Recording for the 5th episode of the Rural Postgraduate Programme/Division of Rural Hospital Medicine New Zealand’s webinar series. Garry, Rory and Matilda discuss the management of heart failure.
Rural health news and research from the Rural Section, Dept. GP and Rural Health
Medical RiSC is a course run by the University of Otago Rural Postgraduate Programme. Designed specifically for interprofessional rural hospital teams in New Zealand, it is an immersive three-day course that focuses on emergency medical care using highly realistic skills simulations and workshops.
We are inviting rural hospital doctors, nurses, paramedics and rural GPs to attend and extend their clinical knowledge and skills for medical emergency management.
Is looking to be a great course!
Sign up your team or attend as an individual!
Register @ bit.ly/RuralCME-StrokeUpdate
Recording from the latest Rural CME webinar in case you missed it or want to watch it again. Below are some additional resources including Dan’s Pneumonic device for delirium (I CLAP in time).
There are some really good printable self help guides here; https://web.ntw.nhs.uk/selfhelp/
I often recommend people have a look at https://www.headspace.com/ which is a smart phone app that teaches / guides people through relaxation exercises.
http://www.mhaids.health.nz/your-health/help-for-mild-to-moderate-mental-health-issues/ is a page with a lot of links to other support resources and there are a whole load of other information and support agencies out there.
I CLAP (in time)
I Inattention (most sensitive sign)
C Cognitive Impairment (Think of the domains on the MoCA)
L Level of Consciousness (usually decreased but can be increased arousal)
A Affective changes (usually depression)
P Perceptual disturbance (visual hallucinations)
These are the classic symptoms of delirium.
They occur ACUTELY and TEND TO FLUCTUATE (that’s the ‘time’ bit).
Conway JC, Friedman BW. Medical Expulsive Therapy (Alpha Blockers) for Urological Stone Disease. Academic Emergency Medicine. 2020 Feb 7. EZ Proxy link
A systematic review that updates the Cochrane review from 2014. Table summarising findings below: Alpha blockers appear safe and effective, especially if stone >5mm, for expelling stone and reducing need for hospital admissions.
Urinary tract stones are common and usually painful. Lifetime prevalence is approximately 10%.1 Direct health care costs are estimated to be over $10 billion dollars annually.2 First‐line treatment is typically analgesia with nonsteroidal anti‐inflammatory drugs until the stone passes. If the stone does not pass spontaneously, urologic intervention may be necessary.3 Spontaneous passage rates for small stones less than 5 mm is 68% and for stones between 5 and 10 mm is 47%.4 Certain medications such as alpha blockers are sometimes used to hasten passage of stones and decrease the need for urologic intervention or hospitalization. Alpha blockers act on ureteral alpha‐1 receptors and decrease the basal tone and peristalsis, thereby facilitating stone passage.5 However, conflicting results from randomized controlled trials (RCTs) have limited their use. The systematic review discussed here is an update of a 2014 Cochrane review.6 It includes several new, large, RCTs.
