Network Five Emergency Medicine

Theme: 
Paediatrics.

Participants: 

Dr Surbhi Rikhi, Dr Kerf Tan, Dr Pramod Chandru, Johann De Alwis (PEM trainee) Omal Fernando (PEM trainee), Min Park (EM trainee), Shreyas Iyer, Kit Rowe, Caroline Tyers and Samoda Wilegoda Mudalige.

Discussion 1:
Kuppermann, N., Dayan, P., Levine, D., Vitale, M., Tzimenatos, L., & Tunik, M. et al. (2019). A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatrics, 173(4), 342. https://doi.org/10.1001/jamapediatrics.2018.5501.

Presenter - Johann De Alwis.

Summary:

• Serious bacterial infections (SBIs); which include UTI, meningitis, and bacteraemia, lead to dangerous complications in infants.
• This was a prospective observational study between 2011 and 2013, looking at previously healthy febrile infants aged 60 days or younger, who were evaluated for SBIs.
• The clinical rule considered the urinalysis, absolute neutrophil count (ANC), and serum procalcitonin, and had a sensitivity of 97.7%, with a specificity of 60%, and a negative predictive value of 99.6%.
• One infant with bacteraemia and two with UTI who were misclassified. 
• This tool decreased the number of lumbar punctures performed, antibiotics administered, and infants admitted to the hospital. 

Take-Home Points:

• Remember that these infants are the most at-risk population; do more rather than less.
• Safety net: no matter what you do or what investigations reveal, always have a safety net! 

Discussion 2:
Pan, P. (2020). Validation of the Testicular Workup for Ischemia and Suspected Torsion (TWIST) Score in the Diagnosis of Testicular Torsion in Children With Acute Scrotum. Indian Pediatrics, 57(10), 926-928. https://doi.org/10.1007/s13312-020-1992-6.

Presenter - Omal Fernando.

Summary:

• The TWIST score includes - testicular swelling (2), hard testicle (2), absent cremasteric reflex (1), nausea or vomiting (1), a high-riding testicle (1). 
• Low risk was a score of 0-2, intermediate risk was a score of 3-4 and high risk was a score 5-7.
• Of those with testicular torsion, the mean TWIST score was 5.7 (none in low-risk category, 13 in intermediate-risk group, and 55 in high-risk group). 
• Of those without testicular torsion, the mean TWIST score was 1.46 (21 in low-risk group, 7 in the intermediate-risk group, and 0 in the high-risk group).
• All patients with a high-riding testis or absent cremasteric reflex were found to have testicular torsion.

Take-Home Points:

• This score reminds us what we should be looking for when assessing a patient with acute testicular pain and thus help to build clinical gestalt, however, there is not enough evidence at present to rely on this tool alone (although this may change in the years to come). 
• It is important to involve the urologist/general surgeon if there is any suspicion of torsion.
• Given the time-critical nature of this presentation, patients should be taken to the theatre (rather than further investigated with ultrasound) if testicular torsion is suspected.

Discussion 3:
Iramain, R., Castro‐Rodriguez, J., Jara, A., Cardozo, L., Bogado, N., Morinigo, R., & De Jesús, R. (2019). Salbutamol and ipratropium by inhaler is superior to nebulizer in children with severe acute asthma exacerbation: Randomized clinical trial. Pediatric Pulmonology, 54(4), 372-377. https://doi.org/10.1002/ppul.24244.

Presenter - Min Park.

Take-Home Points:

• 103 children between the age of 2 and 14 years with severe asthma exacerbations (pulmonary score 7) were randomly allocated to a nebulizer or metred dose inhaler (MDI) and spacer with nasal prong oxygen.
• The primary outcome was the rate of hospitalization with the secondary outcome being oxygen saturations at 60 and 90 minutes.
• Children in the MDI group had significantly improved oxygen saturation from 60 minutes compared with the nebulizer group, with significantly lower rates of admission to hospital (5.8% vs. 27.5%). 

