Yearly Archives: 2011

All Updates, PHARM, Resus, Trauma

Effect of physician specialty on pre-hospital intubation success

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Researchers from the London Helicopter Emergency Medical Service describe the success of pre-hospital laryngoscopy according to the grade and specialty of the HEMS physician…

There is conflicting evidence concerning the role and safety of prehospital intubation, and which providers should deliver it. Success rates for physician-performed rapid sequence induction are reported to be 97-100%, with limited evidence of improved survival in some patient groups. However, there is also evidence that prehospital intubation and ventilation can do harm. Prospective data were recorded on the success of intubation, the quality of the laryngeal view obtained and the number of attempts at intubation. These data were then analysed by the grade of intubating doctor and whether the intubating doctor had a background in anaesthesia or emergency medicine. All groups had a similar success rate after two attempts at intubation. Doctors with a background in anaesthesia and consultant emergency physicians had a significantly better first-pass intubation rate than emergency medicine trainees. The quality of laryngeal view was significantly better in doctors with an anaesthetics background.

Success in physician prehospital rapid sequence intubation: what is the effect of base speciality and length of anaesthetic training?
Emerg Med J. 2011 Mar;28(3):225-9

All Updates, ICU, Resus

Crike rate 1 in 500 in Scottish ED

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A review of over 2500 intubation attempts in the emergency department1, (of which 1671 were rapid sequence intubation attempts) revealed five cricothyroidotomies, giving a crike rate of 0.2% which is much lower than in some other ED based registries. In four patients, predictors of difficult airway were identified before the endotracheal intubation attempt, and formal preparation for rescue surgical airway was performed. Three of the surgical airways were performed by emergency medicine trainees, one by an emergency medicine specialist and one by an ear, nose and throat specialist. There was a 100% success rate for placement of all surgical airways on the first attempt.

Four surgical airways were done in trauma patients: laryngeal fracture, facial burns, Le Fort II facial fracture and penetrating neck injury.
This study is of interest to UK emergency physicians who may be interested in Edinburgh Royal Infirmary’s collaborative approach to emergency airway management by the Departments of Emergency Medicine, Anaesthesia and Critical Care.
It is not possible to tell from this paper whether there were patients in whom surgical airway was indicated but not performed, and therefore in my view the ostensibly ‘good’ low rate of 0.2% should be viewed with interest rather than awe. Having said that, this figure is more in keeping with my own experience and expectation from UK/Australasian practice; it has been highlighted in the UK EM literature before2, including by myself3, that in our patient group good training and supervision should result in lower surgical airway rates than the ~1% often quoted.


OBJECTIVES: To determine the frequency of and primary indication for surgical airway during emergency department intubation.

METHODS: Prospectively collected data from all intubations performed in the emergency department from January 1999 to July 2007 were analysed to ascertain the frequency of surgical airway access. Original data were collected on a structured proforma, entered into a regional database and analysed. Patient records were then reviewed to determine the primary indication for a surgical airway.

RESULTS: Emergency department intubation was undertaken in 2524 patients. Of these, only five patients (0.2%) required a surgical airway. The most common indication for a surgical airway was trauma in four of the five patients. Two patients had attempted rapid sequence induction before surgical airway. Two patients had gaseous inductions and one patient received no drugs. In all five patients, surgical airway was performed secondary to failed endotracheal intubation attempt(s) and was never the primary technique used.

CONCLUSION: In our emergency department, surgical airway is an uncommon procedure. The rate of 0.2% is significantly lower than rates quoted in other studies. The most common indication for surgical airway was severe facial or neck trauma. Our emergency department has a joint protocol for emergency intubation agreed by the Departments of Emergency Medicine, Anaesthesia and Critical Care at the Edinburgh Royal Infirmary. We believe that the low surgical airway rate is secondary to this collaborative approach. The identified low rate of emergency department surgical airway has implications for training and maintenance of skills for emergency medicine trainees and physicians.

