Network Five Emergency Medicine

Theme: 
Pulmonary Embolism.

Participants: 
Dr Kevin Lai (senior emergency physician), Dr Arwen Morath (emergency physician), Dr Pramod Chandru, Naveendran Rajendran, Harry Hong, Samoda Wilegoda Mudalige, Kit Rowe and Caroline Tyers.  

Discussion:
Robert-Ebadi, H., Robin, P., Hugli, O., Verschuren, F., Trinh-Duc, A., & Roy, P. et al. (2021). Impact of the Age-Adjusted D-Dimer Cutoff to Exclude Pulmonary Embolism. Circulation, 143(18), 1828-1830. https://doi.org/10.1161/circulationaha.120.052780.

Presenter:
Naveendran Rajendran - ED Resident at Westmead Hospital. 

Summary:

• This was a multinational, prospective, diagnostic outcome study designed to determine the impact of the use of age-adjusted D-dimer on clinical practice in the outpatient setting.  
• This study follows on from the ADJUST-PE study released in 2014, which established the safety of using an age-adjusted D-dimer cut-off retrospectively.  
• The primary outcome was the incidence of symptomatic thromboembolic events in the period following which a PE had been excluded in a patient based on a negative D-dimer (with the age-adjusted cut-off), and a low pre-test probability. 
• The secondary outcome looked at the number of D-dimer results which sat between the conventional cut-off of 0.5 and the age-adjusted value in the whole cohort, as well as more specifically in those aged over 75 years (to determine the diagnostic yield of the age-adjusted cut-off).  
• Of the 1421 patients with a low pre-test probability for PE and a D-dimer below 0.5, only 1 was found to have a non-fatal PE. 
• The proportion of patients with D-dimers that fell between the conventional cut-off of 0.5 and the age-adjusted cut-off was 301 of 1507 patients, with 0 identified thromboembolic events noted during follow-up.  
• This translates to a 20% increase in the number of negative D-dimer tests using the age-adjusted cut-off, with an even more pronounced increase of 67% in the group of patients over the age of 75. 

 Take-Home Points:

• The age-adjusted D-dimer is a potential tool to assist with risk-stratifying patients presenting with possible PE. 
• Previous concerns regarding various assays may have limited the implementation of an age-adjusted D-dimer in prior years. 
• Further audits to quantify the impact of utilizing the age-adjusted D-dimer (with regards to imaging, treatment, costs, etc.) are required.  

References: 

• Righini M, Van Es J, Den Exter P. Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism: The ADJUST-PE Study. Journal of Vascular Surgery. 2014;59(5):1469.

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects

• Got My Love by LiQWYD & Markvard | https://www.liqwydmusic.com, https://soundcloud.com/markvard, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
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Thank you for listening!

Please send us an email to let us know what you thought.
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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: 
General Surgery

Participants: 

Dr Michael Haddock (ED consultant), Dr Sergei Tsakanov (general surgical Fellow), Sunny Rajput (ED trainee), Edgardo Solis (general surgical registrar), Shreyas Iyer, Samoda Wilegoda Mudalige, Kit Rowe, Caroline Tyers, Harry Hong and Yelise Foon. 

Discussion:
A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. The CODA Collaborative. (2020), 383(20), 1907-1919. https://doi.org/10.1056/nejmoa2014320.

Summary:

• This study was undertaken in the United States towards the end of their initial COVID-19 wave.  
• The results were reported at 90-days, however, they still have analysis intended for the first 2 years (so it is an ongoing study).   
• It looked at patients 18 years or older, with image-confirmed acute appendicitis in emergency departments across 25 centers in the United States.   
• Septic, diffusely peritonitic, complicated, or recurrent appendicitis patients were excluded.  
• The study compared antibiotics (with IV antibiotics for at least the first 24 hours, followed by oral antibiotics to complete a total 10-day course) with appendectomy.  
• The primary outcome was a ‘general health survey’ which was conducted at the 24 hours, 1-, 2-, and 4-weeks, and 3-, 6- and 12 months following discharge.  
• The secondary outcomes included resolution of symptoms, adverse events, complications (including abscess formation, C.diff infection, the requirement of a more extensive operation, perforation, and neoplasm rates), ED presentations related to appendicitis, length of stay in hospital, and days of missed work (for patients and caregivers).  
• The results of this study found that antibiotics were non-inferior to appendectomy at 30-days according to the ‘general health survey’.  
• However, representation to the emergency department was significantly higher for those treated with antibiotics (9% compared with 4% for appendectomy patients), as were adverse events.  
• It is important to note that the presence of an appendicolith is an indicator for complicated appendicitis (carrying the risk of ischemia and subsequent appendiceal perforation) and an increased likelihood of failed management with IV antibiotics alone- however, such patients were included in this study. 