Summary:

• MDIs may be at least equally effective if not more effective than nebulizers.
• MDIs are also cheaper and provide an opportunity to educate patients regarding their use.
• It is important to re-assess your patients following initial treatment.
• There may be variability in the way you approach each patient to meet their individual needs. 
• Always refer to your local guidelines. 

Interlude Segment 1:
Presenter - Dr Surbhi Rikhi.

Interlude Segment 2:
Presenter - Dr Kerf Tan.

Resources (to support doctor well-being) - 

• Applications: Shift (Black Dog Institute app for healthcare workers), Calm, Headspace, Feeling Good, Smiling Minds, Insight Timer.  
• JMO support line (NSW): 1300 566 321.
• Access EAP (free confidential service for all NSW Health employees).
• Doctors for doctors: www.drs4drs.com.au.
• Beyond Blue: 1300 224 636.
• Lifeline: 13 11 14. 
• Suicide call-back service: 1300 659 467. 

Other References:
“Step by step” approach to the febrile infant - 
Mintegi, S., Bressan, S., Gomez, B., Da Dalt, L., Blázquez, D., & Olaciregui, I. et al. (2013). Accuracy of a sequential approach to identify young febrile infants at low risk for invasive bacterial infection. Emergency Medicine Journal, 31(e1), e19-e24. https://doi.org/10.1136/emermed-2013-202449.

Original study validating the TWIST score -
Barbosa, J., Tiseo, B., Barayan, G., Rosman, B., Torricelli, F., & Passerotti, C. et al. (2013). Development and Initial Validation of a Scoring System to Diagnose Testicular Torsion in Children. Journal Of Urology, 189(5), 1859-1864. https://doi.org/10.1016/j.juro.2012.10.056.

Starship Hospital (NZ) study examining nebuliser vs. MDI delivery for asthma -
Klassen, T. (2001). Spacers were better and less expensive than nebulisers for giving albuterol to children with moderate to severe acute asthma. Evidence-Based Medicine, 6(1), 31-31. https://doi.org/10.1136/ebm.6.1.31.

Further evidence regarding female ACS presentations (as covered in our previous episode) -
van Oosterhout, R., de Boer, A., Maas, A., Rutten, F., Bots, M., & Peters, S. (2020). Sex Differences in Symptom Presentation in Acute Coronary Syndromes: A Systematic Review and Meta‐analysis. Journal Of The American Heart Association, 9(9). https://doi.org/10.1161/jaha.119.014733.

Sederholm Lawesson, S., Isaksson, R., Thylén, I., Ericsson, M., Ängerud, K., & Swahn, E. (2018). Gender differences in symptom presentation of ST-elevation myocardial infarction – An observational multicenter survey study. International Journal Of Cardiology, 264, 7-11. https://doi.org/10.1016/j.ijcard.2018.03.084.

Credits:
The discussions were mediated by PEM consultant Dr Surbhi Rikhi, ED consultant Dr Kerf Tan 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, ...

Theme: 
Women In Medicine.

Participants: 

Dr Danielle Unwin, Amanda De Silva (ED advanced trainee) Jessica Stabler (neurology advanced trainee), Istabraq Raashed (ED advanced trainee), Harry Hong (ED SRMO), Shreyas Iyer, Caroline Tyers and Samoda Wilegoda Mudalige.

Discussion 1:
Stehli, J., Martin, C., Brennan, A., Dinh, D., Lefkovits, J., & Zaman, S. (2019). Sex Differences Persist in Time to Presentation, Revascularization, and Mortality in Myocardial Infarction Treated With Percutaneous Coronary Intervention. Journal Of The American Heart Association, 8(10). https://doi.org/10.1161/jaha.119.012161.

Presenter - Amanda De Silva.
Starting - 02:30.