The purpose of this systematic review was to determine the effectiveness of alpha blockers for adult patients with symptomatic ureteral stones measuring less than 1 cm and confirmed by imaging. The systematic review included 67 trials with 10,509 patients. The included studies compared alpha blockers with placebo or medical therapy with non-steroidal anti‐inflammatory drugs, corticosteroids, or antispasmodics. The primary outcomes were stone clearance (defined as stone free imaging, symptomatic relief, or stone collection by the last day of the trial) and major adverse events (defined as orthostatic hypotension, collapse, syncope, palpitations, or tachycardia). Secondary outcomes included hospitalization and the need for surgical intervention. Subgroup analysis compared stone clearance rates for stones 5 mm or smaller versus stones greater than 5 mm. Further analyses examined only high‐quality studies, excluding studies at high risk of bias.6
Overall, the use of alpha blockers was associated with increased stone passage (relative risk [RR] = 1.45, 95% confidence interval [CI] = 1.36 to 1.55, absolute risk difference [ARD] = 28%, number needed to treat [NNT] = 4, low‐quality evidence) without increasing the risk of major adverse events. Alpha blockers were also associated with a lower risk of hospitalization (RR = 0.51, 95% CI = 0.34 to 0.77, ARD = 14%, NNT = 7, moderate‐quality evidence) and no difference in the risk of surgical intervention (low‐quality evidence). The subgroup analysis based on the size of the stone revealed that alpha blockers did not impact passing of stones ≤ 5 mm but did improve passing of stones > 5 mm (RR = 1.45, 95% CI = 1.22 to 1.72, ARD = 30%, NNT = 3, moderate‐quality evidence).6 When the analysis was performed using high‐quality trials only, alpha blockers increased stone passing (RR = 1.09, 95% CI = 1.06 to 1.13; ARD = 7%, NNT = 15, high‐quality evidence, five studies, 4,133 participants) while having no effect on major adverse events, hospitalization, or surgical intervention.6
This review is limited in several ways. Most importantly, the quality of evidence for most outcomes was low due to several methodologic limitations of the included studies, inconsistency in study results, publication bias, a lack of prospectively stratified subgroups, and clinically important heterogeneity.
The findings of this meta‐analysis are consistent with other recently published meta‐analyses.7 However, some included RCTs, such as the SUSPEND trial, did not demonstrate a benefit for MET.8–10 The findings of individual RCTs may have been skewed toward no benefit because of limited sample size, a high percentage of smaller stones, and insufficient power to detect group differences between small and large stones. Additionally, a recent, large RCT, the STONE trial, was not included in this meta‐analysis. The STONE trial, which included 512 patients found no significant differences in outcomes.11 These findings are unsurprising as this trial has the same limitations as other individual RCTs. Because of the lack support for MET by several well‐designed RCTs, it is important to counsel patients on the potential limitations of the evidence that is being used to recommend MET.
In summary, using alpha blockers appears to be beneficial in increasing ureteral stone passage (especially if stones are >5 mm) and reducing hospitalization. They appear to be safe as they do not increase the risk of major adverse events when compared to placebo, non-steroidal anti‐inflammatory drugs, corticosteroids, or antispasmodics. Because benefit is likely (particularly for stones larger than 5 mm) and there is no apparent harm, we have assigned a color recommendation of green (benefits > harm) to this treatment.
Parker CM and Cooper MN. Prednisolone Versus Dexamethasone for Croup: a Randomized Controlled Trial. Pediatrics. 2019;144(3):e20183772
Comment from Yan:
Parker et al concluded that there is no significant difference between dexamethasone 0.6mg/kg, 0.15 mg/kg and prednisolone at 1 mg/kg in the treatment of croup in this prospective, double-blind, noninferiority randomised controlled trial in an Australian tertiary ED paediatric population. Primary outcomes were an hourly croup score and 7 days re-attendance rate.
My biggest criticism of this otherwise well carried out trial was that only 1 in 7 croup cases were enrolled (deemed ‘convenience sample’). There was also no analysis to look at any potential differences between the enrolled and non enrolled group. The study in the end did not achieve the pre-determined target number of subjects for the non inferiority analysis, but the confidence intervals clearly overlap across the groups.
Also 30% of enrolled patients did not have phone follow up (meaning GP re-attendance not accounted for in this group). Note also that the single dose prednisolone 1mg/kg group is more likely to require further doses of steroids than the dexamethasone groups. I think this study still doesn’t answer the question about which steroid to give these kids conclusively.
In practice, this study seems not to contradict what is probably the most common practice in rural—for the bulk of croup patients, prescribe single dose oral dexamethasone if available or a course of prednisolone if not (Starship recommends 2 days at 1mg/kg.)
OBJECTIVES: The use of either prednisolone or low-dose dexamethasone in the treatment of childhood croup lacks a rigorous evidence base despite widespread use. In this study, we compare dexamethasone at 0.6 mg/kg with both low-dose dexamethasone at 0.15 mg/kg and prednisolone at 1 mg/kg.