 Take-Home Points:

• Acute uncomplicated appendicitis may be considered for treatment with IV antibiotics alone, although an appendicolith would still exclude a patient from this at this stage in most cases.  
• 10% of patients treated with IV antibiotics alone will fail in the initial treatment phase and may represent to the emergency department during their antibiotic course.  
• Thus, the emergency department may start to see a new cohort of patients; rather than ‘post-operative complications’, we may start to see ‘post-non-operative complications’ (such as recurrence, intra-abdominal abscess, or those from antibiotics themselves).  
• 7/10 of patients will be able to avoid an operation with antibiotics in acute uncomplicated appendicitis. 
• However, long-term data (over the course of more than 5 years) is still required to characterize this issue further.  

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects

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See you next time,
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~

Theme: 
General Surgery

Participants: 

Dr Michael Haddock (ED consultant), Dr Sergei Tsakanov (general surgical Fellow), Sunny Rajput (ED trainee), Edgardo Solis (general surgical registrar), Andy Chen (general surgical registrar), Shreyas Iyer, Samoda Wilegoda Mudalige, Kit Rowe, Caroline Tyers, Harry Hong and Yelise Foon. 

Discussion:
Nepogodiev, D., Bhangu, A., Glasbey, J., Li, E., Omar, O., & Simoes, J. et al. (2020). Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. The Lancet, 396(10243), 27-38. https://doi.org/10.1016/s0140-6736(20)31182-x. 

Summary:

• This was a cohort study extending over 24 countries hit by the initial COVID-19 pandemic, conducted from January 1st to March 31st 2020.
• The aim of the study was to evaluate the effect of COVID-19 infection on post-operative recovery, with particular focus on 30-day mortality and pulmonary complication rates in patients with peri-operative COVID-19 infection.
• 1128 patients were included in the study, with 74% undergoing emergency surgery and 24% having elective surgery.
• 294 patients had a pre-operative diagnosis and 806 had a post-operative diagnosis of COVID-19. 
• 30-day mortality for the cohort overall was 23.8%.
• Post-operative pulmonary complications occurred in half of the patients with peri-operative COVID-19 infection and were associated with significantly higher mortality.
• This can be compared with data suggesting a pre-pandemic post-operative pulmonary complication rate of only 10% and 30-day mortality of up to 3%.
• Even in those patients undergoing elective procedures, the mortality rate was 18.9%.

 Take-Home Points:

• This data suggests that a diagnosis of peri-operative COVID-19 carries significant risk for higher rates of mortality and pulmonary complications. 
• This supports current practice within Australia where elective surgeries are not taking place. 
• However, as this pandemic continues to evolve and potentially becomes a part of the ‘new normal’, guidelines surrounding both emergency and elective surgery will need to be further developed and finessed.

Interlude:
Virtual Ward Rounds:
- https://open.spotify.com/show/5K2TdBc35lh77oWJFHWOuh

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects

• Medical Examination by MaxKoMusic | https://maxkomusic.com/, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US. 
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Thank you for listening!

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You can contact us at [email protected].

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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: 
General Surgery

Participants: 

Dr Michael Haddock (ED consultant), Dr Sergei Tsakanov (general surgical Fellow), Edgardo Solis (general surgical registrar), Shreyas Iyer, Samoda Wilegoda Mudalige, Kit Rowe, Caroline Tyers, Harry Hong and Yelise Foon. 

Discussion:
Jaung, R., Nisbet, S., Gosselink, M., Di Re, A., Keane, C., & Lin, A. et al. (2021). Antibiotics Do Not Reduce Length of Hospital Stay for Uncomplicated Diverticulitis in a Pragmatic Double-Blind Randomized Trial. Clinical Gastroenterology And Hepatology, 19(3), 503-510.e1. https://doi.org/10.1016/j.cgh.2020.03.049. 

Summary:

• This was the first randomized-controlled trial comparing antibiotics to no antibiotics in uncomplicated acute diverticulitis with a placebo control.  
• The primary outcome assessed was the length of stay in hospital, with secondary outcomes including withdrawal rates from the study, the occurrence of adverse events, readmission to hospital within 1 week and 30 days, procedural interventions, change in the serial inflammatory markers, and patient-reported pain scores at 12 and 24 hours from admission. 
• Exclusion criteria included meeting 2 or more of the SIRS criteria (including fever, and WCC <4 or >12), and inability to give consent or answer symptom-related questions (due to language barrier or cognitive impairment), amongst others. 
• The study found that placebo was not inferior to antibiotics for uncomplicated acute diverticulitis regarding hospital length of stay.  
• There was also no significant difference between groups with regards to adverse events and readmission to hospital within 1 week and 30 days (although the power of the study was not high enough to definitively answer these outcomes).  

 Take-Home Points:

• There may be a role for treating uncomplicated acute diverticulitis without antibiotics, although this is not the standard of practice in Australia yet. 
• If these patients are treated without antibiotics, there would need to be an adequate follow-up plan (to account for patients potentially deteriorating and developing a complication of diverticulitis). 
• This is a growing area of research; with practices varying between institutions.  

References: 

• Chabok A, Pahlman L, Haapaniemi S, Smedh K, et al. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. British Journal of Surgery. 2012;99(4):540-540. 
• Daniels L, Unlu C, de Korte N, et al. Randomised clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg.2017; 104: 52-61. 