1. Surgical airway in emergency department intubation
Eur J Emerg Med. 2011 Jun;18(3):168-71
2. Rapid sequence induction in the emergency department: a strategy for failure.
Emerg Med J. 2002 Mar;19(2):109-13
3. RSI by non-anaesthetists in the UK – lower incidence of cricothyrotomy than in the US
EMJ e-letters 2002; 3 April

All Updates, Guidelines, PHARM

Pre-hospital NIV

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"The driver's dyspneic - pass the Boussignac valve!"

Pre-hospital non-invasive ventilation for patients with acute dyspnoea features in two journals this month. Researchers at the Ambulance Service New South Wales published an evidence-based review of pre-hospital NIV for acute cardiogenic pulmonary oedema, concluding that there are probable benefits.

Background Non-invasive ventilation (NIV) is increasingly being implemented by many ambulance jurisdictions as a standard of care in the out-of-hospital management of acute cardiogenic pulmonary oedema (ACPO). This implementation appears to be based on the body of evidence from the emergency department (ED) setting, with the assumption that earlier administration by paramedics would give benefits with regard to inhospital mortality and the rate of endotracheal intubation beyond those seen when initiated in the ED. This paper sought to identify and review the current level of evidence supporting NIV in the prehospital setting.

Methods Electronic searches of Medline, EMBASE, CINAHL, Cochrane Database of Systematic Reviews and Cochrane Database of Controlled Trials were conducted and reference lists of relevant articles were hand searched.

Results The search identified 12 primary studies documenting the use of NIV, either continuous positive airway pressure or bi-level non-invasive ventilation, for ACPO in the out-of-hospital setting. Only three studies were randomised controlled trials, with none addressing inhospital mortality as a primary outcome measure. The majority of articles were non-comparative descriptive studies.

Conclusion Early prehospital NIV appears to be a safe and feasible therapy that results in faster improvement in physiological status and may decrease the need for intubation when compared with delayed administration in the ED. There is weak evidence that is may decrease mortality. The cost versus benefit equation of system-wide prehospital implementation of NIV is unclear and, based on the current evidence, should be considered with caution.

Prehospital non-invasive ventilation for acute cardiogenic pulmonary oedema: an evidence-based review.
Emerg Med J. 2011 Jul;28(7):609-12
At the same time, the National Association of EMS Physicians has published a position statement on noninvasive positive pressure ventilation, for the general indication of acute dyspnoea. It states:

The general indication for NIPPV is dyspnea accompanied by early respiratory failure in patients with intact protective airway reflexes and mental status. The majority of NIPPV studies have focused on patients with acute pulmonary edema.

However, NIPPV may prove useful with other reversible disease processes such as chronic obstructive pulmonary disease or asthma exacerbations. While utilized in in-hospital practice, the role of NIPPV for pneumonia-associated respiratory failure is less clear. While some clinicians advocate the use of NIPPV to augment oxygenation prior to ETI in the in- hospital setting, there are no studies evaluating this strategy in the prehospital setting.

 
Noninvasive positive pressure ventilation: resource document for the National Association of EMS Physicians position statement.
Prehosp Emerg Care. 2011 Jul-Sep;15(3):432-8
Full Text of Position Statement

Acute Med, All Updates, ICU, PHARM, Resus

How much oxygen after ROSC?

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I reported a previous JAMA publication demonstrating an association between hyperoxia and mortality in patients resuscitated post-cardiac arrest. The same authors have published furthur data to better define the relationship between supranormal oxygen tension and outcome in postresuscitation patients. They hypothesised that a linear dose-dependent relationship would be present in the association between supranormal oxygen tension and in-hospital mortality.

Background– Laboratory and recent clinical data suggest that hyperoxemia after resuscitation from cardiac arrest is harmful; however, it remains unclear if the risk of adverse outcome is a threshold effect at a specific supranormal oxygen tension, or is a dose-dependent association. We aimed to define the relationship between supranormal oxygen tension and outcome in postresuscitation patients.