Take-Home Points:

• Women with STEMI had longer times to presentation and door to balloon times, compared with their male counterparts, with a higher rate of mortality. 
• Such data has been produced before, however, the underlying reason for these discrepancies is unclear.
• Possible reasons behind delayed presentation to the emergency department include atypical symptoms, competing priorities (with homelife, children, or careers), and sick behaviours. 
• This is a reminder to broaden our differentials for women with chest pain - could this be a STEMI?
• Remember time is myocardium: the outcomes are significantly different between men and women in the context of this delay to PCI. 
• This is an issue that we need to make the public and our patients more aware of.  

Discussion 2:
Hoffman, R., Mullan, J., Nguyen, M., & Bonney, A. (2020). Motherhood and medicine: a systematic review of the experiences of mothers who are doctors. Medical Journal Of Australia, 213(7), 329-334. https://doi.org/10.5694/mja2.50747.

Presenter -Jessica Stabler.
Starting - 24:55. 

Three main themes raised in this review:

1. Motherhood: the impact of being a doctor on raising children.

• Women found decisions around balancing children and career progression difficult.
• Women defer having children for career reasons.
• Decisions about career progression are likely to influence family size (most women reported having smaller families as a consequence of prioritizing career advancement or starting families later in life).

2. Medicine: the impact of being a mother on a medical career.

• Motivation to return to work was not lessened by motherhood.
• There are significant systemic barriers that women face on returning to work.

3. Combining motherhood and medicine: strategies and policies to aid women in medicine.

• Maternity leave policies.
• Access to lactation rooms and childcare, as well as flexible working options.

Take-Home Points:

• It is important to acknowledge that medicine has a significant impact on the experience of motherhood (both in terms of the number and timing of children you have) and can contribute to the family strain. 
• Equally, medical careers offer financial freedom and great job satisfaction for women.
• Mothers are not less motivated to make career advancements, but there are very real systemic factors and prejudice that can make this challenging.
• There is a mental load that is associated strongly with motherhood; women do bear the greater parenting and domestic load. 

Discussion 3:
Ju, M., & van Schaik, S. (2019). Effect of Professional Background and Gender on Residents’ Perceptions of Leadership. Academic Medicine, 94, S42-S47. https://doi.org/10.1097/acm.0000000000002925.

Presenter - Istabraq Raashed.
Starting - 01:12:05.

Take-Home Points:

• This study asked residents (in the US) to rate male and female leaders in an identically scripted video of a resuscitation, on overall performance, leadership, communication, problem-solving, situational awareness, and resource utilization skills.
• Women were given statistically significant lower scores in both leadership skills and communication domains.
• This study raises the concept of a ‘backlash effect’: where women who do not display characteristics typical of a female stereotype are at increased risk of prejudice or discrimination.
• It is important for everyone to check their bias in the workplace.
• Reflect on your interactions (good and bad) and be careful with what you take personally.
• Empathise with your colleagues and consider what other things may be going on in their lives 

Interlude Segment:
Presenter - Dr Danielle Unwin
Starting - 01:05:40.

Other References:
Mnatzaganian, G., Hiller, J., Braitberg, G., Kingsley, M., Putland, M., & Bish, M. et al. (2019). Sex disparities in the assessment and outcomes of chest pain presentations in emergency departments. Heart, 106(2), 111-118. https://doi.org/10.1136/heartjnl-2019-315667.

Credits:
The discussions were mediated by ED consultant Dr Danielle Unwin.

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.

Music/Sound Effects

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Theme: 
Bonus Episode.

Participants: 

Dr Pramod Chandru, Kit Rowe, Shreyas Iyer, Caroline Tyers and, Samoda Wilegoda Mudalige.

Discussion 1:
Chandru, P., Priyambada Mitra, T., Dutt Dhanekula, N., Dennis, M., Eslick, A., Kruit, N., & Coggins, A. Out of hospital cardiac arrest in Western Sydney: an analysis of outcomes and estimation of future eCPR eligibility - not yet available online.

