David J Lowe

Focal Cerebral Ischemia in the Cat: Pretreatment with a Competitive NMDA Receptor Antagonist, D-CPP-ene:

The effects of the competitive N-methyl-D-aspartate (NMDA) receptor antagonist D-(E)-4-(3-phosphonoprop-2-enyl)piperazine-2-carboxylic acid (D-CPP-ene; SDZ EAA 494) upon ischemic brain damage have been examined in anesthetized cats. Focal cerebral ischemia was produced by permanent occlusion of the middle cerebral artery (MCA) and the animals were killed 6 h later. The amount of early ischemic brain damage was assessed in coronal sections at 16 predetermined stereotaxic planes. Pretreatment with D-CPP-ene (15 mg/kg i.v. followed by continuous infusion at 0.17 mg/kg/min until death), 15 min prior to MCA occlusion, significantly reduced the volume of ischemic brain damage (from 20.6 ± 9.9% of the cerebral hemisphere in vehicle-treated cats to 7.2 ± 4.4% in drug-treated cats; p < 0.01). The competitive NMDA receptor antagonist D-CPP-ene is as effective as noncompetitive NMDA antagonists in reducing the amount of ischemic brain damage in this model of focal cerebral ischemia in a gyrencephalic species.

Analysis and clinical findings of cases positive for the novel synthetic cannabinoid receptor agonist MDMB-CHMICA

Abstract Context: MDMB-CHMICA is a synthetic cannabinoid receptor agonist which has caused concern due to its presence in cases of adverse reaction and death. Method: 43 cases of suspected synthetic cannabinoid ingestion were identified from patients presenting at an Emergency Department and from post-mortem casework. These were subjected to liquid-liquid extraction using tertiary-butyl methyl ether and quantitatively analysed by Electrospray Ionisation Liquid Chromatography–tandem Mass Spectrometry. For positive samples, case and clinical details were sought and interrogated. Results: 11 samples were found positive for MDMB-CHMICA. Concentrations found ranged from <1 to 22 ng/mL (mean: 6 ng/mL, median: 3 ng/mL). The age range was 15–44 years (mean: 26 years, median: 21 years), with the majority (82%) of positive results found in males. Clinical presentations included hypothermia, hypoglycaemia, syncope, recurrent vomiting, altered mental state and serotonin toxicity, with corresponding concentrations of MDMB-CHMICA as low as <1 ng/mL. Duration of hospitalisation ranged from 3 to 24 h (mean: 12 h, median: 8 h). Discussion: The concentration range presented in this case series is indicative of MDMB-CHMICA having a high potency, as is known to be the case for other synthetic cannabinoid receptor agonists. The age range and gender representation were consistent with that reported for users of other drugs of this type. The clinical presentations observed were typical of synthetic cannabinoid receptor agonists and show the difficulties in identifying reactions potentially associated with drugs of this type. Conclusion: The range of MDMB-CHMICA concentrations in Emergency Department presentations (n = 9) and post-mortem cases (n = 2) was reported. No correlation between the concentration of this drug and clinical presentation or cause of death was reported in this sample. However, the potential for harm associated with low concentrations of MDMB-CHMICA and the symptoms of toxicity being non-specific were highlighted.

Exploring situational awareness in emergency medicine: developing a shared mental model to enhance training and assessment.

Non-technical skills (NTS) are gaining increasing prominence within the field of emergency medicine. Situational awareness (SA), one key component of NTS, is a key skill for emergency physicians (EPs) during initial training and throughout their career. Furthermore, the majority of frameworks used to evaluate clinical performance incorporate SA as one key component. This review seeks to define and explore the concept of SA within the context of emergency medicine. We describe SA at an individual, team and departmental level. Development of this ability enables EPs to function effectively within the challenging environment of the emergency department (ED). Enhancing our understanding of SA may develop the cognitive process that underpins our clinical performance. We propose a model for consideration to support evaluation and training of SA within the ED, linking the model to the novice expert continuum.

Optimising clinical performance during resuscitation using video evaluation

Video evaluation of resuscitation is becoming increasingly integrated into practice in a number of clinical settings. The purpose of this review article is to examine how video may enhance clinical care during resuscitation. As healthcare and available therapeutic interventions evolve, re-evaluation of accepted paradigms requires data to describe current practice and support change. Analysis of video recordings affords creation of a framework to evaluate individual and team performance and develop unique and tailored strategies to optimise care delivery. While video has been used in a number of non-clinical settings, there has been a recent increase of video systems in the prehospital and other clinical areas. This paper reviews the key opportunities in the emergency department-based resuscitation setting to enhance ergonomics, technical and non-technical skills—at both team and individual level—through video-assisted care performance analysis and feedback.

