Colin Banks

Distal ureteric stones and tamsulosin: a double-blind, placebo-controlled, randomized, multicenter trial

STUDY OBJECTIVE We assess the efficacy and safety of tamsulosin compared with placebo as medical expulsive therapy in patients with distal ureteric stones less than or equal to 10 mm in diameter. METHODS This was a randomized, double-blind, placebo-controlled, multicenter trial of adult participants with calculus on computed tomography (CT). Patients were allocated to 0.4 mg of tamsulosin or placebo daily for 28 days. The primary outcomes were stone expulsion on CT at 28 days and time to stone expulsion. RESULTS There were 403 patients randomized, 81.4% were men, and the median age was 46 years. The median stone size was 4.0 mm in the tamsulosin group and 3.7 mm in the placebo group. Of 316 patients who received CT at 28 days, stone passage occurred in 140 of 161 (87.0%) in the tamsulosin group and 127 of 155 (81.9%) with placebo, a difference of 5.0% (95% confidence interval -3.0% to 13.0%). In a prespecified subgroup analysis of large stones (5 to 10 mm), 30 of 36 (83.3%) tamsulosin participants had stone passage compared with 25 of 41 (61.0%) with placebo, a difference of 22.4% (95% confidence interval 3.1% to 41.6%) and number needed to treat of 4.5. There was no difference in urologic interventions, time to self-reported stone passage, pain, or analgesia requirements. Adverse events were generally mild and did not differ between groups. CONCLUSION We found no benefit overall of 0.4 mg of tamsulosin daily for patients with distal ureteric calculi less than or equal to 10 mm in terms of spontaneous passage, time to stone passage, pain, or analgesia requirements. In the subgroup with large stones (5 to 10 mm), tamsulosin did increase passage and should be considered.

Review article: Hypertonic saline use in the emergency department

Hypertonic saline (HS) is being increasingly used for the management of a variety of conditions, most notably raised intracranial pressure. This article reviews the available evidence on HS solutions as they relate to emergency medicine, and develops a set of recommendations for its use. To conclude, HS is recommended as an alternative to mannitol for treating raised intracranial pressure in traumatic brain injury. HS is also recommended for treating severe and symptomatic hyponatremia, and is worth considering for both recalcitrant tricyclic antidepressant toxicity and for cerebral oedema complicating paediatric diabetic ketoacidosis. HS is not recommended for hypovolaemic resuscitation.

Free open access medical education resource knowledge and utilisation amongst emergency medicine trainees: a survey in four countries

Introduction Free Open Access Medical Education encompasses a broad array of free online resources and discussion fora. The aim of this paper was to describe whether Emergency Medicine trainees in different contexts know about Free Open Access Medical Education, whether or not they know about its different platforms, which ones they use, and what the major barriers to regular usage are. Methods A convenience sample was surveyed on awareness and use of Free Open Access Medical Education blogs, podcasts, websites and Twitter at three institutions (in Australia, Botswana and Papua New Guinea) and one deanery (United Kingdom) between June 2013 and June 2014 using an online survey tool or via hand-distributed survey. Results 44 trainees responded: four from Botswana, seven from Papua New Guinea, ten from the United Kingdom and 23 from Australia. 82% were aware of blogs, 80% of websites, 75% of podcasts and 61% of Twitter as resources in Emergency Medicine. Awareness and use of specific resources were lower in Botswana and Papua New Guinea. For blogs, podcasts and websites, trainees who had looked at a resource at least once were neutral or agreed that it was relevant. For Twitter, some trainees found it difficult to navigate or not relevant. Lack of awareness of resources rather than lack of internet access was the main barrier to use. Conclusion The Emergency Medicine trainees in both developed and low resource settings studied were aware that Free Open Access Medical Education resources exist, but trainees in lower income settings were generally less aware of specific resources. Lack of internet and device access was not a barrier to use in this group.

Seizures Secondary to Lamotrigine Toxicity in a Two-Year-Old

Objective: To report a case of acute pediatric lamotrigine ingestion resulting in seizures. Case Summary: A 2-year-old boy presented to the emergency department after an acute ingestion of up to 43 mg/kg of lamotrigine. He had 2 generalized seizures, with the first occurring 60 minutes after ingestion. Examination revealed alternate drowsiness and irritability, as well as nystagmus and hyperreflexia. Results of electrocardiogram, blood glucose, complete blood count, urea, electrolytes, and venous blood gas evaluations were all within normal limits. There was a mildly raised lactate level of 3.4 mEq/L (reference range 0.7-2.5). He was given intravenous diazepam 1 mg for irritability. After a 12-hour observation period, the patient was discharged with no further complications. Discussion: The Naranjo probability scale in this case suggested a probable causality between the acute lamotrigine ingestion and seizures. This is the lowest acute dose causing pediatric seizure reported in the literature; however, this dose is still significant higher than a therapeutic dose. A MEDLINE search (1966-January 2010) using the search terms tamotrigine, seizures, toxicity, overdose, ingestion, and pediatritípaediatric, not limited to English-language literature, revealed 5 other cases of seizures in children after lamotrigine ingestion. In all the acute cases, time to first seizure onset ranged from 20 to 60 minutes after ingestion. Two children had gastrointestinal decontamination, both after the onset of seizures. All had full recovery with supportive care. Conclusions: Lamotrigine has the ability to cause seizures in children from acute single ingestion at a lower dose than previously described. There is not enough information available to establish a toxic dose or dose that requires hospital assessment. Gastrointestinal decontamination should be contraindicated. Supportive care, including administration of benzodiazepines, is appropriate.