Take-Home Points:

• This paper was a prospective observational study of consecutive out-of-hospital of cardiac arrests (OOHCAs) at Westmead Hospital over a 3-year period.
• It looked at the feasibility of setting up an ECMO service for refractory OOHCAs (i.e. for patients who have received CPR for 20 minutes or longer, between the ages of 18 and 70 years, and had a VF arrest).
• This study had 17 patients who would have qualified as true refractory OOHCAs (none of whom survived to hospital discharge).  
• This proportion of patients was similar to other studies that have been undertaken on this topic, which also demonstrated a survival to hospital discharge with good neurological recovery of around 35-40% with the use of ECMO CPR. 
• The 2CHEER study performed out of Melbourne is also a good reference for this subject - this was one of the first RCTs for the use of ECMO CPR in a pre-hospital setting (see reference below).
• Westmead Hospital will be one of the centers involved in the upcoming RESET trial looking at the implementation of ECMO CPR.  

Discussion 2:

Bima, P., Pivetta, E., Nazerian, P., Toyofuku, M., Gorla, R., & Bossone, E. et al. (2020). Systematic Review of Aortic Dissection Detection Risk Score Plus D‐dimer for Diagnostic Rule‐out of Suspected Acute Aortic Syndromes. Academic Emergency Medicine, 27(10), 1013-1027. https://doi.org/10.1111/acem.13969. 

Take-Home Points:

• This meta-analysis suggested a sensitivity of 97.6-99.9% for an aortic dissection risk score of 0-1 and a negative D-dimer (<0.5) or age-adjusted D-dimer in the identification of acute aortic syndromes. 
• However, this meta-analysis only included 4 studies, only one of which was prospective. 
• This may be a useful clinical tool when used in the right context, while still using our clinical gestalt (it should not be used unless you have a clinical suspicion that your patient may have an acute aortic syndrome). 
• On the other hand, the use of this tool also has the potential to increase the number of CT scans performed to investigate the presence of acute aortic syndromes (particularly if wrongly applied). 
• Lastly, remember to make sure you are only using D-dimer to work up low-risk patients. 

Discussion 3:

Miraglia, D., Miguel, L., & Alonso, W. (2020). Double Defibrillation for Refractory In- and Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. The Journal Of Emergency Medicine, 59(4), 521-541. https://doi.org/10.1016/j.jemermed.2020.06.024.

Take-Home Points:

• This systematic review of RCTs looking at double defibrillation for refractory VT and VF demonstrated no significant effect on rates of return of spontaneous circulation (apart from one study, whose rates of ROSC actually favoured the control group), survival to hospital admission or survival to discharge (all with low-grade evidence). 
• This is likely to be reflective of the fact that the data on double defibrillation at this stage is insufficient (rather than demonstrating that it does not work). 
• Double defibrillation at this stage can be viewed as a rescue measure that can be attempted in refractory cases, provided it does not distract from the rest of the resuscitation effort. 
• Keep your eyes peeled for the DOSE VF study which is due to be released at the end of 2022! 

Other References:

• Dennis, M., Buscher, H., Gattas, D., Burns, B., Habig, K., Bannon, P., Patel, S., Buhr, H., Reynolds, C., Scott, S., Nair, P., Hayman, J., Granger, E., Lovett, R., Forrest, P., Coles, J., Lowe, D.A.; Sydney ECMO Research Interest Group. (2020). Prospective observational study of mechanical cardiopulmonary resuscitation, extracorporeal membrane oxygenation and early reperfusion for refractory cardiac arrest in Sydney: the 2CHEER study. Crit Care Resusc. 22(1):26-34. PMID: 32102640.
• Drennan, I., Dorian, P., McLeod, S., Pinto, R., Scales, D., & Turner, L. et al. (2020). DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE VF): study protocol for a randomized controlled trial. Trials, 21(1). https://doi.org/10.1186/s13063-020-04904-z.

Credits:
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.