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects

• Medical Examination by MaxKoMusic | https://maxkomusic.com/, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US. 
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Thank you for listening!

Please send us an email to let us know what you thought.
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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: 
COVID-19. 

Participants: 

Dr Matthew O'Sullivan (infectious diseases specialist), Prof. Sanjay Swaminathan (immunologist), Dr George Zhou (intensivist), Ali Sayeed (ICU registrar), Dr James Tadros (ED consultant), Dr Pramod Chandru (ED consultant), Harry Hong, Samoda Wilegoda Mudalige, Shreyas Iyer, Kit Rowe, and Caroline Tyers.

Discussion:
Ansems, K., Grundeis, F., Dahms, K., Mikolajewska, A., Thieme, V., & Piechotta, V. et al. (2021). Remdesivir for the treatment of COVID-19. Cochrane Database Of Systematic Reviews, 2021(8). https://doi.org/10.1002/14651858.cd014962.

Presenter - Ali Sayeed, ICU Registrar at Westmead Hospital.

Summary:

• Remdesivir is a small molecule pro-drug that inhibits viral replication via its inhibition of RNA polymerase - In Australia, it has been provisionally approved by the TGA for its use in COVID-19. 
• The theory behind using Remdesivir is really in the early stages of COVID-19 pneumonitis (by reducing the viral load and thereby preventing the augmentation of the inflammatory response). 
• This was a systematic review with included meta-analyses looking at the use of Remdesivir in COVID-19 compared with placebo or standard care. 
• It included only randomised control trials, with the primary outcomes being all-cause mortality, changes in clinical status (such as time to liberation from mechanical intervention) and adverse events. 
• The 5 studies analysed for this review were: the Beigel study (ACTT-1 trial) which enrolled 1,000 patients, the Spinner trial which had 600 patients, the Wang trial with 230 patients, the Mahajan trial with 82 patients, and the WHO Solidarity trial with over 5,000 patients. 
• Remdesivir was found to have little to no impact on all-cause mortality at 28 days. 
• The duration to liberation from non-invasive and invasive mechanical ventilation was found to be 17 days in the Remdesivir group compared with 20 days in the control group in the Beigel study, and 7 days in the Remdesivir group compared with 15 days in the control group in the Wang study, although neither of these results were statistically significant. 
• The Beigel study demonstrated a difference in time to recovery in the Remdesivir group compared with the placebo group, with a median difference of 5 days (however it is unclear whether this result was statistically significant). 
• The significant heterogeneity in study protocols, methodology, subgroups and settings made it very difficult to compare these studies statistically. 

 Take-Home Points:

• Remdesivir likely has very limited or no effect on hard outcomes in COVID-19 (in particular on mortality). 
• The benefit of Remdesivir is not constant across disease severities; if there is a benefit it is likely to be a subset of patients (which appears to be those on low-flow oxygen).  
• It does not appear to affect hospital length of stay (there is not sufficient evidence to suggest it does). 
• All outcomes were based on low certainty evidence, and it is unlikely that there will be further evidence on Remdesivir alone to come, as most patients will be receiving combination therapy in ongoing studies.  
• Of all the treatment modalities that we have for COVID-19, Remdesivir appears to be the one that has the least impact, but it was the one that was available first, and has very few side effects.  
• At present in NSW, COVID-19 patients requiring oxygen are being treated with a combination of Dexamethasone, Remdesivir and Baracitinib (or Tocilizumab). 

References: 