METHODS: Prospective, double-blind, noninferiority randomized controlled trial based in 1 tertiary pediatric emergency department and 1 urban district emergency department in Perth, Western Australia. Inclusions were age >6 months, maximum weight 20 kg, contactable by telephone, and English-speaking caregivers. Exclusion criteria were known prednisolone or dexamethasone allergy, immunosuppressive disease or treatment, steroid therapy or enrollment in the study within the previous 14 days, and a high clinical suspicion of an alternative diagnosis. A total of 1252 participants were enrolled and randomly assigned to receive dexamethasone (0.6 mg/kg; n = 410), low-dose dexamethasone (0.15 mg/kg; n = 410), or prednisolone (1 mg/kg; n = 411). Primary outcome measures included Westley Croup Score 1-hour after treatment and unscheduled medical re-attendance during the 7 days after treatment.
RESULTS: Mean Westley Croup Score at baseline was 1.4 for dexamethasone, 1.5 for low-dose dexamethasone, and 1.5 for prednisolone. Adjusted difference in scores at 1 hour, compared with dexamethasone, was 0.03 (95% confidence interval −0.09 to 0.15) for low-dose dexamethasone and 0.05 (95% confidence interval −0.07 to 0.17) for prednisolone. Re-attendance rates were 17.8% for dexamethasone, 19.5% for low-dose dexamethasone, and 21.7% for prednisolone (not significant [P = .59 and .19]).
CONCLUSIONS: Noninferiority was demonstrated for both low-dose dexamethasone and prednisolone. The type of oral steroid seems to have no clinically significant impact on efficacy, both acutely and during the week after treatment.
Yan Wong is a rural doctor in Balclutha, Otago. He is also a convener for the GENA725 – Communication in Rural Hospital Medicine, which is running in semester 1 of this year. This course covers palliative care, Māori health, mental health, alcohol and drugs/addiction among other things, all with a rural context focus. The residential is based on a marae in the beautiful Hoikianga
Recording of the inaugural webinar hosted by Dr. Matilda Hamilton. Gerry Wilkins, a cardiologist at Dunedin Hospital gives an update on Atrial Fibrillation.
Webinar will be recorded and posted here for viewing when suits.
Guest Author: Dr Jonathon Wills 2019
This is a big topic, which I have tried to divide up and cover as broadly as possible. I am only qualified in this by having done a few more than your average rural doctor, due to a previous life as a registrar in cardiothoracics. This hopefully draws together a number of guidelines with a rural focus. If there are any big gaps or contradicting evidence please comment below.
Firstly, here is a summary of my interpretation of the evidence:
Obviously needs decompression immediately. This can be via finger thoracostomy or needle decompression. Physician choice as to which method, but the main consideration is timeliness.
There is some evidence that decompression in the midaxillary line, 2nd intercostal space often fails with standard cannulas due to chest wall thickness and that the anterior/midaxillary line, 5th intercostal space may be more reliable.1 Needle decompression needs to be followed by a drain.
Make a distinction between primary and secondary.
Evidence here is changing, it seems there has been some local work which is yet to be published, but the results favour more conservative management of primary pneumothorax in most instances. The recommendations here are based on the currently published literature, but watch this space.
Small (ie: less than 2cm at the hilum or 3cm at the apex) can probably be managed conservatively, and are probably safe to monitor out of hospital.2
Large: (more than 2cm at the hilum or 3cm at the apex) may still be able to be managed conservatively in minimally symptomatic patients, but will resolve quicker with aspiration or drainage. Really big ones (ie; complete lung collapse) should have a percutaneous/Seldinger drain.3
This evidence requires a little caution in the rural context where patient might not be able to get back to hospital quickly. I would have a lower threshold for small bore percutaneous/Seldinger drain and making sure no ongoing air leak (ie: the bubbling stops)
There are currently no good studies comparing needle aspiration to small bore saldinger drains (original studies were using large surgical drains and benefit was decreased admission rates plus length of stay.4
Needle aspiration is likely to fail to resolve the pneumothorax with complete lung collapse and tends to fail about ⅓ of the time anyway.5,6 Likewise, if more than 2.5L of air is aspirated there is a high likelihood of ongoing leak, therefore these patients should have a drain.7
BTS guidelines suggest ok to fly after full resolution, rather than a mandatory time-frame. If you work in a part of the world with loads of tourists this may be an indication to drain more frequently.
