Journal Club Podcast April 2022
Dr Bertha Wu Prof Peter Cameron Dr Divya Karna
Editor: Dr David McCreary
WELCOME TO THIS MONTH’S JOURNAL CLUB PODCAST. WE ARE JOINED BY PROFESSOR PETER CAMERON, ACADEMIC DIRECTOR FOR THE ALFRED EMERGENCY AND TRAUMA CENTRE, AND DR DIVYA KARNA, EMERGENCY PHYSICIAN.
This month we review 4 papers covering topics of pre-hospital resuscitation of trauma patients with blood products, pad positioning for cardioverting AF, large-bore vs pigtail intercostal catheter use for traumatic haemothorax, and whether pain scores impact the prediction of patient outcome by triage scores.
PAPER 1: RESUSCITATION WITH BLOOD PRODUCTS IN PATIENTS WITH TRAUMA-RELATED HAEMORRHAGIC SHOCK RECEIVING PREHOSPITAL CARE (REPHILL): A MULTICENTRE, OPEN-LABEL, RANDOMIZED CONTROLLED, PHASE 3 TRIAL
READ IT HERE
CLINICAL QUESTION:
Is prehospital administration of packed red cells and lyophilised plasm (LyoPlas) superior to 0.9% in resuscitating patients with trauma-related haemorrhagic shock?
DESIGN
Multicentre, open-label, parallel group, randomized controlled trial, with allocations concealed and primary outcome accessors blinded. The study was performed over 6 years from 2016-2021.
POPULATION
Inclusion:
Adults (>16 years)
Trauma-related haemorrhagic shock and hypotension (defined as SBP<90mmHg or absent palpable radial pulse)
Exclusion:
Patient had already been transfused blood products prior to assessment for eligibility
Known refusal to receive blood products
Pregnancy (known or apparent)
Isolated head injury without evidence of haemorrhage
Prisoners
INTERVENTION
Participants receive up to two units each of PRBC and LyoPlas
COMPARISON
Participants receive up to 4 x 250mL bags of 0.9% NaCl
For both groups, the interventions were administered until either hospital arrival, a return of systolic BP to 90mmHg or more, or when a radial pulse was palpable. If BP decreased on the way to hospital, treatment was re-instigated.
OUTCOMES
Composite primary outcome: (powered for 10% difference)
Episodic mortality OR
Impaired lactate clearance (<20% in 2 hours) OR
Both
Secondary outcomes:
Rates of transfusion related complication sin the first 24hrs after ED arrival
Serious adverse events
Treatment-related deaths
FINDINGS
Trial recruitment was stopped before it achieved the intended sample size of 490 participants due to disruption caused by the COVID pandemic
Only 432 participants were assigned to the PRBC-LyoPlas (n=209) or to the 0.9% sodium chloride group (n=223)
The composite primary outcome occurred in 128 (64%) of 199 participants randomly assigned to PRBC-LyoPLas and 136 (65%) of 210 randomly assigned to 0.9% sodium chloride adjusted risk difference -0.025% with 95% CI -9.0 to 9.0, p = 0.996
Rates of transfusion related complication in first 24hrs after ED arrival were low and similar across treatment groups (PRBC-LyoPlas 11 (7%) of 148 vs 0.9% NaCl 9 (7%) of 137, adjusted relative risk 1.05 (95% CI 0.46-2.42)
One rare serious adverse events in each treatment group (Cerebral infarct in PRBC-LyoPlas vs deranged LFTs 0.9% NaCl)
No treatment-related deaths
AUTHORS' CONCLUSIONS
The study did not show that prehospital PRBC-LyoPlas resuscitation was superior to 0.9% NaCl for adult patients with trauma related haemorrhagic shock.
JOURNAL CLUB THOUGHTS
The study had a robust design and an important clinical question asked. It was disappointing that a positive outcome wasn’t found and it won’t add much to our current practice. The choice of including lactate clearance in the composite outcome was interesting… It’s not very relevant to clinical practice! Notably, death within 3 hours was 16% for the PRBC-LyoPlas group and 22% for the 0.9% NaCl group, correlating to a 6% difference. It leaves one to wonder if the study would have had a different finding if it was better powered and mortality was used as the primary outcome.
However, average prehospital time for participants in the study was 20-30 minutes, so it’s possible that whether we resuscitate with blood products vs crystalloids in this patient cohort with a short prehospital transport time indeed does not make a difference. This is likely much more relevant for the patients from rural and remote areas where transport times to a major trauma centre can sometimes take a few hours.
BOTTOM LINE
Unfortunately, this study did not have any practice-changing findings, even though it set out to be a very promising trial. Further trials with improved study power and including patient cohorts with longer prehospital transport times would add to the clinical question asked.