Sound Effects

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 ~

Thank you for listening to our bonus episode!

Please send us an email to let us know what you thought.

You can contact us at [email protected]

See you next time,

Caroline, Kit, Pramod, Samoda and Shreyas.

Theme: 
POCUS.

Participants: 

Oliver Archer (ED resident and previous cardiac sonographer), Hung Diep (ED advanced trainee), Dr Richard McNulty, Dr Kenny Yee, Dr Pramod Chandru, Kit Rowe, Shreyas Iyer, Caroline Tyers and Samoda Wilegoda Mudalige.

Discussion 1:
Presenter - Oliver Archer.
Starting - 02:00.
Atkinson, P., Beckett, N., French, J., Banerjee, A., Fraser, J., & Lewis, D. (2019). Does Point-of-care Ultrasound Use Impact Resuscitation Length, Rates of Intervention, and Clinical Outcomes During Cardiac Arrest? A Study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators. Cureus. https://doi.org/10.7759/cureus.4456.

Take-Home Points:

• This study showed that visualizing cardiac activity on ultrasound resulted in increased duration and effort of resuscitation, and was associated with improved clinical outcomes. 
• It is difficult to know whether the improved clinical outcomes were secondary to increased resuscitation efforts or due to identification (with ultrasound) of those with a better prognosis. 
• Ultimately, ultrasound should be used as an adjunct to your clinical decision-making, but should not get in the way of the established standard ALS protocol. 
• The COACHRED protocol (referenced below) assists in incorporating POCUS into the arrest algorithm.

Discussion 2:
Presenter - Hung Diep.
Starting - 29:10.
Daley, J., Dwyer, K., Grunwald, Z., Shaw, D., Stone, M., & Schick, A. et al. (2019). Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs. Academic Emergency Medicine, 26(11), 1211-1220. https://doi.org/10.1111/acem.13774.

Take-Home Points:

• This study shows that focused cardiac ultrasound (FOCUS): involving right ventricular dilation, McConnell’s sign, septal flattening, tricuspid regurgitation, and tricuspid annular plane systolic excursion (TAPSE), maybe a useful adjunct in the workup of patients with a high pre-test probability of PE.
• The most sensitive component of the FOCUS was TAPSE. 
• The most specific components of the FOCUS were McConnell’s sign and septal flattening. 
• However, it is important to remember that illnesses associated with chronic right heart strain such as COPD would also yield a positive FOCUS.
• At this stage, there is not enough evidence for FOCUS in diagnosing PE to alter clinical decision-making. 

Discussion 3:
Presenter - Pramod Chandru.
Starting - 01:03:35. 
Chartier, L., Bosco, L., Lapointe-Shaw, L., & Chenkin, J. (2016). Use of point-of-care ultrasound in long bone fractures: a systematic review and meta-analysis. CJEM, 19(2), 131-142. https://doi.org/10.1017/cem.2016.397

Take-Home Points:

• This study looked at the use of POCUS to assist with both the diagnosis and reduction of long bone fractures (radius, ulna, humerus, tibia, fibula, and femur). 
• POCUS use had reasonable sensitivity and specificity in the diagnosis of fractures, particularly paediatric forearm fractures and adult ankle fractures - however, it may not provide all the information required regarding a fracture once identified. 
• In the absence of fluoroscopy, using POCUS to delineate the satisfactory nature of a reduction in ED (such as of the wrist) may reduce the risks associated with recurrent reductions and the need for operative fixation, however, further research with randomized controlled trials is needed.
• All in all, it is hard to see how ultrasound would replace x-ray as the imaging modality of choice for fractures, but there is an argument to be made for the use of ultrasound in assessing for the adequacy of reduction particularly in specific populations and this would be an interesting area for future studies. 

Interlude Segment:
Starting - 56:10.
Ioannidis, J. (2005). Why Most Published Research Findings Are False. PLoS Medicine, 2(8), e124. https://doi.org/10.1371/journal.pmed.0020124.