Methods and Results– This was a multicenter cohort study using the Project IMPACT database (intensive care units at 120 US hospitals). Inclusion criteria were age >17 years, nontrauma, cardiopulmonary resuscitation preceding intensive care unit arrival, and postresuscitation arterial blood gas obtained. We excluded patients with hypoxia or severe oxygenation impairment. We defined the exposure by the highest partial pressure of arterial oxygen (PaO(2)) over the first 24 hours in the ICU. The primary outcome measure was in-hospital mortality. We tested the association between PaO(2) (continuous variable) and mortality using multivariable logistic regression adjusted for patient-oriented covariates and potential hospital effects. Of 4459 patients, 54% died. The median postresuscitation PaO(2) was 231 (interquartile range 149 to 349) mm Hg. Over ascending ranges of oxygen tension, we found significant linear trends of increasing in-hospital mortality and decreasing survival as functionally independent. On multivariable analysis, a 100 mm Hg increase in PaO(2) was associated with a 24% increase in mortality risk (odds ratio 1.24 [95% confidence interval 1.18 to 1.31]. We observed no evidence supporting a single threshold for harm from supranormal oxygen tension.

Conclusion– In this large sample of postresuscitation patients, we found a dose-dependent association between supranormal oxygen tension and risk of in-hospital death.

Relationship Between Supranormal Oxygen Tension and Outcome After Resuscitation From Cardiac Arrest
Circulation. 2011 Jun 14;123(23):2717-2722
Australasian investigators provided the following critique of the original JAMA study:

Unfortunately, these investigators used only the first set of arterial blood gases in the ICU to assess oxygenation, excluded close to 30% of patients because of lack of arterial blood gas data and did not adjust for standard illness severity scores. Their conclusion that hyperoxia is a robust predictor of mortality in patients after resuscitation form cardiac arrest was therefore potentially affected by selection bias and by insufficient adjustment for major confounders. Thus, their results are of uncertain significance and require confirmation.
They undertook their own study of 12,108 patients:

INTRODUCTION: Hyperoxia has recently been reported as an independent risk factor for mortality in patients resuscitated from cardiac arrest. We examined the independent relationship between hyperoxia and outcomes in such patients.
METHODS: We divided patients resuscitated from nontraumatic cardiac arrest from 125 intensive care units (ICUs) into three groups according to worst PaO2 level or alveolar-arterial O2 gradient in the first 24 hours after admission. We defined ‘hyperoxia’ as PaO2 of 300 mmHg or greater, ‘hypoxia/poor O2 transfer’ as either PaO2 < 60 mmHg or ratio of PaO2 to fraction of inspired oxygen (FiO2 ) < 300, ‘normoxia’ as any value between hypoxia and hyperoxia and ‘isolated hypoxemia’ as PaO2 < 60 mmHg regardless of FiO2. Mortality at hospital discharge was the main outcome measure.

RESULTS: Of 12,108 total patients, 1,285 (10.6%) had hyperoxia, 8,904 (73.5%) had hypoxia/poor O2 transfer, 1,919 (15.9%) had normoxia and 1,168 (9.7%) had isolated hypoxemia (PaO2 < 60 mmHg). The hyperoxia group had higher mortality (754 (59%) of 1,285 patients; 95% confidence interval (95% CI), 56% to 61%) than the normoxia group (911 (47%) of 1,919 patients; 95% CI, 45% to 50%) with a proportional difference of 11% (95% CI, 8% to 15%), but not higher than the hypoxia group (5,303 (60%) of 8,904 patients; 95% CI, 59% to 61%). In a multivariable model controlling for some potential confounders, including illness severity, hyperoxia had an odds ratio for hospital death of 1.2 (95% CI, 1.1 to 1.6). However, once we applied Cox proportional hazards modelling of survival, sensitivity analyses using deciles of hypoxemia, time period matching and hyperoxia defined as PaO2 > 400 mmHg, hyperoxia had no independent association with mortality. Importantly, after adjustment for FiO2 and the relevant covariates, PaO2 was no longer predictive of hospital mortality (P = 0.21).