• Beigel JH, Tomashek KM, Dodd LE, Mehta AK, Zingman BS, Kalil AC, et al. Remdesivir for the treatment of COVID-19 – final report. New England Journal of Medicine 2020;383:1813-26.[DOI: 10.1056/NEJMoa2007764]. 
• Spinner CD, Gottlieb RL, Criner GJ, Arribas Lopez JR, Cattelan AM, Soriano Viladomiu A, et al. Effect of remdesivirvs standard care on clinical status at 11 days in patientswith moderate COVID-19: a randomised clinical trial. JAMA2020;324(11):1048-57. [DOI: 10.1001/jama.2020.16349] [PMID:32821939]. 
• Wang Y, Zhang D, Du G, Du R, Zhao J, Jin Y, et al. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. The Lancet2020;395(10236):1569-78. [CLINICALTRIALS.GOV: NCT04257656][DOI: 10.1016/s0140-6736(20)31022-9]. 
• Mahajan L, Singh AP, GiSy. Clinical outcomes of using Remdesivir in patients with moderate to severe COVID-19: a prospective randomised study. Indian Journal of Anaesthesia2021;65:41-6. [DOI: 10.4103/ija.IJA_149_21]. 
• WHO Solidarity Trial Consortium. Repurposed antiviral drugs for COVID-19 - interim WHO solidarity trial results. New England Journal of Medicine 2021;384(8):497-511. [CLINICALTRIALS.GOV:NCT04315948] [DOI: 10.1056/NEJMoa2023184] [EUCTR:EUCTR2020-001366-11] [ISRCTN: ISRCTN83971151]. 
• Living Guidelines [Internet]. Caring for people with COVID-19. 2021 [cited 16 September 2021]. Available from: https://covid19evidence.net.au/#living-guidelines. 
• The RECOVERY Collaborative Group. Dexamethasone in Hospitalized Patients with Covid-19. New England Journal of Medicine [Internet]. 2021 [cited 16 September 2021];384(8):693-704. Available from: https://www.nejm.org/doi/full/10.1056/NEJMoa2021436.  
• Kalil AC, Patterson TF, Mehta AK, Tomashek KM, et al. Baricitinib plus Remdesivir for Hospitalized Adults with COVID-19. N Engl J Med 2021; 384:795-807. 
• Gupta A, Gonzalez-Rojas Y, Juarez E, Crespo Casal M, Moya J, Falci DR, Sarkis E, Solis J, Zheng H, Scott N, Cathcart AL, Hebner CM, Sager J, Mogalian E, Tipple C, Peppercorn A, Alexander E, Pang PS, Free A, Brinson C, Aldinger M, Shapiro AE. Early COVID-19 Treatment with SARS-CoV-2 Neutralizing Antibody Sotrovimab [Internet]. medRxiv; May 2021 [cited 16 September 2021]. Available from: https://www.medrxiv.org/content/10.1101/2021.05.27.21257096v1.  
• Tomazini B, Maia I, Cavalcanti A, Berwanger O, Rosa R, Veiga V et al. Effect of Dexamethasone on Days Alive and Ventilator-Free in Patients With Moderate or Severe Acute Respiratory Distress Syndrome and COVID-19. JAMA [Internet]. 2020 [cited 16 September 2021];324(13):1307. Available from: https://jamanetwork.com/journals/jama/fullarticle/2770277. 
• Hasan MJ, Rabbani R, Anam AM, Huq SMR, Polash MMI, Nessa SST, Bachar SC. Impact of high dose Baracitinib in severe COVID-19 pneumonia: a prospective cohort study in Bangladesh. BMC Infect Dis. May 2021; 21(1): 427. Available from: https://pubmed.ncbi.nlm.nih.gov/33962573/. 

Kit's Corner 

• Signbank [Internet]. Auslan.org.au. 2021 [cited 01 October 2021]. Available from: https://www.auslan.org.au/dictionary/words/COVID-19-1.html. 

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects

• Angel by Ikson | https://youtube.com/ikson, Music promoted by

Theme: 
COVID-19. 

Participants: 

Dr Nicole Gilroy (infectious diseases specialist), Prof. Sanjay Swaminathan (immunologist), Dr Caroline Bahn (infectious diseases advanced trainee), Dr Joanna Koryzna (ED consultant), Dr James Tadros (ED consultant), Dr Pramod Chandru (ED consultant), Harry Hong, Samoda Wilegoda Mudalige, Shreyas Iyer, Kit Rowe, and Caroline Tyers.

Discussion:
Sharifian-Dorche, M., Bahmanyar, M., Sharifian-Dorche, A., Mohammadi, P., Nomovi, M., & Mowla, A. (2021). Vaccine-induced immune thrombotic thrombocytopenia and cerebral venous sinus thrombosis post COVID-19 vaccination; a systematic review. Journal Of The Neurological Sciences, 428, 117607. https://doi.org/10.1016/j.jns.2021.117607.

Presenter - Vincent Tsui, ED Trainee at Westmead Hospital.

Summary:

• According to the European Medicine Agency's Pharmacovigilance Risk Assessment Committee, 169 cases of central venous sinus thrombosis and 53 cases of splanchnic vein thrombosis were reported from 34 million people who had received the AstraZeneca COVID-19 vaccine. 
• This systematic review examines published cases of vaccine-induced thrombotic thrombocytopaenia and central venous sinus thrombosis following the Astra Zeneca, Johnson & Johnson, and Janssen COVID-19 vaccines, to comment on the incidence, symptoms, investigations, treatment, and complications. 
• Only English papers were included in their review. 
• 12 papers on Astra Zeneca vaccination and 2 papers on the Johnson and Johnson vaccine were included, out of the 877 articles identified in their search.  
• The most common symptom of CVST was headache (and there was no characteristic development or distribution of the headache). 
• In their case series, there were 54 cases of CVST, with 36 of these being women.  
• Most patients had their symptom onset within one week following the first vaccination (with a range from 4-19 days following vaccination).
• Most patients with CVST had a platelet abnormality, with all patients having a positive D-dimer and platelet factor IV immunoglobulin.  
• The recommended treatment for these patients is anticoagulation, and avoidance of administration platelets (in addition to IVIG and/or plasmapheresis).  

 Take-Home Points:

• This is a very rare disease even in presence of COVID-19 vaccines. 
• It is also a very difficult disease to diagnose, although early recognition is critical with regard to morbidity and mortality.  
• The ACEM guide and local health district pathways for diagnosing VITT reflect the findings of this systematic review.  
• The public response to the information surrounding VITT and the resultant vaccine hesitancy reflects the changing nature of health information and consent in modern medicine. 

