December 2018

Interview by Becky Maxwell with Dan Horner after his talk at Spring CPD Conference.

Link to the BTS pulmonary embolism outpatient management guidelines

podcast with Kerstin Hogg available here

Clinical Question:

Does routine pelvic exam add anything to your history to diagnose cervicitis or pelvic inflammatory disease (PID)?

Title of Paper:

The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections for Young Female Patients With Suspected Cervicitis or Pelvic Inflammatory Disease

[PMID 30251627]

Journal and Year:

Annals of Emergency Medicine. 2018.

Lead Author:

Shamyla Farrukh

Background:

• The textbook assessment of female patients with pelvic pain or PV discharge includes a pelvic examination
• Current CDC guidelines suggest using a combination of history and physical examination, relying heavily on pelvic examination to make the diagnosis of cervicitis/PID.
• Diagnostic criteria for cervicitis:
  • Visualisation of inflamed cervix or abnormal discharge in the vaginal canal or cervix
• Diagnostic criteria for PID:
  • Lower abdominal pain with no other obvious cause
  • Abnormal findings on bimanual exam:
    • Cervical motion tenderness
    • Adnexal tenderness
    • Uterine tenderness

Study Design:

• Prospective observational study in a US urban paediatric ED

Patients Studied:

Included:

• Female patients aged 14-20 years
• Presenting to ED with vaginal discharge or lower abdominal pain

Excluded:

• Unstable vital signs
• Need for critical care management
• Patient refusal
• No previous pelvic examination

Methods

• All patients had urine testing for chlamydia, gonorrhoea, trichomonas
• Practitioner recorded standardised history to assess for cervicitis/PID and recorded likelihood of disease on 100mm VAS
• Same practitioner then performed pelvic examination (inspection, speculum and bimanual) and again recorded likelihood of disease on VAS with the additional information taken into account
• VAS ≥50mm indicated they believed the patient had cervicitis or PID
• Assessors were blind to STI testing results

Outcomes:

• VAS before and after examination for STI +ve and STI -ve patients
• Number of cases where examination changed management (moved VAS across the 50mm mark)
• Urine STI results were used as the criteria standard for diagnosis of cervicitis/PID and used to assess the test characteristics of pelvic exam

Summary of Results:

• 288 patients
  • 79 STI +ve
  • STI rate 27.4%
    • Chlamydia 22.6%
    • Gonorrhoea 6%
    • Trichomonas 3.5%
    • Coinfection 3.5%
  • History alone for dx of cervicitis/PID:
    • Sensitivity 54.5% [95%CI 42.8% – 65.5%]
    • Specificity 59.8% [95%CI 52.8% – 66.4%]
    • +LR 1.35 [1.04 – 1.75]
    • -LR 0.76 [0.59 – 0.98]
  • History plus pelvic exam for dx cervicitis/PID:
    • Sensitivity 48.1% [95%CI 36.8% – 59.5%]
    • Specificity 60.7% [95%CI 53.8% to 67.3%]
    • +LR 1.23 [0.92 – 1.63]
    • -LR 0.85 [0.68 – 1.06]
  • Information from examination changed management in 71 cases:
    • 35 correlated to STI +ve
    • 36 did not

Authors Conclusion:

“For young female patients with suspected cervicitis or PID, the pelvic examination does note increase the sensitivity of diagnosis of chlamydia, gonorrhoea, trichomonad compared with taking a history alone.  Test characteristics for pelvic examination are not adequate, its routine performance should be reconsidered.”

Clinical Bottom Line:

• This confirms at least my personal practice: if it looks like a duck and quacks, I don’t need to examine it’s feathers to know its a duck.  I don’t tend to perform intimate examinations unless there is a clinical/diagnostic benefit, and I think this study supports that there probably isn’t a benefit in the routineperformance of pelvic exam for these patients.
• The authors comment in the discussion that the CDC are pushing for a lower threshold for empiric treatment in areas with high prevalence for the overall public health benefit.
• They also comment that pelvic examination is uncomfortable and emotionally distressing to most women, in particular for teenage girls – so are they not less likely to engage in healthcare if they think they are routinely going to have to undergo an intimate exam?

Authors:

– Felipe Teran
– Nick Lim
– Andy Neill

This interview was recorded at EuSEM18 in Glasgow.

Felipe is an emergency physician with extended training in TOE with focus on TOE in cardiac arrest.

He runs a great website with further material

He kept spelling TOE wrong throughout the interview but we were too polite to correct him…

Authors:

– Andy Neill

– Dave McCreary

Clinical Question

– does PoCUS help in guiding position for LPs in infants.

Paper Title:

– The Effect of Bedside Ultrasonographic Skin Marking on Infant Lumbar Puncture Success: A Randomized Controlled Trial

Author

– Neal, Annals of EM, 2017

Background

– LPs are frequently needed in infants as part of of work up for fever less than 60-90 days. Their unvaccinated state means they’re still at risk of meningitis despite the massive reduction in incidence in older kids over the past 20 years.

– LPs are commonly failed in this age group with rates as high as 40% failure reported in the literature.

Methods-

– non blinded RCT done in Boston Children’s hospital ED.

– All infants needing an LP under age 6 months

– Randomised to “have a go as usual” versus the PoCUS guided approach

– Ultrasound was performed by one of 3 people (A ninja, a paduan and a med student with no real experience…)

– The ultrasound was done in the position that the child would be in for the eventual LP (sitting or lateral)

– Images were taken in longitudinal and transverse planes and the conus and subarachnoid space were identified. A depth measurement was taken to give the proceduralist an idea of how far to place the needle.