PAPER 2: ANTERIOR-LATERAL VERSUS ANTERIOR-POSTERIOR ELECTRODE POSITION FOR CARDIOVERTING ATRIAL FIBRILLATION
READ IT HERE
CLINICAL QUESTION:
Is either anterior-lateral or anterior-posterior electrode position superior to the other for cardioverting Atrial Fibrillation?
DESIGN
Multicentre, open-label, randomized controlled trial
POPULATION
Inclusion criteria
Adult patients (>18yo) with AF
Scheduled for elective cardioversion
Pts had received sufficient anticoagulation or a TTE documenting the absence of intracardiac thrombi
Exclusion criteria
Pt with arrhythmias other than AF
Untreated hyperthyroidism
Known or suspected pregnancy
Those previously enrolled in the trial
INTERVENTION
Receiving cardioversion shocks using anterior-lateral electrode positioning
Shocks were delivered until sinus rhythm was restored or up to max of 4 shocks – using escalating energy shocks of 100J, 150J, 200J, 360J
COMPARISON
Receiving cardioversion shocks using anterior-posterior electrode positioning
OUTCOMES
Primary outcome:
The proportion of patients in sinus rhythm 1 minute after the first shock
Secondary outcome:
The proportion of patients in sinus rhythm 1 minute after final shock (up to 4 shocks)
Cardioversion efficacy at discharge 2 hrs after cardioversion
Safety outcomes:
Number of pts with arrhythmic events (asystole, AV block, transient brady, ventricular Arrhythmia)
Skin redness
Patient-reported periprocedural pain
FINDINGS
Primary outcome (return to SR after first shock)
Anterior-lateral: 54% | Anterior-posterior: 33% | 22% risk difference (95% CI 13-30, p < 0.001); corresponding to NNT 5.
Secondary outcome
Number of patients in sinus rhythm after final shock was 93% in anterior-lateral compared to 85% in anterior-posterior positioning. Risk difference 7% (95% CI, 2-12), corresponding to NNT 14 (95%, CI 8-50).
Safety outcomes similar between treatment groups.
AUTHORS' CONCLUSIONS
Anterior-lateral electrode positioning resulted in significantly more patients obtaining SR when compared with Anterior-posterior electrode position for cardioverting AF.
JOURNAL CLUB THOUGHTS
The study finding was interesting, as the traditional teaching is that anterior-posterior electrode positioning is better than anterior-lateral positioning in cardioverting AF. Unfortunately, participants included in this study were not representative of the ED patient cohort as they were all elective patients booked for cardioversion in the outpatient setting. A study in the future including patients indicated for cardioversion in the emergency department would be useful.
BOTTOM LINE
The study finding changes how we think about electrode positioning in cardioverting AF. I may be more inclined to use anterior-lateral electrode positioning in the future, especially for the unstable patient who requires multiple people to do a log roll for posterior pad placement in a busy department.
PAPER 3: THE SMALL (14 FR) PERCUTANEOUS CATHETER (P-CAT) VERSUS LARGE (28-32 FR) OPEN CHEST TUBE FOR TRAUMATIC HEMOTHORAX: A MULTICENTRE RANDOMIZED CLINICAL TRIAL
READ IT HERE
CLINICAL QUESTION:
Are small (14 Fr) percutaneous catheters (P-CAT) non-inferior to large (28-32 Fr) open chest tubes in the treatment of traumatic hemothorax?
DESIGN
Multicentre RCT performed over 6yrs from 2015-2020
POPULATION
Inclusion:
18yrs or older, and
Traumatic haemothorax, or
Haemopneumothorax requiring drainage
Exclusion:
Pt in extremis e.g. haemodynamic instability that required emergent tube placement
Those who refused to participate
INTERVENTION
Small (14 Fr) percutaneous catheter (P-CAT) insertion
COMPARISON
Large (28-32Fr) open chest tube insertion
OUTCOMES
Primary outcome:
Failure rate – defined as retained haemopneumothorax requiring a second intervention
Secondary outcome:
Daily drainage output
Tube days
Intensive care unit LOS
Hospital LOS
Insertion perception experience (IPE score) on a scale of 1-5 (1 tolerable, 5 worst experience)
FINDINGS
The study was cut short due to prolonged period of enrollment and interruption by COVID outbreak.
After exclusion, 119 pts participated in the trial - 56 randomized to the P-CAT arm and 63 to the chest tube arm. Baseline characteristics between two groups were similar. The failure rate for P-CATs was 11% vs 13% for chest tubes (p = 0.74).