References:
Burnet.edu.au. 2021. Initial modelling projections for second epidemic wave in Sydney, NSW | Burnet Institute. [online] Available at: https://www.burnet.edu.au/news/1506_initial_modelling_projections_for_second_epidemic_wave_in_sydney_nsw.

Interlude Segment:
Presenter - Prof. Sanjay Swaminathan.

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects

• Island by extenz | https://soundcloud.com/extenz, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US. 
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Thank you for listening!

Please send us an email to let us know what you thought.
You can contact us at [email protected].

You can also follow us on Facebook, Instagram, and Twitter!

See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: 
COVID-19. 

Participants: 

Dr George Zhou (intensivist), Dr James Tadros (ED consultant), Dr Pramod Chandru (ED consultant), Dr Nicole Gilroy (infectious diseases specialist), Prof. Sanjay Swaminathan (immunologist), Harry Hong, Samoda Wilegoda Mudalige, Shreyas Iyer, Kit Rowe, and Caroline Tyers. 

Discussion:
Rosén, J., von Oelreich, E., Fors, D., Jonsson Fagerlund, M., Taxbro, K., & Skorup, P. et al. (2021). Awake prone positioning in patients with hypoxemic respiratory failure due to COVID-19: the PROFLO multicenter randomized clinical trial. Critical Care, 25(1). https://doi.org/10.1186/s13054-021-03602-9. 

Presenter - Caroline Tyers, ED Trainee at Westmead Hospital.

Summary:

• This was a prospective, multicentre, open-label, parallel-arm, randomized clinical superiority trial conducted in Sweden between October 2020 and February 2021, which examined the impact of awake prone positioning on the rates of endotracheal intubation in COVID-19 patients with hypoxaemic respiratory failure.  
• Interim analysis of 75 patients revealed a 33% rate of intubation in both the prone and control groups, with no significant differences in secondary outcomes either.  
• The study was consequently terminated early due to an assessment of futility.  
• However, the small sample size of patients in this study limited the statistical power of this study. 
• In addition, the use of prone positioning in the control group, as well as the prone group, may have also attenuated the differences in outcomes between the two groups.  
• This likely reflects the standard of practice that has been established for patients with hypoxaemic respiratory failure where prone positioning can be used as a rescue technique to improve oxygenation (see landmark PROSEVA trial, 2013). 
• Evidence for awake prone positioning can be found in a recently published meta-trial (published in The Lancet in August 2021) which demonstrated a decrease in intubation or mortality of 5% in the prone group.  

 Take-Home Points:

• There is some limited evidence for awake prone positioning in COVID-19 patients with hypoxaemic respiratory failure, in reducing rates of intubation and mortality.  
• Given that awake-prone positioning is relatively easy to implement, with minimal associated risks, it has thus become a standard of care in treating COVID-19 patients with hypoxaemic respiratory failure.   
• Practically, however, awake prone positioning can be uncomfortable for patients, and difficult to implement; particularly in an emergency department where there may be limited pillows, varying patient body habitus, as well as limited medical staff, time, and difficulty providing continuous patient observation. 

Interlude Segment:
Presenter - Dr George Zhou.

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects

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~

Theme: 
Emergency Medicine 

Participants: 

Yelise Foon, Harry Hong, Dr Pramod Chandru, Shreyas Iyer, Caroline Tyers, Kit Rowe, and Samoda Wilegoda.

Discussion 1:
Morley, C., Unwin, M., Peterson, G., Stankovich, J., & Kinsman, L. (2018). Emergency department crowding: A systematic review of causes, consequences and solutions. PLOS ONE, 13(8), e0203316. https://doi.org/10.1371/journal.pone.0203316

Presenter - Kit Rowe, ED Trainee at Westmead Hospital.

Summary:

• This is a systematic review from 2018 involving 102 studies. 
• 47% of these studies were from the US, with 18% from Australia and 9% from Canada.
• 14 studies investigated causes, while 52 studies looked at potential solutions to emergency department  (ED) crowding, and 40 studies examined the consequences of ED crowding. 
• The findings were divided into consequences (regarding the patient, staff, and system-level effects), causes, and solutions (both with reference to input into ED, throughput within ED, and output out of ED). 
• This study highlights a notable paucity of research into the causes of ED crowding. 
• It also demonstrates that the nature of ED crowding is multi-faceted.

Take-Home Points:

• This is a complex issue that needs a system-wide approach but that also needs to focus on the fact that every system is different, every patient is different, and every patient is different within every system.
• We really need to look at the causes; there is a real paucity in research of what actually drives overcrowding in ED.  

Discussion 2:
Brown, S., Ball, E., Perrin, K., Asha, S., Braithwaite, I., & Egerton-Warburton, D. et al. (2020). Conservative versus Interventional Treatment for Spontaneous Pneumothorax. New England Journal Of Medicine, 382(5), 405-415. https://doi.org/10.1056/nejmoa1910775

Presenter - Harry Hong - ED senior resident medical officer, at Westmead Hospital.