Other References:
Finn, T., Ward, J., Wu, C., Giles, A., & Manivel, V. (2019). COACHRED: A protocol for the safe and timely incorporation of focused echocardiography into the rhythm check during cardiopulmonary resuscitation. Emergency Medicine Australasia, 31(6), 1115-1118. https://doi.org/10.1111/1742-6723.13374.

Credits:
The discussions were mediated by ED consultant and ultrasound guru Dr Kenny Yee, ED consultant and clinical toxicologist Dr Richard Mc Nulty, 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.

Music/Sound Effects

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• Sea Curr...

Theme: 
Cardiology.

Participants: 

Dr Aaisha Ferkh (cardiology fellow), Dr Samia Kazi (cardiology fellow), Dr Khanh Nguyen, Dr Pramod Chandru, Kit Rowe, Shreyas Iyer, Caroline Tyers and Samoda Wilegoda Mudalige.

Discussion 1:
Lemkes, J., Janssens, G., van der Hoeven, N., Jewbali, L., Dubois, E., & Meuwissen, M. et al. (2019). Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. New England Journal Of Medicine, 380(15), 1397-1407. https://doi.org/10.1056/nejmoa1816897.  

Take-Home Points:

• This study showed that in patients successfully resuscitated from out-of-hospital cardiac arrest, who did not have STEMI, immediate coronary angiography and revascularisation did not improve survival at 90 days.
• It may be reasonable to consider early coronary angiography in certain patients after discussion with the interventional cardiologist (e.g. if there is a good history of ischemic symptoms prior to the arrest or if the patient has a significant cardiac background).
• It is also important to focus on other aspects of post-resuscitation care e.g. targeted temperature management, vital organ support, and treating the underlying aetiology of the cardiac arrest.

Discussion 2:

Aslanger, E., Yıldırımtürk, Ö., Şimşek, B., Sungur, A., Türer Cabbar, A., & Bozbeyoğlu, E. et al. (2020). A new electrocardiographic pattern indicating inferior myocardial infarction. Journal Of Electrocardiology, 61, 41-46. https://doi.org/10.1016/j.jelectrocard.2020.04.008.

Take-Home Points:

• ECG criteria for this pattern (or "Aslanger’s pattern"): ST-segment elevation isolated to lead III, concomitant ST depression in any of V4 to V6 (with a positive/terminally positive T-wave), and ST-segment in V1 > V2.
• This pattern may indicate inferior MI in patients “with concomitant critical lesion/s in coronary arteries other than the infarct-related artery”.
• This study shows that patients with this particular ECG pattern have a higher risk of short- and long-term mortality than other NSTEMI patients; however, more research is required to corroborate these findings. 
• If the patient has ongoing chest pain (without any other obvious cause), it is important to do serial ECGs and escalate concerns to the cardiology team (regardless of what their ECG might show). 

ECG example (from Life In The Fast Lane):
https://litfl.com/wp-content/uploads/2020/12/Aslanger-pattern-of-ECG-chages-in-inferior-myocardial-infarction-2020.png.

Discussion 3:

Schüpke, S., Neumann, F., Menichelli, M., Mayer, K., Bernlochner, I., & Wöhrle, J. et al. (2019). Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes. New England Journal Of Medicine, 381(16), 1524-1534. https://doi.org/10.1056/nejmoa1908973. 

Take-Home Points:

• This study demonstrated that, in patients with ACS (with or without ST-segment elevation), the incidence of death, MI, and stroke was significantly lower among patients who were treated with Prasugrel than among patients who were treated with Ticagrelor. 
• The incidence of major bleeding was similar between the two treatment groups.
• Prasugrel is currently unavailable in the Australian market and in this context, the preferred agent is Ticagrelor (unless it is contraindicated). However, prior to choosing an agent, it is worth discussing with the cardiology team due to variations in individual practice, local protocols, and time of administration. 
• When choosing DAPT, always consider the drug's contraindications and risk of potential complications (e.g. bleeding). If a patient has a higher risk of bleeding and is above the age of 70 years, it might be safer to use Clopidogrel. The main contraindications for use of Ticagrelor are increased risk of bleeding and higher degrees of conduction block. With Prasugrel, watch out for history of stroke as that increases the risk of intracranial bleeding. 