– An “X” was marked on the child’s back and the ultrasound was removed and the back sterilised as normal.

– Primary outcome was successful first attempt

– powered for a 20% increase in success (assuming 40% failure)

Results

– 128 patients enrolled

– 58% v 31% favouring the PoCUS arm

– this seemed to extend into the 2nd and 3rd attempts also

– especially useful in the less experienced proceduralists (most were in this study)

Thoughts

– there has been some similar work done in adults so it’s not surprising that this might be helpful in infants too.

– hard to see the downside of this but like all things PoCUS related you need the skills available in your ED to make this happen.

Authors

– Nikki Abela

– Stephen Mullen

This interview was recorded at the RCEM CPD conference in 2018

They cover paediatric burns and prediction of non accidental causes. There is a useful paper describing the BURN tool here.

The CORE INFO site mentioned as a resource for NAI can be found here

Clinical Question:

Just how much magnesium do we need to rate control AF?

Title of Paper:

Low dose Magnesium sulphate versus High dose in the early management of rapid atrial fibrillation: randomised controlled double blind study (LOWMAGHI Study)

Journal and Year:

Academic Emergency Medicine. 2018.

Lead Author:

Wahid Bouida

Background:

• We see AF a fair bit, a lot of which is fast…sorry…has rapid ventricular response
• When it comes to slowing down the ticker there are many (many) schools of thought on how to skin this particular cat – calcium channel blockers, beta blockers, digoxin, magnesium, the music of Jack Johnson (RCT pending)
• We love magnesium in medicine, and it’s pretty good at improving ventricular rates – check out the ALiEM review
• It decreases frequency of sinus node depolarisation to prolong the refractory period of the AV node via calcium antagonism, apparently.

Study Design:

• Prospective, randomised, controlled, double-blind study in three Tunisian EDs

Patients Studied:

Inclusion:

• Adults with rapid AF (>120bpm)

Exclusion:

• Hypotension – SBP <90mmHg
• Impaired consciousness
• Renal failure (Cr >180)
• Wide complex tachycardia
• Magnesium contraindication
• Acute MI, CCF, sick sinus, other arrhythmias

Intervention:

• Low dose magnesium – 4.5g MgSO4 in 100ml normal saline

OR

• High dose magnesium – 9g MgSO4 in 100ml normal saline

Comparison:

• Placebo (100ml normal saline)

(Other AV nodal blocking agents given at treating clinicians discretion for all three groups)

Outcomes:

• Primary: Ventricular Rate (VR) control within first 4 hours – reduction in baseline to ≤90bpm or by 20% from baseline
  • Had to maintain to end of protocol to be considered therapeutic response
• Secondary:
  • Time to therapeutic response
  • Sinus rhythm conversion rate
  • Adverse events

Summary of Results:

• 450 patients
• Use of other rate control agents equivalent across groups
  • Digoxin was the most favoured – 47.5%
• At 4 hours: Therapeutic response vs placebo, absolute difference
  • Low dose +20.5%
  • High dose +15.8%
  • No difference between Mg groups
• At 24 hours: vs placebo
  • Low dose +14.1%
  • High dose +10.3%
• Resolution time:
  • Low dose 5.2±2 hours
  • High dose 6.1±1.9 hours
  • Placebo 8.4±2.5 hours
  • Difference significant only between Mg groups vs placebo
• Rhythm control at 24 hours:
  • Low dose 22.9%
  • High dose 13.0% — (p=0.03 vs low dose Mg)
  • Placebo 10.7% – (p=0.005 vs low dose Mg, NS vs high dose)
• Adverse effects:
  • More common in Mg groups
  • More common in high dose (21 patients) vs low dose (8 patient)
  • Most common was transient flushing.
  • Others were hypotension and bradycardia
  • Nil major AEs

Authors Conclusion:

IV MgS appears to have a synergistic effect when combined with other AV nodal blockers resulting in improved rate control.  Similar efficacy was observed with 4.5g and 9g, but 9g was associated with more side effects

Clinical Bottom Line:

I’m going to keep adding in MgSO4 to my standard rate control (which is usually a beta blocker 1st line, digoxin 2nd line – not for any particular reason, just what I do) and I’ll keep going with my current dosing of 10-20mmols, which is around 2.5-5g.

Other #FOAMed Resources / References:

There are a few sources to choose from here…turns out us ED guys like talking about AF, and about Magnesium – who’d have thought?

• Jenny Koehl (@jlkoehl) wrote this reviewon the PharmERToxGuy site
• orgincluded this review is their regular spoon-feed email – I’ve recommended it before, I recommend it again, go sign up to their mailing list.
• ALiEM had a nice review of magnesium for rate control here(by Bryan Hayes, @PharmERToxGuy)
• Josh Farkas (@PulmCrit) wrote this reviewof magnesium infusions – if you haven’t read his stuff before – prepare to learn.  I’d highly recommend following him on twitter if you don’t already.

Authors:
– Felipe Teran
– Nick Lim
– Andy Neill

This interview was recorded at EuSEM18 in Glasgow.

Authors:
– Patricia O’Connor, Hairmyres Hospitalm Scotland
– Eoghan Colgan, Glasgow Royal Infirmary and St Mungos Podcast

This podcast was recorded at EuSEM18 in Glasgow

This is the link to the New in EM podcast segment on the Lever test in ACL injury: b.