CONCLUSIONS: Among patients admitted to the ICU after cardiac arrest, hyperoxia did not have a robust or consistently reproducible association with mortality. We urge caution in implementing policies of deliberate decreases in FiO2 in these patients.

Arterial hyperoxia and in-hospital mortality after resuscitation from cardiac arrest.
Crit Care. 2011 Mar 8;15(2):R90. [Epub ahead of print]
Open Access Full Text
What’s the best approach in the light of these differing results? My approach is to avoid hypoxia, since that’s probably bad, and to actively avoid overoxygenating as part of my general neuroprotection checklist in a post-cardiac arrest patient. It would seem prudent to follow the recommendations of ILCOR, summarised by the European Resuscitation Council guidelines as:

Recognition of the potential harm caused by hyperoxaemia after ROSC is achieved: once ROSC has been established and the oxygen saturation of arterial blood (SaO2) can be monitored reliably (by pulse oximetry and/or arterial blood gas analysis), inspired oxygen is titrated to achieve a SaO2 of 94–98%

All Updates

ECG in a prone patient

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A case report in Prehospital Emergency Care describes an obese (>200 kg) chest pain patient who refused to lie supine because of severe back pain. A 12 lead ECG was done with all the leads placed posteriorly, and the resultant electrocardiograph showed characteristic ST elevation in II, III and AVF with ST depression in AVL. The inferior MI was confirmed in hospital on repeat ECG, biomarker rise, and a thrombus in his right coronary artery at angiography.

Abstract A prehospital 12-lead electrocardiogram (ECG) is commonly used for patients with suspected ST-segment elevation myocardial infarction (STEMI). This case report describes how paramedics diagnosed inferior STEMI with all ECG leads positioned on a patient’s back (i.e., “all-posterior” positioning). The patient was hemodynamically stable but morbidly obese and markedly diaphoretic. Owing to severe back pain, he refused to lie in the supine position for assessment or transport. At the emergency department, a 12-lead ECG with the patient in lateral recumbency confirmed the diagnosis of inferior STEMI. This case shows that an all-posterior 12-lead ECG can be used to identify STEMI when optimal patient positioning is not possible.

Prehospital Diagnosis of ST-segment Elevation Myocardial Infarction Using an “All-Posterior” 12-Lead Electrocardiogram
Prehosp Emerg Care. 2011 Jul-Sep;15(3):410-3

Acute Med, All Updates, ICU, PHARM, Resus

Paeds BVM for adult resuscitation

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Three hand-ventilation systems were used in a simulated adult resuscitation to determine the delivered volumes. The mean minute ventilation delivered by each of the three devices investigated was significantly different, with the paediatric (500-ml) self-inflating bag producing the result most consistent with the guideline.

There is a discrepancy between resuscitation teaching and witnessed clinical practice. Furthermore, deleterious outcomes are associated with hyperventilation. We therefore conducted a manikin-based study of a simulated cardiac arrest to evaluate the ability of three ventilating devices to provide guideline-consistent ventilation. Mean (SD) minute ventilation was reduced with the paediatric self-inflating bag (7.0 (3.2) l.min(-1) ) compared with the Mapleson C system (9.8 (3.5) l.min(-1) ) and adult self-inflating bag (9.7 (4.2) l.min(-1) ; p = 0.003). Tidal volume was also lower with the paediatric self-inflating bag (391 (52) ml) compared with the others (582 (87) ml and 625 (103) ml, respectively; p < 0.001), as was peak airway pressure (14.5 (5.2) cmH(2) O vs 20.7 (9.0) cmH(2) O and 30.3 (11.4) cmH(2) O, respectively; p < 0.001). Participants hyperventilated patients' lungs in simulated cardiac arrest with all three devices. The paediatric self-inflating bag delivered the most guideline-consistent ventilation. Its use in adult cardiopulmonary resuscitation may ensure delivery of more guideline-consistent ventilation in patients with tracheal intubation.