Summary:

• This is a multicentre prospective randomized open label non-inferiority trial that compared the insertion of a chest tube with conservative management for first-time primary spontaneous moderate to large pneumothorax in patients from 14 to 50 years of age.
• The primary measured outcome was complete lung re-expansion radiologically at 8 weeks. 
• A 90% success rate in the conservative group at 8 weeks was determined as the acceptable non-inferiority threshold (compared with the 99% success rate of intervention).
• 25 out of the 162 patients allocated to the conservative group required intervention, while 10 out of the 154 allocated to the intervention group declined treatment.
• 98.5% in the intervention group had resolution within 8 weeks as compared with 94.4% in the conservative management group, and thus conservative management was deemed non-inferior to intervention.
• Conservative management spared 85% of patients from an invasive intervention and resulted in fewer hospitalization days, a lower likelihood of prolonged chest tube drainage, less need for surgery, and fewer adverse events than interventional management (and the percentage of recurrent pneumothorax was also lower in the conservative management group).
• Exclusion criteria included previous primary spontaneous pneumothorax on the same side, secondary or bilateral pneumothorax, coexistent haemothorax, tension pneumothorax, pregnancy, social circumstances preventing safe discharge or planned air travel within 12 weeks.

Take-Home Points:

• There is evidence to suggest conservative management is not any worse in treating a primary spontaneous pneumothorax in this subset of patients; you may not need to rush into interventions if the patient is stable.

Discussion 3:
Perry, J., Sivilotti, M., Émond, M., Hohl, C., Khan, M., & Lesiuk, H. et al. (2020). Prospective Implementation of the Ottawa Subarachnoid Hemorrhage Rule and 6-Hour Computed Tomography Rule. Stroke, 51(2), 424-430. https://doi.org/10.1161/strokeaha.119.026969.

Presenter - Caroline Tyers - ED Trainee at Westmead Hospital.

Summary:

• This implementation study is a follow-on from several other studies published by Perry et al. from 2010 onwards which first established the Ottawa Subarachnoid Haemorrhage Rule and the 6-Hour CT rule.
• It was a prospective, multicentre before-after controlled study to determine the impact of the Ottawa SAH and 6-hour-CT rule on clinical practice.
• It involved 2 consecutive study periods: a control period from 2010 to 2013 and an intervention period between 2013 and 2016 in which the tools were implemented. 
• 3672 patients with acute headache were enrolled; with 1743 in the control phase and 1929 in the intervention phase. 
• These patients had to be > 16 years old, have a GCS 15, and be presenting with a headache that had reached maximal intensity within 1 hour, with onset in the prior 14 days.
• The sensitivity of the 6-hour-CT rule was 95.5% for SAH, with an associated 13% decrease in a subsequent lumbar puncture (LP).
• This study suggests that the Ottawa SAH rule and 6-hour-CT rule are ready to use and may help to decrease the use of additional investigations to exclude SAH in these patients. 

Take-Home Points:

• Not every patient requires LP or CTA. 
• Although not perfect, the 6-hour-CT rule in many cases will be sufficient to justify not pursuing an LP or CTA.
• When ordering a CT scan for a patient, the Ottawa SAH rules may be occasionally helpful in identifying a patient that you don’t actually need to scan.

Interlude Segment:
Presenter - Dr Pramod Chandru.
References: Kahneman, D., & Egan, P. (2011). Thinking, fast and slow. Random House Audio.

Other References:

• Chu KH, Keijzers G, Furyk JS, et al. Applying the Ottawa subarachnoid haemorrhage rule on a cohort of emergency department patients with headache. Eur J Emerg Med. 2018;25(6):e29-e32.
• Dubosh NM, Bellolio MF, Rabinstein AA, Edlow JA. Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. Stroke. 2016;47(3):750-755. 
• Morgenstern J. Subarachnoid Hemorrhage: What is the role of LP? - First10EM [Internet]. First10EM. 2021 [cited 20 August 2021]. Available from: https://first10em.com/subarachnoid-hemorrhage-lp/.
• Perry JJ, Stiell IG, Sivilotti ML, et al. High-risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study. BMJ. 2010;341:c5204. Published 2010 Oct 28.
• Perry JJ, Stiell IG, Sivilotti ML, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ. 2011;343:d4277. Published 2011 Jul 18.

Credits:
The discussions were mediated by ED consultant Dr Pramod Chandru. 

This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects

• Back To Me by Jay Someday | https://soundcloud.com/jaysomeday, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https:/...

Theme: 
Medical Oncology.

Participants: 

Professor Nicholas Wilcken, Sarah Rashid, Bratati Karmakar, Harry Hong, Dr Pramod Chandru, Shreyas Iyer, Caroline Tyers, and Kit Rowe.