Diagnosis of subarachnoid haemorrhage: A survey of Australasian emergency physicians and trainees

This study aims to establish current practice among Australasian emergency physicians and trainees on several aspects of the investigation of suspected subarachnoid haemorrhage (SAH).

Pediatric flecainide toxicity from a double dose

A 23-month-old boy was brought to the emergency department of an adult and pediatric tertiary care center 1 hour after an inadvertent “double dose” of 120 mg flecainide (9.2 mg/kg). His electrocardiogram revealed sinus rhythm with a terminal R wave in aVR greater than 7 mm, a bifascicular block, and prolonged QRS and QTc intervals. A dramatic improvement in the bifascicular block and terminal R wave occurred after the administration of sodium bicarbonate. He was discharged after 36 hours with no complications. This case demonstrates that flecainide can cause significant cardiac conduction disturbances in doses much lower than previously described. All supratherapeutic ingestions should be assessed in hospital.

Emergency department presentations during the State of Origin rugby league series: a retrospective statewide analysis

Objective: To evaluate the effect of the State of Origin rugby league series on the number of emergency department (ED) presentations in Queensland.

From Other Journals: From Other Journals

Until recently, the evidence for medical radiation causing cancer was largely an extrapolation of the Life Span Study on Japanese atomic bomb survivors. The actual dose response curve at the lower dose used in CT scans was unknown. A UK study last year reported a relationship between CTs and brain cancers and leukaemia (Pearce MS et al. Lancet 2012; 380: 499–505). This Australian study used centralised data from Medicare (national funding body) to identify all Australians aged 19 or under at 1985 and those born until the end of 2005. All CT scans funded by Medicare were obtained, and this cohort was divided into those who had had a CT (680 000) and those who had not (10.3 million). All cancers were obtained from the Australian Cancer Database and National Death Index up until the end of 2007. CT scans done in larger hospitals would not have been included (as non-Medicare funded) and any scans done pre-1985 were not taken into account. They found a 24% increase in incidence rate ratio (IRR, 1.24; 95% confidence interval [CI], 1.20–1.29; P < 0.001) per patient exposed, or 16% increase per scan (IRR, 1.16; 95% CI, 1.13–1.19; P < 0.001), as 18% had multiple scans. Note that the average dose per scan was 4.5 mSv. This effect was maintained when a lag of 1, 5 and 10 years was introduced (to minimise reverse causality). The effect was greatest for younger children and occurred over a wide range of malignancies. Although there was an unequivocal association, the absolute risk was still minimal. The background risk for the non-exposed was 1 in 178 (0.56%) over a mean of 17 years of follow up. Increasing this by 16% or 24% equates to an overall risk of 1 in 154 (0.65%) or 1 in 143 (0.70%) respectively. An accompanying editorial highlights that the increase in cancers for a head CT (most common scan) at 2 mSv exposure is 1 per 4000. Nonetheless, this risk is real, so the scans must be indicated and the least amount of radiation used as possible (Matthews JD et al. BMJ 2013; 346: f2360).

From Our Journal

The handover process in the emergency department (ED) is known to be a high-risk time for adverse events. The variable quality of the handover might also contribute to inefficiency and potential harm. There is a relative paucity of evidence on the handover process. This was an observational study in three EDs of the medical handover process incorporating a survey of the recipients 2 h post-handover. There was also a second more general survey of the process. Handover format varied between the centres. A single researcher observed the handover process, and items communicated during handover were recorded from a list of 22 potentially relevant details. Recipients of the handover were then surveyed as to the quality of the handover, information lacking and whether they perceived there to be adverse consequences to the ED or patient as a result. The authors acknowledged the Hawthorne effect might have influenced handover behaviour. Of the 914 patient handovers observed, 77.4% were followed by a post-handover survey. The overall quality was deemed adequate or better in the majority of cases (only 5% were poor or very poor). Quality was not associated with the number of items handed over, or doctor seniority. In 15.4% of cases, it was reported that all required information was not handed over, most often as regards management, investigation and disposition details. The most common adverse effects were repetition of assessment (5.0%) and time wasting (4.7%). There were no adverse medical outcomes. In the general survey, the most commonly reported problems were delays or confusion in communication with inpatient units. Most respondents believed that handovers could be improved and approximately half thought guidelines and pro formas might be useful. (Ye K, Taylor DMcD, Knott J et al. Handover in the emergency department: deficiencies and adverse effects. Emerg. Med. Australas. 2007; 19: 433–41)