Comparison of the Mapleson C system and adult and paediatric self-inflating bags for delivering guideline-consistent ventilation during simulated adult cardiopulmonary resuscitation
Anaesthesia. 2011 Jul;66(7):563-7

All Updates, Kids

CRP helpful in risk stratifying febrile kids

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In febrile children, peripheral white blood cell counts were not helpful in separating children with self limiting infections from those with serious bacterial infections, but serum C reactive protein was1: febrile children with serum C reactive protein concentrations of 20 mg/L or less have a 5% risk of serious infection, whereas those with serum concentrations greater than 80 mg/L have a risk of 72%; children with intermediate values have a risk of about 15%. According to the accompanying BMJ editorial2:
This grouping, although imperfect, provides some guidance to help clinicians deciding which children may avoid extensive evaluation and treatment.

OBJECTIVE: To collate all available evidence on the diagnostic value of laboratory tests for the diagnosis of serious infections in febrile children in ambulatory settings.

DESIGN: Systematic review.

DATA SOURCES: Electronic databases, reference tracking, and consultation with experts.

STUDY SELECTION: Studies were selected on six criteria: design (studies of diagnostic accuracy or deriving prediction rules), participants (otherwise healthy children and adolescents aged 1 month to 18 years), setting (first contact ambulatory care), outcome (serious infection), features assessed (in first contact care), and data reported (sufficient to construct a 2×2 table).

DATA EXTRACTION: Quality assessment was based on the quality assessment tool of diagnostic accuracy studies (QUADAS) criteria. Meta-analyses were done using the bivariate random effects method and hierarchical summary receiver operating characteristic curves for studies with multiple thresholds.

DATA SYNTHESIS: None of the 14 studies identified were of high methodological quality and all were carried out in an emergency department or paediatric assessment unit. The prevalence of serious infections ranged from 4.5% to 29.3%. Tests were carried out for C reactive protein (five studies), procalcitonin (three), erythrocyte sedimentation rate (one), interleukins (two), white blood cell count (seven), absolute neutrophil count (two), band count (three), and left shift (one). The tests providing most diagnostic value were C reactive protein and procalcitonin. Bivariate random effects meta-analysis (five studies, 1379 children) for C reactive protein yielded a pooled positive likelihood ratio of 3.15 (95% confidence interval 2.67 to 3.71) and a pooled negative likelihood ratio of 0.33 (0.22 to 0.49). To rule in serious infection, cut-off levels of 2 ng/mL for procalcitonin (two studies, positive likelihood ratio 13.7, 7.4 to 25.3 and 3.6, 1.4 to 8.9) and 80 mg/L for C reactive protein (one study, positive likelihood ratio 8.4, 5.1 to 14.1) are recommended; lower cut-off values of 0.5 ng/mL for procalcitonin or 20 mg/L for C reactive protein are necessary to rule out serious infection. White blood cell indicators are less valuable than inflammatory markers for ruling in serious infection (positive likelihood ratio 0.87-2.43), and have no value for ruling out serious infection (negative likelihood ratio 0.61-1.14). The best performing clinical decision rule (recently validated in an independent dataset) combines testing for C reactive protein, procalcitonin, and urinalysis and has a positive likelihood ratio of 4.92 (3.26 to 7.43) and a negative likelihood ratio of 0.07 (0.02 to 0.27).

CONCLUSION: Measuring inflammatory markers in an emergency department setting can be diagnostically useful, but clinicians should apply different cut-off values depending on whether they are trying to rule in or rule out serious infection. Measuring white blood cell count is less useful for ruling in serious infection and not useful for ruling out serious infection. More rigorous studies are needed, including studies in primary care, to assess the value of laboratory tests alongside clinical diagnostic measurements, including vital signs.

1. Diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review
BMJ. 2011 Jun 8;342:d3082
2. How useful are laboratory tests in diagnosing serious infections in febrile children?
BMJ. 2011 Jun 8;342:d2782

All Updates, Kids, PHARM, Resus

Normal heart and respiratory rates in children

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A large review has established normal ranges of heart rate and respiratory rate in children from birth to 18 years of age. Some of the results differed markedly from some existing ranges quoted, such as in the Advanced Paediatric Life Support Course.

BACKGROUND: Although heart rate and respiratory rate in children are measured routinely in acute settings, current reference ranges are not based on evidence. We aimed to derive new centile charts for these vital signs and to compare these centiles with existing international ranges.

METHODS: We searched Medline, Embase, CINAHL, and reference lists for studies that reported heart rate or respiratory rate of healthy children between birth and 18 years of age. We used non-parametric kernel regression to create centile charts for heart rate and respiratory rate in relation to age. We compared existing reference ranges with those derived from our centile charts.

FINDINGS: We identified 69 studies with heart rate data for 143,346 children and respiratory rate data for 3881 children. Our centile charts show decline in respiratory rate from birth to early adolescence, with the steepest fall apparent in infants under 2 years of age; decreasing from a median of 44 breaths per min at birth to 26 breaths per min at 2 years. Heart rate shows a small peak at age 1 month. Median heart rate increases from 127 beats per min at birth to a maximum of 145 beats per min at about 1 month, before decreasing to 113 beats per min by 2 years of age. Comparison of our centile charts with existing published reference ranges for heart rate and respiratory rate show striking disagreement, with limits from published ranges frequently exceeding the 99th and 1st centiles, or crossing the median.

INTERPRETATION: Our evidence-based centile charts for children from birth to 18 years should help clinicians to update clinical and resuscitation guidelines.

Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies
Lancet. 2011 Mar 19;377(9770):1011-8

All Updates, ICU, PHARM, Resus, Trauma

How about pre-hospital tranexamic acid?

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The CRASH 2 trial showed improved outcomes in trauma from the administration of the antifibrinolytic drug tranexamic acid. A further analysis of the data has shown that benefit was only seen in CRASH-2 when tranexamic acid was administered within 3 hours of injury1.
An accompanying editorial2 makes the following interesting points:

  • Acute traumatic coagulopathy is a hyperacute process in which systemic fibrinolysis releases D-dimers that are detectable within 30 min of injury.
  • Those severely injured patients who develop acute coagulopathy are much more likely to die and to die early.
  • Once fully activated, fibrinolysis has been shown to continue unabated until endogenous antifibrinolytic elements are restored.
  • The earlier that tranexamic acid is administered, the more likely it might be to prevent full activation of fibrinolysis.
  • Hospital massive transfusion protocols incorporate fresh frozen plasma that contains all the endogenous antifibrinolytic elements in plasma and so the place for tranexamic acid in high income countries with such protocols is unclear.
  • The best place for tranexamic acid in developed trauma systems might actually be in the prehospital environment, where trauma bypass policies have extended prehospital times and the administration of plasma is uncommon and often impractical.

BACKGROUND: The aim of the CRASH-2 trial was to assess the effects of early administration of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage. Tranexamic acid significantly reduced all-cause mortality. Because tranexamic acid is thought to exert its effect through inhibition of fibrinolysis, we undertook exploratory analyses of its effect on death due to bleeding.

METHODS: The CRASH-2 trial was undertaken in 274 hospitals in 40 countries. 20,211 adult trauma patients with, or at risk of, significant bleeding were randomly assigned within 8 h of injury to either tranexamic acid (loading dose 1 g over 10 min followed by infusion of 1 g over 8 h) or placebo. Patients were randomly assigned by selection of the lowest numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Both participants and study staff (site investigators and trial coordinating centre staff ) were masked to treatment allocation. We examined the effect of tranexamic acid on death due to bleeding according to time to treatment, severity of haemorrhage as assessed by systolic blood pressure, Glasgow coma score (GCS), and type of injury. All analyses were by intention to treat. The trial is registered as ISRCTN86750102, ClinicalTrials.gov NCT00375258, and South African Clinical Trial Register/Department of Health DOH-27-0607-1919.