Discussion 1:
Thomas, B., Lo, W., Nangati, Z., & Barclay, G. (2021). Dexmedetomidine for hyperactive delirium at the end of life: An open-label single-arm pilot study with dose escalation in adult patients admitted to an inpatient palliative care unit. Palliative Medicine, 35(4), 729-737. https://doi.org/10.1177/0269216321994440. 

Presenter -  Sarah Rashid, physician trainee at Westmead Hospital. 

Summary:

• Terminal agitation and delirium are difficult to define and even harder to design studies around which to improve its management.
• The current treatment algorithm advises the use of neuroleptics, benzodiazepines, opiates, and barbiturates; often at the cost of wakefulness and interaction with loved ones.
• Dexmedetomidine can provide rousable sedation, a decreased severity of delirium, analgesia, a decrease in secretions, and potential anti-emetic effects. 
• The aim of this study was to describe a potential reduction in delirium and the presence of rousable sedation with dexmedetomidine in palliative care patients suffering terminal delirium, with a secondary aim to determine whether reduced opiate requirements were observed.
• There was a reduction in delirium (as measured by MDAS scores).
• Almost 50% of patients crossed over to routine care, with 27% of these due to family request for deeper sedation. 
• 15 of the 22 patients required an increase in opiate dosing, however, there were no negative survival benefits and there was a notable reduction in the use of other PRN medications (such as, for secretions). 
• Ultimately, this pilot demonstrated promise for the use of dexmedetomidine in these patients (and prompts the need for further research in this area). 

Take-Home Points:

• There is minimal evidence even behind our standard of care for these patients (midazolam, neuroleptics, and barbiturates). 
• This paper encourages us to think laterally about what medications can be used for these patients. 
• Terminal delirium is distressing for patients and their families, and at present, our treatments provide comfort but at the expense of wakefulness and interaction.
• More research needs to be done into agents such as dexmedetomidine which could allow for a better-sedated experience.
• More research also needs to be done into the experience of the dying process for patients and their families. 
• Families have large effects on the management of dying patients, and thus there is limited value in doing a study without measuring outcomes for both the patients and their families. 

Discussion 2:
Wang, D., Salem, J., Cohen, J., Chandra, S., Menzer, C., & Ye, F. et al. (2018). Fatal Toxic Effects Associated With Immune Checkpoint Inhibitors. JAMA Oncology, 4(12), 1721. https://doi.org/10.1001/jamaoncol.2018.3923.

Presenter - Harry Hong - ED senior resident medical officer, at Westmead Hospital.

Summary:

• This study looks at immune checkpoint inhibitors targeting cytotoxic T lymphocyte antigen-4 (CTLA-4) and programmed death-1/ligand-1 (PD-1/PD-L1). 
• There is increasing use of these agents individually and in combination for various cancers.
• This paper looks at multiple databases and analyzed data to characterize the rare but fatal side effects of these drugs. 
• 613 fatal adverse effects were described: 193 associated with ipilimumab (anti-CTLA-4), 333 with anti-PD-1/PD-L1, and 87 in combination therapy (most commonly for the treatment of melanoma and lung cancer).  
• The type of fatal adverse events differed between the treatment groups; with ipilimumab monotherapy associated mostly with colitis (70% of adverse events) compared with anti-PD-1/PD-L1 monotherapy where adverse events were more varied (colitis, pneumonitis, hepatitis) and combination regimens where there were additionally increased rates of myocarditis and myositis. 
• The highest fatality rates were seen in myocarditis. 
• The multicentre analysis also revealed the median time to onset of disease following commencement on therapy was 40 days with monotherapy and 14.5 days for those on combination treatment. 
• Interestingly, the median time to steroid use for these patients was 5 days (suggested to be due to difficulty recognizing the diagnosis in these patients). 

Take-Home Points:

• These drugs for some cancers have completely revolutionized treatment (they are not going away!). 
• It is important to remember that the rate of fatal adverse events with these agents is still very low (particularly when compared with other oncology treatments). 
• This data gives us information for what to be vigilant for when caring for these patients (particularly those presenting with non-specific symptoms and recent commencement on these agents). 
• Take colitis seriously; it can be fatal. 
• We are all learning; this is a new class of drugs with completely different toxicity to what we are used to – if in doubt ask the medical oncologist! 

Discussion 3:
Biganzoli, L., Mislang, A., Di Donato, S., Becheri, D., Biagioni, C., & Vitale, S. et al. (2017). Screening for Frailty in Older Patients With Early-Stage Solid Tumors: A Prospective Longitudinal Evaluation of Three Different Geriatric Tools. The Journals Of Gerontology: Series A, 72(7), 922-928. https://doi.org/10.1093/gerona/glw234.

Presenter - Bratati Karmakar, physician trainee at Napean Hospital.  