Secondary outcomes were similar between groups, except patients in the P-CAT arm reported lower insertion perception experience IPE scores (median 1 “tolerable experience”, IQR 1-2) vs chest tubes (median 3 “it was a bd experience”, IQR 2-5 p < 0.001).
AUTHORS CONCLUSION
Small caliber 14 Fr P-CATs are equally as effective as 28-32 Fr chest tubes in their ability to drain traumatic haemothorax with no difference in complications.
JOURNAL CLUB THOUGHTS
This study has many design flaws. Patients who were hemodynamically unstable were excluded from the study – this patient cohort constitutes most of those who we would usually insert a large bore chest tube for in ED. The authors created their own institutional score termed IPE scores which was subjective and not scientifically validated. They also didn’t standardize the dosage or type of analgesia used for tube insertion. There was also significant conflict of interest – the study was partially funded by Cook Medical LLC – the company that makes pigtails.
BOTTOM LINE
This is not a well-designed study, performed on a population that is not generalizable to the ED patient cohort. It will not change my practice.
PAPER 4: IMPACT OF PAIN ASSESSMENT ON CANADIAN TRIAGE AND ACUITY SCALE PREDICTION OF PATIENT OUTCOMES
READ IT HERE
CLINICAL QUESTION:
How does pain as a triage factor affect the ability of CTAS to predict patient acuity?
DESIGN
Single centre, retrospective observational cohort study performed in a tertiary ED
POPULATION
All adults aged >18yrs who visited the Jewish General Hospital ED over June 2017 – Jan 2022
All patient visits prior to COVID-19 pandemic were included
Data post COVID-19 pandemic was not included as this substantially altered patient population and workflow
INTERVENTION
A modified “pain-free” CTAS algorithm used for each visit in the cohort, assuming that pt had not reported any pain.
COMPARISON
Using standard CTAS algorithm which combined patient-reported pain levels with other data to generate a triage score for each visit, The standard CTAS algorithm has a minimum level of acuity that must be assigned to a patient based on the severity, location and chronicity of pain.
OUTCOMES
Primary outcome: Acuity of patient, defined by 3 variables
Admission
ICU consultation
In-hospital mortality within 72 hours on arrival to ED
FINDINGS
A sample of 229,744 patients were analysed. Distribution of standard CTAS scores showed that most visits were assigned to the mid range CTAS – 2 (22.5%), 3 (50%), 4 (21%). The study found that removing pain scale from CTAS algorithm can lower the acuity of a case compared to the standard CTAS, but can never increase it. Higher pain was slightly negatively correlated with hospital admission, ICU consultation, and 72-hour mortality (r = - 0.008, -0.009, -0.006 respectively).
AUTHORS' CONCLUSIONS
The removal of pain scale from CTAS did not reduce its ability to predict hospital admission, ICU consultation or the 72-hour mortality. But this did move a large number of patients to the less acute triage categories.
JOURNAL CLUB THOUGHTS
We all know that patients’ reported pain score do not always correlate with the severity of the underlying pathology that caused the pain. However, these patient groups do require early medical attention for pain management. We’re not sure what this study adds.
BOTTOM LINE
The study is somewhat irrelevant and there will be no change to current practice.
REFERENCES
Crombie N, Doughty HA, Bishop JRB, Desai A, Dixon EF, Hancox JM, et al. Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial. Lancet Haematol. 2022;
Schmidt AS, Lauridsen KG, Møller DS, Christensen PD, Dodt KK, Rickers H, et al. Anterior–Lateral Versus Anterior–Posterior Electrode Position for Cardioverting Atrial Fibrillation. Circulation. 2021;144(25):1995–2003.
Kulvatunyou N, Bauman ZM, Edine SBZ, Moya M de, Krause C, Mukherjee K, et al. The small (14 Fr) percutaneous catheter (P-CAT) versus large (28–32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial. J Trauma Acute Care. 2021;91(5):809–13.
Davis S, Ju C, Marchandise P, Diagne M, Grant L. Impact of Pain Assessment on Canadian Triage and Acuity Scale Prediction of Patient Outcomes. Ann Emerg Med. 2022;79(5):433–40.MBBS, CCPU (eFAST, AAA, BELS). Emergency Medicine Advanced Trainee and Intensive Care Medicine Trainee in Melbourne, Australia. Particular interests in POCUS, medical education and health care in resource-poor settings. Twitter: @berthawu29
DR BERTHA WU
Emergency Registrar
MBBS, CCPU (eFAST, AAA, BELS). Emergency Medicine Advanced Trainee and Intensive Care Medicine Trainee in Melbourne, Australia. Particular interests in POCUS, medical education and health care in resource-poor settings. Twitter: @berthawu29