FINDINGS: 10,096 patients were allocated to tranexamic acid and 10,115 to placebo, of whom 10,060 and 10,067, respectively, were analysed. 1063 deaths (35%) were due to bleeding. We recorded strong evidence that the effect of tranexamic acid on death due to bleeding varied according to the time from injury to treatment (test for interaction p<0.0001). Early treatment (≤1 h from injury) significantly reduced the risk of death due to bleeding (198/3747 [5.3%] events in tranexamic acid group vs 286/3704 [7.7%] in placebo group; relative risk [RR] 0.68, 95% CI 0.57-0.82; p<0.0001). Treatment given between 1 and 3 h also reduced the risk of death due to bleeding (147/3037 [4.8%] vs 184/2996 [6.1%]; RR 0.79, 0.64-0.97; p=0.03). Treatment given after 3 h seemed to increase the risk of death due to bleeding (144/3272 [4.4%] vs 103/3362 [3.1%]; RR 1.44, 1.12-1.84; p=0.004). We recorded no evidence that the effect of tranexamic acid on death due to bleeding varied by systolic blood pressure, Glasgow coma score, or type of injury.

INTERPRETATION: Tranexamic acid should be given as early as possible to bleeding trauma patients. For trauma patients admitted late after injury, tranexamic acid is less effective and could be harmful.

1. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial
Lancet. 2011 Mar 26;377(9771):1096-101
2. Tranexamic acid for trauma
Lancet. 2011 Mar 26;377(9771):1052-4

Acute Med, All Updates, ICU, Resus

Dexamethasone for community acquired pneumonia

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Another Dutch study has examined steroids for community acquired pneumonia, this time with the primary outcome measure being hospital length of stay, which was reduced by one day on the steroid group. Compare this study with a previous negative study of prednisolone for pneumonia.

BACKGROUND: Whether addition of corticosteroids to antibiotic treatment benefits patients with community-acquired pneumonia who are not in intensive care units is unclear. We aimed to assess effect of addition of dexamethasone on length of stay in this group, which might result in earlier resolution of pneumonia through dampening of systemic inflammation.

METHODS: In our double-blind, placebo-controlled trial, we randomly assigned adults aged 18 years or older with confirmed community-acquired pneumonia who presented to emergency departments of two teaching hospitals in the Netherlands to receive intravenous dexamethasone (5 mg once a day) or placebo for 4 days from admission. Patients were ineligible if they were immunocompromised, needed immediate transfer to an intensive-care unit, or were already receiving corticosteroids or immunosuppressive drugs. We randomly allocated patients on a one-to-one basis to treatment groups with a computerised randomisation allocation sequence in blocks of 20. The primary outcome was length of hospital stay in all enrolled patients. This study is registered with ClinicalTrials.gov, number NCT00471640.

FINDINGS: Between November, 2007, and September, 2010, we enrolled 304 patients and randomly allocated 153 to the placebo group and 151 to the dexamethasone group. 143 (47%) of 304 enrolled patients had pneumonia of pneumonia severity index class 4-5 (79 [52%] patients in the dexamethasone group and 64 [42%] controls). Median length of stay was 6·5 days (IQR 5·0-9·0) in the dexamethasone group compared with 7·5 days (5·3-11·5) in the placebo group (95% CI of difference in medians 0-2 days; p=0·0480). In-hospital mortality and severe adverse events were infrequent and rates did not differ between groups, although 67 (44%) of 151 patients in the dexamethasone group had hyperglycaemia compared with 35 (23%) of 153 controls (p<0·0001).

INTERPRETATION: Dexamethasone can reduce length of hospital stay when added to antibiotic treatment in non-immunocompromised patients with community-acquired pneumonia.

Dexamethasone and length of hospital stay in patients with community-acquired pneumonia: a randomised, double-blind, placebo-controlled trial
Lancet. 2011 Jun 11;377(9782):2023-30