Summary:

• Frailty is a concept or syndrome which lacks a unified definition.
• It is broadly defined as a vulnerability to stressors such as illness or treatment, which may aid in patient prognostication. 
• Currently, there is no single standardized frailty assessment tool to guide our clinical practice. 
• The presence of frailty has been associated with increased mortality, increased frequency of hospitalizations, intolerance to treatments, and a reduction in quality of life.
• Data suggests that we as clinicians at the bedside are not accurate assessors of patient frailty.
• This study compares well-established (however cumbersome) frailty scores; the Balducci frailty criteria and the Fried frailty criteria, with the Vulnerable Elders Survey (VES-13) which may be easier to use and apply in the emergency setting (requiring only self-reported data from the patient). 
• The outcomes measured were functional decline (or loss of an ADL) and mortality.
• 17% of patients were classified as frail using the Fried frailty criteria, and 25% when looking at the Balducci criteria and the VES-13.
• The Fried frailty criteria and the VES-13 both showed that the probability of a functional event was higher in the frail group (with time to functional decline being 13 months in the frail and 36 months in the non-frail group using the VES-13). 
• Regarding mortality, all 3 tools demonstrated prognostic value for overall survival.
• Thus, according to this study, the VES-13 can be used to predict mortality and functional decline.
• However, there was poor concordance between the three tools, suggesting that no single ...

Theme: 
Retrieval Medicine.

Participants: 

Dr Ruby Hsu, Dr Ruth Parsell, Dr Pramod Chandru, Shannon Townsend, Yelise Foon, Shreyas Iyer and Samoda Wilegoda Mudalige.

Discussion 1:
Benoit, J., Stolz, U., McMullan, J., & Wang, H. (2021). Duration of exposure to a prehospital advanced airway and neurological outcome for out-of-hospital cardiac arrest: A retrospective cohort study. Resuscitation, 160, 59-65. https://doi.org/10.1016/j.resuscitation.2021.01.009.

Presenter - Yelise Foon - ED senior resident medical officer.

Summary:

• This study was a retrospective cohort study that looked at adult, non-traumatic OOHCA patients with an advanced airway (supraglottic or endotracheal).
• The timing of airway placement (intra-arrest versus post-ROSC) and patient outcomes (with respect to the cerebral performance category, or CPC) were analyzed. 
• They observed a higher CPC in the group that had the advanced airway placed post-ROSC (i.e. 21.7% in post-arrest group versus 7.5% in intra-arrest group).
• They concluded that the timing of the airway placement was not associated with poor neurological outcomes. 

Discussion 2:
Aziz, S., Foster, E., Lockey, D., & Christian, M. (2021). Emergency scalpel cricothyroidotomy use in a prehospital trauma service: a 20-year review. Emergency Medicine Journal, 38(5), 349-354. https://doi.org/10.1136/emermed-2020-210305.

Presenter - Shannon Townsend, ED advanced trainee at Orange Health Service.

Summary & Take-Home Points:

• This was a retrospective observational study conducted from 2000 to 2019 using clinical records and aimed to (1) ascertain the rate of scalpel cricothyroidotomy and (2) understand indications for and factors associated with this procedure.
• They observed that the main indication for scalpel cricothyroidotomy was as a rescue airway (for failed laryngoscopy due to a large volume of blood in the airway).
• They noted high levels of procedural success, but the overall mortality in patients receiving this procedure was high (due to a number of factors). 
• The rate of scalpel cricothyroidotomy has decreased over the years due to factors such as the introduction of supraglottic airways and longer-acting muscle relaxants (rocuronium versus suxamethonium). 
• It is important to remember that, if we optimize our intubation conditions (e.g. improving patient position, carefully choosing drugs and equipment according to patient's clinical situation), we are likely to increase our first pass success with laryngoscopy. 
• It is important to (1) recognize the indications for scalpel cricothyroidotomy, (2) be familiar with the procedure itself, (3) overcome the mental barriers against performing it, and (4) perform it confidently and competently.

Discussion 3:
Sperry, J., Guyette, F., Brown, J., Yazer, M., Triulzi, D., & Early-Young, B. et al. (2018). Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. New England Journal Of Medicine, 379(4), 315-326. https://doi.org/10.1056/nejmoa1802345.

Presenter - Dr Ruth Parsell.

Summary:

• In this pragmatic, multi-center, cluster-randomized, phase 3 superiority trial, the efficacy of administering thawed plasma to patients at risk of haemorrhagic shock was studied. 
• The comparative arm was standard-care resuscitation (with crystalloid fluids).
• The primary outcome was mortality at the 30-day mark. 
• They concluded that administration of thawed plasma to patients at risk of haemorrhagic shock resulted in (1) lower 30-day mortality and (2) lower median prothrombin-time ratio. 

Interlude Segment 1:
Presenter - Dr Ruth Parsell.

Interlude Segment 2:
Presenter - Dr Ruby Hsu.

Credits:
The discussions were mediated by retrieval specialists and ED consultants, Dr Ruby Hsu and Dr Ruth Parsell and ED consultant Dr Pramod Chandru. 

This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney, Deepa Dasgupta, Cynthia De Macedo Franco, and Paul Scott.

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~

Thank you for listening!

Please send us an email to let us know what you thought.
You can contact us at [email protected].

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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.