If there is a need for ongoing transfer, particularly air transport, consideration should be given to drainage prior.
My general philosophy is if I am going to intervene, I do so with a percutaneous drain, mainly because then I don’t have to stand there aspirating, but also because having punctured the pleura, it doesn’t take much to saldinger exchange for a drain.
diseased lung eg asthma, COPD e.t.c.
Due to the compromised underlying lung, these patients are less likely to be suitable for conservative management. Firstly smaller pneumothoraces cause more respiratory compromise due to less physiological reserve.8 Secondly, there is higher risk of ongoing air leak from diseased lung.9
Small secondary pneumothoraces should be observed in hospital and large or symptomatic ones should be drained, needle aspiration has higher failure rates due to ongoing air leak.
Therefore, similar to treating primary spontaneous pneumothorax, if I am going to intervene (which is much more likely in secondary pneumothorax) I tend to put in a percutaneous drain.
Oxygen therapy; very old small human and animal studies show up to four fold increase in resorption with oxygen therapy.10 There is no recent or high quality evidence for this, particularly in light of growing evidence of harm from oxygen.
If your are draining the pneumothorax, short of treating hypoxia there is no point. When pneumothoraces are managed conservatively (and patient not hypoxic) I am not sure of the of the benefit to potential harm ratio.
Drain properly/dry; 50% will reaccumulate.11 They are likely to need repeat procedure earlier if just aspirated/incompletely drained. Clamp at 1.5L for 2 hours (see note below about re-expansion pulmonary oedema).
Consider early pleurodesis; talc is best agent.12 VATS (video assisted thoracic surgery) pleurodesis is probably the most effective method (95%), though talc slurry is almost as good (90%).13 Lung expansion needs to be confirmed first, as pleurodesis can’t be effective if the pleura aren’t in contact.14 In the rural setting, bedside talc pleurodesis is probably a reasonable therapy given similar success rates to VATS and it could be delivered locally.
Most malignant pleural effusions will reaccumulate. Therefore if survival more than a few months is predicted (LENT score is the only validated tool for this15) more definitive management (ie pleurodesis talc slurry versus VATS procedure) or indwelling pulmonary catheter (particularly if lung trapped because pleurodesis very likely to fail if lung can’t re-expand) should be considered,16 though these procedures are likely to be unavailable at rural hospitals.
Re-expansion pulmonary oedema is a rare but nasty complication of pleural space drainage. Risk factors for re-expansion pulmonary oedema are younger age(20–40), duration of collapse longer than 1 week and volume greater than 3000mL. There is no real evidence for the arbitrary value of 1.5L, re-expansion pulmonary oedema has been reported at much lower volumes. In fact most of these risk factors seem to be very old and week evidence and the most recent case series suggests it doesn’t matter, (though they did use manometry to ensure no greater than –20cm intrapleural pressure). In this case fluid was removed manually via syringe- not by free drainage.17
ie: either too small to sample, or a free-flowing small effusion has a neutrophilic exudate (an elevated protein level >0.5 percent of serum and/or a lactate dehydrogenase (LDH) level >0.6 that in the serum), a normal pH, a normal glucose level, and does not contain micro-organisms
Probably OK to leave alone and will resolve with appropriate treatment for pneumonia. Parapneumonic effusions that don’t meet above criteria are considered complicated and should be drained percutaneously.18
Needs to be drained, small bore probably ok.21 Intrapleural fibrinolysis as above can reduce the need for surgery
Should probably be drained based on current practise. There is very little data unless they are small.24
ATLS convention says all traumatic pneumothoraces should be drained.25
Occult traumatic pneumothoraces (those seen on CT but not plain X-ray can probably be managed conservatively (90% no significant deterioration), even those on positive pressure ventilation.26,27 (This is retrospective observational data and those treated conservatively had smaller pneumothoraces than those who were drained.) Those with concurrent haemo-pneumothorax were more likely to fail conservative management.