Credits:
The discussions were mediated by ED consultants,  Dr Khanh Nguyen and 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.

Music/Sound Effects

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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]

See you next time,

Caroline, Kit, Pramod, Samoda, and Shreyas.

Theme: 
Toxicology.

Participants: 

Dr Satish Mitter, Pramod Chandru, Samoda Wilegoda Mudalige, Kit Rowe, Rachel Ng, Shreyas Iyer, and Caroline Tyers.

Discussion 1:
“Clinical outcomes from early use of digoxin specific antibodies versus observation in chronic digoxin poisoning (ATOM-4)”

Betty S. Chan, Geoffrey K. Isbister, Colin B. Page, Katherine Z. Isoardi, Angela L. Chiew, Katharine A. Kirby & Nicholas A. Buckley

https://doi.org/10.1080/15563650.2018.1546010.

Take-Home Points:

• The results from this study suggest no benefit from routine use of DigiFab for chronic digoxin toxicity. 
• Clinical indications for DigiFab use include - cardiac arrest, ventricular arrhythmias or runs of ventricular ectopic complexes and bradyarrhythmias associated with hypotension. 
• Digoxin levels should only be performed under specific circumstances (not routinely for all patients on digoxin but rather in the context of an AKI or when there is a clinical suspicion of potential toxicity). 
• When managing chronic digoxin toxicity, correcting any precipitating factors such as volume depletion and electrolyte abnormalities is critically important.
• Identifying patients at risk of digoxin toxicity (the typical patient is the elderly patient with multiple comorbidities) and drugs that impair digoxin toxicity (NSAIDs and diuretics) is also vital to your overall assessment. 

Discussion 2:

Case of malathion (organophosphate) poisoning. 

• 55-year-old male found unconscious surrounded by chemicals at home. 
• Developed clear cholinergic toxidrome, tachycardia, and hypotension in ICU.
• Received atropine on a doubling regimen every 5 minutes: reaching 16mg (and then a continuous infusion) with improvement in his symptoms (including this tachycardia).
• Infusion weaned after 24 hours with recurrence of hemodynamic instability requiring inotropic support and recommencement of atropine on day 3.
• Required atropine for 31 days in total. 

 Take-Home Points:

• The standard, routinely taught presentations for cases do not always apply: this patient was tachycardic rather than bradycardic with his organophosphate toxicity (and this tachycardia responded to atropine). 
• Atropine for organophosphate toxicity is vital. 
• Oximes (such as pralidoxime) are occasionally used in the treatment of organophosphate toxicity but should be discussed with toxicology specialists prior to use. 

Discussion 3:

“Use of antipsychotics and risk of myocardial infarction: a systematic review and meta‐analysis”

Zheng-he Yu, Hai-yin Jiang, Li Shao, Yuan-yue Zhou, Hai-yan Shi and Bing Ruan                            

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5338104/.

Take-Home Points:

• This study suggests an association between antipsychotic use and an increased risk of MI (OR 1.88). 
• This risk appeared to be greater within the first 30 days of use (when taking daily doses); with the risk decreasing over time. 
• There was however significant heterogeneity in the data studied. 
• The recent commencement of an antipsychotic may be worth considering as an added risk factor for ischaemic heart disease in a patient presenting with chest pain.

Credits:
The discussions were mediated by ED consultant and toxicologist Dr Satish Mitter 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 to our first podcast episode!

Please send us an email to let us know what you thought.

You can contact us at [email protected]

See you next time,

Caroline, Kit, Pramod, Samoda and Shreyas.