Episode 8 - The Lockdown Special

This episode is the LOCKDOWN SPECIAL - we will (1) explore the pertinent issue of access block in our emergency departments, (2) discuss management options for first-time primary spontaneous moderate to large pneumothorax, and (3) dissect two valuable tools that help us in the management of patients who present with a headache that is concerning for a subarachnoid haemorrhage (SAH). This month's interlude segment will be presented by Dr Pramod Chandru.
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. 


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Thank you for listening!


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

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