Predicting admission at triage: are nurses better than a simple objective score?

Aim We compared two methods of predicting hospital admission from ED triage: probabilities estimated by triage nurses and probabilities calculated by the Glasgow Admission Prediction Score (GAPS). Methods In this single-centre prospective study, triage nurses estimated the probability of admission using a 100 mm visual analogue scale (VAS), and GAPS was generated automatically from triage data. We compared calibration using rank sum tests, discrimination using area under receiver operating characteristic curves (AUC) and accuracy with McNemars test. Results Of 1829 attendances, 745 (40.7%) were admitted, not significantly different from GAPS’ prediction of 750 (41.0%, p=0.678). In contrast, the nurses’ mean VAS predicted 865 admissions (47.3%), overestimating by 6.6% (p<0.0001). GAPS discriminated between admission and discharge as well as nurses, its AUC 0.876 compared with 0.875 for VAS (p=0.93). As a binary predictor, its accuracy was 80.6%, again comparable with VAS (79.0%), p=0.18. In the minority of attendances, when nurses felt at least 95% certain of the outcome, VAS’ accuracy was excellent, at 92.4%. However, in the remaining majority, GAPS significantly outperformed VAS on calibration (+1.2% vs +9.2%, p<0.0001), discrimination (AUC 0.810 vs 0.759, p=0.001) and accuracy (75.1% vs 68.9%, p=0.0009). When we used GAPS, but ‘over-ruled’ it when clinical certainty was ≥95%, this significantly outperformed either method, with AUC 0.891 (0.877–0.907) and accuracy 82.5% (80.7%–84.2%). Conclusions GAPS, a simple clinical score, is a better predictor of admission than triage nurses, unless the nurse is sure about the outcome, in which case their clinical judgement should be respected.

SODAS: Surveillance of Drugs of Abuse Study.

Objective Novel psychoactive substance (NPS) as a form of recreational drug use has become increasingly popular. There is a paucity of information with regard to the prevalence and clinical sequelae of these drugs. The aim of this study was to detect NPS in patients presenting to the emergency department with suspected toxicological ingestion. Patients and methods The prospective study was performed in a large emergency department in the UK. During a 3-month period 80 patients were identified by clinicians as having potentially ingested a toxicological agent. Urine samples were analysed using liquid chromatography high-resolution mass spectrometry, and basic clinical data was gathered. Results Eighty patients with a history of illicit or recreational drug consumption had urine screenings performed. Forty-nine per cent (39) of the patients undergoing a screen had more than one illicit substance detected. Twenty per cent (16) of the patients tested positive for at least one NPS. Conclusion Almost half of the presented patients revealed ingestion of multiple substances, which correlated poorly with self-reporting of patients. Developing enhanced strategies to monitor evolving drug trends is crucial to the ability of clinicians to deliver care to this challenging group of patients.

Comparison of Glasgow Admission Prediction Score and Amb Score in predicting need for inpatient care.

Aim We compared the abilities of two established clinical scores to predict emergency department (ED) disposition: the Glasgow Admission Prediction Score (GAPS) and the Ambulatory Score (Ambs). Methods The scores were compared in a prospective, multicentre cohort study. We recruited consecutive patients attending ED triage at two UK sites: Northern General Hospital in Sheffield and Glasgow Royal Infirmary, between February and May 2016. Each had a GAPS and Ambs calculated at the time of triage, with the triage nurses and treating clinicians blinded to the scores. Patients were followed up to hospital discharge. The ability of the scores to discriminate discharge from ED and from hospital at 12 and 48 hours after arrival was compared using the area under the curve (AUC) of their receiving-operator characteristics (ROC). Results 1424 triage attendances were suitable for analysis during the study period, of which 567 (39.8%) were admitted. The AUC for predicting admission was significantly higher for GAPS at 0.807 (95% CI 0.785 to 0.830), compared with 0.743 (95% CI 0.717 to 0.769) for Ambs, P<0.00001. Similar results were seen when comparing ability to predict hospital stay of >12 hour and >48 hour. GAPS was also more accurate as a binary test, correctly predicting 1057 outcomes compared with 1004 for Ambs (74.2vs70.5%, P=0.012). Conclusion The GAPS is a significantly better predictor of need for hospital admission than Ambs in an unselected ED population.

