Editor’s note: Hong Kong Journal of Emergency Medicine has partnered with a small group of selected journals of international emergency medicine societies to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of our readership to research developments in the international emergency medicine literature, promote collaboration among the selected international emergency medicine journals, and support the improvement of emergency medicine world-wide, as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health. Abstracts are reproduced as published in the respective participating journals, and are not peer reviewed or edited by Hong Kong Journal of Emergency Medicine.
Poor adherence to Tranexamic acid guidelines for adult, injured patients presenting to a district, public, South African hospital
Wiese JGG, Van Hoving DJ, Hunter L, Lahri S and Bruijns SR
Wiese et al. Afr J Emerg Med 2017;7(2):63–67
Introduction: In South Africa’s high injury prevalent setting, it is imperative that injury mortality is kept to a minimum. The CRASH-2 trial showed that Tranexamic acid (TXA) in severe injury reduces mortality. Implementation of this into injury protocols has been slow despite the evidence. The 2013 Western Cape Emergency Medicine Guidelines adopted the use of TXA. This study aims to describe compliance.
Methods: A retrospective study of TXA use in adult injury patients presenting to Khayelitsha Hospital was done. A sample of 301 patients was randomly selected from Khayelitsha’s resuscitation database and data were supplemented through chart review. The primary endpoint was compliance with local guidance: systolic blood pressure <90 or heart rate >110 or a significant risk of haemorrhage. Injury Severity Score (ISS) was used as a proxy for the latter. ISS >16 was interpreted as high risk of haemorrhage and ISS <8 as low risk. Linear regression and Fischer’s Exact test were used to explore assumptions.
Results: Overall compliance was 58% (172 of 295). For those without an indication, this was 96% (172 of 180). Of the 115 patients who had an indication, only eight (18%) received the first dose of TXA and none received a follow-up infusion. Compliance with the protocol was significantly better if an indication for TXA did not exist, compared to when one did (p < 0.001). Increased TXA use was associated only with ISS >15 (p < 0.001).
Discussion: TXA is not used in accordance with local guidelines. It was as likely not to be used when indicated than when not indicated. Reasons for this are multifactorial and likely include stock levels, lack of administration equipment, time to reach definitive care, poor documentation and hesitancy to use. Further investigation is needed to understand the barriers to administration.
Is the pelvic examination in patients with threatened abortion still crucial in the era of readily available emergency department ultrasound? A randomized controlled trial
Judith A Linden, Benjamin Grimmnitz, Laura Hagopian, Alan H Breaud, Breanne K Langlois, Kerrie P Nelson, Lauren L Hart, James Feldman, Jeremy Brown and Patricia Mitchell
Linden et al. Ann Emerg Med. 2017. http://dx.doi.org/10.1016/j.annemergmed.2017.07.487
Study objective: We determine whether omitting the pelvic examination in emergency department (ED) evaluation of vaginal bleeding or lower abdominal pain in ultrasonographically confirmed early intrauterine pregnancy is equivalent to performing the examination.
Methods: We conducted a prospective, open-label, randomized, equivalence trial in pregnant patients presenting to the ED from February 2011 to November 2015. Patients were randomized to no pelvic examination versus pelvic examination. Inclusion criteria were aged 18 years or older, English speaking, vaginal bleeding or lower abdominal pain, positive β–human chorionic gonadotropin result, and less than 16-week intrauterine pregnancy by ultrasonography. Thirty-day record review and follow-up call assessed for composite morbidity endpoints (unscheduled return, subsequent admission, emergency procedure, transfusion, infection, and alternate source of symptoms). Wilcoxon rank sum tests were used to assess patient satisfaction and throughput times.
Results: Only 202 (of a planned 720) patients were enrolled, despite extension of the study enrollment period. The composite morbidity outcome was experienced at similar rates in the intervention (no pelvic examination) and control (pelvic examination) groups (19.6% versus 22.0%; difference −2.4%; 90% confidence interval [CI] −11.8% to 7.1%). Patients in the intervention group were less likely to report feeling uncomfortable or very uncomfortable during the visit (11.2% versus 23.7%; difference −12.5; 95% CI −23.0% to −2.0%).
Conclusion: Although there was only a small difference between the percentage of patients experiencing the composite morbidity endpoint in the 2 study groups (2.4%), the resulting 90% CI was too wide to conclude equivalence. This may have been due to insufficient power. Patients assigned to the pelvic examination group reported feeling uncomfortable more frequently.
