emergency department to be able to identify the “needle in the haystack”. Through keeping a broad differential, being aware of our potential cognitive biases and throughly assessing patients, blood tests and imaging methodically we will be less likely to miss these rare but important diagnoses and provide excellent clinical care.
For more information on Cognitive bias and heuristics please read:
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.....