I can’t find any evidence about ‘occult pneumothoraces’ when diagnosed by ultrasound rather than CT- but maybe similar to ones on CT?
In the setting of chest tube placement for traumatic pneumothorax; antibiotics should be given to cover staph and strep (less pneumonia and empyema).30
Three sided dressing appear out- they mostly don’t work. Recommendations are to occlude wound with a vented dressing if available, if not simply seal the wound with an occlusive dressing and monitor closely for signs of tension pneumothorax.31
I am a little sceptical here, occlusive dressings seem unnecessarily risky. Did someone on the committee have shares in a specialised vented dressing?
Place chest tube through a clean site, close wound (simple dressing is fine initially, or formal closure provided that don’t meet indications for the formal operative thoracotomy)-
I can’t find any good evidence for this other than various brief statements in various trauma guidelines.
Drain it unless very small- retained blood in the pleural space is a problem; complication include empyema (up to 33%) or fibrosis impairing lung function.32
However, there is some suggestion a more conservative approach is coming here too!33 However about ⅓ of those observed initially did require a drain. Four independent predictors of failed observation were identified: older age, fewer ventilation-free days, large hemothorax, concurrent pneumothorax.
therefore transfer to a cardiothoracic service if you haven’t already…
There is some retrospective evidence that a combined total of more than 1500 mL blood from a chest tube has higher mortality and this value can be used regardless of rate of accumulation.36 Beyond this most guidelines state: greater than 1500 mL total or more than 200mL/hr for 2–4 hours.
These should usually be drained as per haemothorax. Also, as above, pneumothoraces are more likely to require drainage if associated blood.
Having covered the covered the evidence, I cannot finish without a personal rant.…
Open tube thoracostomy (ie: surgical drain) is a very different procedure to percutaneous techniques (eg: Saldinger) and you need to have different considerations prior to procedure. I commonly see ideal locations for the two confused.
An open tube thoracostomy is a surgical procedure that requires safe access to the pleura.
Considerations for location of this procedure involves establishing safe passage through minimal tissue to the pleural space. Traditionally this is the ‘triangle of safety’ around the 4/5th intercostal space in the anterior/midaxillary line (though the 2nd intercostal space midclavicular line can also be used). Because the pleural space is entered by blunt dissection and then confirmed by palpation of the back of the ribs it does not matter if the lung is adjacent to the pleura, it will be safely pushed away by blunt objects as you enter the pleura. Therefore the location of an open tube thoracostomy is determined by safe access to the pleural space, NOT maximal point of pneumothorax or blood/fluid.
In contrary, a percutaneous technique involves using a sharp object to enter the pleural space. (Ultrasound guided of course) To enter the pleural space safely with a sharp object you need space between needle tip and lung. Therefore the best location for this procedure depends mainly on biggest space between visceral and parietal pleura. (though safe passage through the chest wall needs to also be considered, given it is a minimally invasive technique this is less important) Ultrasound guidance means in the setting of pleural fluid you can determine the best location based on a large space between pleural layers. (This will depend on patient position). In the setting of pneumothorax, ultrasound can only determine the pleura are not opposed, rather than the distance between them. Regardless, the same principle applies, you should be placing a saldinger drain only where there is a safe gap between parietal pleura and lung.
Finally when you are securing drains, please don’t spiral the tie up around it, the shortest distance around a cylinder is the circumference, not a spiral- a spiralled tie will slide down and come loose, it may look pretty but its not effective!