(The print version of this article has been scheduled for December 2017)
Combined high-sensitivity copeptin and troponin T evaluation for the diagnosis of non-ST elevation acute coronary syndrome in the emergency department
Alquézar A, Santaló M, Rizzi M, Gich I, Grau M, Sionis A, Ordóñez-Llanos J and Investigadores del Estudio TUSCA
Alquézar et al. Emergencias. 2017;29:237−244.
Objectives: To assess the diagnostic yield of a high-sensitivity copeptin (hs-copep) assay alone or in combination with a high-sensitivity cardiac troponin T (hs-cTnt) assay for the diagnosis of non-ST segment elevation acute coronary syndrome (NSTEMI) in patients with chest pain in the emergency department (ED). The secondary aim was to assess the 1-year prognostic utility of these biomarkers in this clinical context.
Material and methods: Retrospective observational study of a series of patients attended for chest pain suggesting myocardial ischemia in 5 Spanish ED. The first blood drawn in the ED was used for hs-copep and hs-cTnt assays, which were processed in a single laboratory serving all centers. Diagnostic utility was assessed by sensitivity, specificity, positive and negative predictive values and likelihood ratios, and the area under the receiver operating characteristic curve (ROC). We also performed a separate analysis with data for the subgroup of patients with early detection of symptoms (3 h of onset of symptoms). We recorded complications, mortality or reinfarction occurring within a year of the index event.
Results: We included 297 patients; 63 (21.2%) with NSTEMI. The median age was 69 years (interquartile range, 70−76 years), and 199 (67%) were men. The ROC was 0.89 (95% CI, 0.85−0.94) for the hs-cTnt assay, 0.58 (95% CI, 0.51−0.66) for the hscopep assay, and 0.90 (95% CI, 0.86–0.94) for the 2 assays combined. The ROC for the 2 assays combined was not significantly better than the ROC for the hs-cTnt by itself (P = .89). We saw the same pattern of results when we analyzed the subgroup of patients who presented early. Sixty percent of the complications occurred in patients with elevated findings on both assays. Elevated hs-copep findings did not provide prognostic information that was not already provided by hs-cTnt findings (P = 0.56)
Conclusion: The hs-copep assay does not increase the diagnostic or prognostic yield already provided by the hs-cTnt assay in patients suspected of myocardial infarction in the ED.
Relationship between non-technical skills and technical performance during cardiopulmonary resuscitation: does stress have an influence?
Ralf Krage, Laura Zwaan, Lian Tjon Soei Len, Mark W Kolenbrander, Dick van Groeningen, Stephan A Loer, Cordula Wagner and Patrick Schober
Published Online First: 26 August 2017. doi: 10.1136/emermed-2016-205754
Background: Non-technical skills, such as task management, leadership, situational awareness, communication and decision-making refer to cognitive, behavioural and social skills that contribute to safe and efficient team performance. The importance of these skills during cardiopulmonary resuscitation (CPR) is increasingly emphasised. Nonetheless, the relationship between non-technical skills and technical performance is poorly understood. We hypothesise that non-technical skills become increasingly important under stressful conditions when individuals are distracted from their tasks, and investigated the relationship between non-technical and technical skills under control conditions and when external stressors are present.
Methods: In this simulator-based randomised cross-over study, 30 anaesthesiologists and anaesthesia residents from the VU University Medical Center, Amsterdam, the Netherlands, participated in two different CPR scenarios in random order. In one scenario, external stressors (radio noise and a distractive scripted family member) were added, while the other scenario without stressors served as control condition. Non-technical performance of the team leader and technical performance of the team were measured using the ‘Anaesthetists’ Non-technical Skill’ score and a recently developed technical skills score. Analysis of variance and Pearson correlation coefficients were used for statistical analyses.
Results: Non-technical performance declined when external stressors were present (adjusted mean difference 3.9 points, 95% CI 2.4 to 5.5 points). A significant correlation between non-technical and technical performance scores was observed when external stressors were present (r = 0.67, 95% CI 0.40 to 0.83, p < 0.001), while no evidence for such a relationship was observed under control conditions (r = 0.15, 95% CI −0.22 to 0.49, p = 0.42). This was equally true for all individual domains of the non-technical performance score (task management, team working, situation awareness, decision-making).
Conclusions: During CPR with external stressors, the team’s technical performance is related to the non-technical skills of the team leader. This may have important implications for training of CPR teams.