Top 10 lessons from the Glasgow major incidents

In November 2013 and again in December 2014, two major incidents were declared at Glasgow Royal Infirmary (GRI). The first was in response to the Clutha bar tragedy,1 in which a helicopter crashed into a crowded pub on a busy Friday night, and the second, when a bin lorry lost control while travelling towards George Square,2 as hundreds of people went about their Christmas shopping. Both locations are within 1.5 miles of GRI and were attended by the emergency services and augmented by the Emergency Medical Retrieval Service, who expertly managed both scenes and facilitated safe and timely transfer to GRI and other receiving hospitals. GRI is an inner city tertiary referral centre with 900 beds and has an ED, which sees in excess of 85 000 attendances per year. Subsequent to both events, reviews were conducted at health board, hospital and departmental level. In addition, GRI has a well-established trauma group, made up of specialties involved in the management of major trauma, which meets to enhance the co-operation between teams. Our hospital updates our major incident planning regularly due to the large number of international events such as the Commonwealth Games. Significant learning has been gained from these unfortunate events and a number of changes have been implemented in relation to major incident planning as well as to the processes in place for trauma care more generally. Following each of the incidents action points were generated from our trauma team meetings, formal major incident debrief and our EDs own internal review. The recommendations from these …

6 Prognostic value of the glasgow admission prediction score: hospital length of stay, mortality and hospital readmission

Introduction As patient numbers presenting to emergency departments (ED) increase, with their myriad of comorbidities, early hospital admission prediction and demand modelling are crucial both in the ED and beyond. The Glasgow admission prediction score (GAPS) (figure 1)1 has already been shown to be accurate in predicting hospital admission from the ED at the point of triage.2 As demand on EDs increase, data driven models such as GAPS will become increasingly important for predicting patient course. However, GAPS has not previously been tested beyond the point of admission. Figure 1 Aim To assess whether GAPS has the ability to predict hospital length of stay (LOS), six-month mortality and six-month hospital readmission. Methods Sampling was conducted in 2016 at the Sheffield Teaching Hospitals NHS foundation trust ED and the NHS Greater Glasgow and Clyde ED. Data were collected prospectively at the point of triage for all consecutive patients who presented to the ED during sampling times. GAPS was calculated independent of patient clinical management and recorded. Patients were followed up at six months, looking at length of any hospital admission, mortality and hospital readmission. Length of hospital stay, mortality and hospital readmission against GAPS was modelled using survival analysis. Results In total 1420 patients were recruited, 39.6% of these patients were initially admitted to hospital. At six months, 30.6% of patients had been readmitted and 5.6% of patients had died. For those admitted at first presentation, the chance of being discharged at any one time fell by 4.3% (95% confidence interval (CI) 3.2%–5.3%) per GAPS point increase. Figure 2 displays the Kaplan Meier curves for 6 month mortality. Cox regression showed a significant association between GAPS and mortality, with a hazard increase of 9% (95% CI:6.9% to 11.2%) for every point increase on GAPS. Figure 3 displays the Kaplan Meier curves for 6 month hospital readmission. Figure 2 Discussion GAPS is a simple tool which utilises data routinely collected at triage. It is predictive of hospital admission, hospital length of stay, six-month all-cause mortality and six-month hospital readmission. Therefore, GAPS could be employed to aid staff in hospital bed planning, clinical decision making and ED resource allocation and utilisation. Figure 3 References Logan E, et al. Predicating admission at triage. Presented at International Acute Medicine Conference, Edinburgh 2016. Cameron A, et al. A simple tool to predict admission at the time of triage. Emergency Medicine Journal2014.

Feasibility of EEG to monitor cognitive performance during venous cannulation: EEG Distracted Intravenous Access (E-DIVA)

Background The feasibility study aims to evaluate the use of EEG in measuring workload during a simulated intravenous cannulation task. Cognitive workload is strongly linked to performance, but current methods to assess workload are unreliable. The paper presents the use of EEG to compare the cognitive workload between an expert and novice group completing a simple clinical task. Methods 2 groups of volunteers (10 final year medical students and 10 emergency medicine consultants) were invited to take part in the study. Each participant was asked to perform 3 components of the simulation protocol: intravenous cannulation, a simple arithmetic test and finally these tasks combined. Error rate, speed of task completion and an EEG-based measure of cognitive workload were recorded for each element. Results EEG cognitive workload during the combined cannulation and arithmetic task is significantly greater in novice participants when compared with expert operators performing the same task combination. EEG workload mean measured for novice and experts was 0.62 and 0.54, respectively (p=0.001, 95% CI 0.09 to 0.30). There was no significant difference between novice and expert EEG workload when the tasks were performed individually. Conclusions EEG provides the opportunity to monitor and analyse the impact of cognitive load on clinical performance. Despite the significant challenges in set up and protocol design, there is a potential to develop educational interventions to optimise clinicians awareness of cognitive load. In addition, it may enable the use of metrics to monitor the impact of different interventions and select those that optimise clinical performance.