De Villiers Smit

Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial).

INTRODUCTION Many patients who suffer cardiac arrest do not respond to standard cardiopulmonary resuscitation. There is growing interest in utilizing veno-arterial extracorporeal membrane oxygenation assisted cardiopulmonary resuscitation (E-CPR) in the management of refractory cardiac arrest. We describe our preliminary experiences in establishing an E-CPR program for refractory cardiac arrest in Melbourne, Australia. METHODS The CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion) is a single center, prospective, observational study conducted at The Alfred Hospital. The CHEER protocol was developed for selected patients with refractory in-hospital and out-of-hospital cardiac arrest and involves mechanical CPR, rapid intravenous administration of 30 mL/kg of ice-cold saline to induce intra-arrest therapeutic hypothermia, percutaneous cannulation of the femoral artery and vein by two critical care physicians and commencement of veno-arterial ECMO. Subsequently, patients with suspected coronary artery occlusion are transferred to the cardiac catheterization laboratory for coronary angiography. Therapeutic hypothermia (33 °C) is maintained for 24h in the intensive care unit. RESULTS There were 26 patients eligible for the CHEER protocol (11 with OHCA, 15 with IHCA). The median age was 52 (IQR 38-60) years. ECMO was established in 24 (92%), with a median time from collapse until initiation of ECMO of 56 (IQR 40-85) min. Percutaneous coronary intervention was performed on 11 (42%) and pulmonary embolectomy on 1 patient. Return of spontaneous circulation was achieved in 25 (96%) patients. Median duration of ECMO support was 2 (IQR 1-5) days, with 13/24 (54%) of patients successfully weaned from ECMO support. Survival to hospital discharge with full neurological recovery (CPC score 1) occurred in 14/26 (54%) patients. CONCLUSIONS A protocol including E-CPR instituted by critical care physicians for refractory cardiac arrest which includes mechanical CPR, peri-arrest therapeutic hypothermia and ECMO is feasible and associated with a relatively high survival rate.

Evaluation of WHO criteria for identifying patients with severe acute respiratory syndrome out of hospital: prospective observational study

Abstract Objectives To determine the clinical and radiological features of severe acute respiratory syndrome (SARS) and to evaluate the accuracy of the World Health Organizations guidelines on defining cases of SARS. Design Prospective observational study. Setting A newly set up SARS screening clinic in the emergency department of a university hospital in Hong Kongs New Territories. Participants 556 hospital staff, patients, and relatives who attended the screening clinic and who had had contact with someone with SARS. Main outcome measure Number of confirmed cases of SARS. Results Of the 556 people, 141 were admitted to hospital, and 97 had confirmed SARS. Fever, chills, malaise, myalgia, rigor, loss of appetite, vomiting, diarrhoea, and neck pain but not respiratory tract symptoms were significantly more common among the 97 patients than among the other patients. The overall accuracy of the WHO guidelines for identifying suspected SARS was 83% and their negative predictive value was 86% (95% confidence interval 83% to 89%). They had a sensitivity of 26% (17% to 36%) and a specificity of 96% (93% to 97%). Conclusions Current WHO guidelines for diagnosing suspected SARS may not be sufficiently sensitive in assessing patients before admission to hospital. Daily follow up, evaluation of non-respiratory, systemic symptoms, and chest radiography would be better screening tools.

Why older patients of lower clinical urgency choose to attend the emergency department.

To examine non‐clinical factors associated with emergency department (ED) attendance by lower urgency older patients.

B-Type Natriuretic Peptide Testing and the Accuracy of Heart Failure Diagnosis in the Emergency Department

Background—It is often difficult to diagnose heart failure (HF) accurately in patients presenting with dyspnea to the emergency department (ED). This study assessed whether B-type natriuretic peptide (BNP) testing in these patients improved the accuracy of HF diagnosis. Methods and Results—Patients presenting to the Alfred and the Northern Hospital EDs with a chief complaint of dyspnea were enrolled prospectively from August 2005 to April 2007. Patients were randomly allocated to have BNP levels tested or not. The diagnostic gold standard for HF was determined by 1 cardiologist and 1 emergency or respiratory physician who, blinded to the BNP result, independently reviewed all available information. The ED diagnosis of HF in the non-BNP group showed a sensitivity, specificity, and accuracy of 65%, 92%, and 81%, respectively. The BNP group had a similar sensitivity, specificity, and accuracy of 66%, 90%, and 78%, respectively, for the diagnosis of HF in the ED. There was no significant difference between the BNP and non-BNP groups in any of the measures of diagnostic accuracy for HF. Conclusion—In the clinical setting of EDs, availability of BNP levels did not significantly improve the accuracy of a diagnosis of HF. Clinical Trial Registration—clinicaltrials.gov. Identifier: NCT00163709.

The spectrum of severe acute respiratory syndrome-associated coronavirus infection

Context Severe acute respiratory syndrome (SARS) is a rapidly progressive pneumonia, but do some infected patients have only mild or no symptoms? Contribution A total 1100 patients had serologic tests when evaluated at a SARS clinic in Hong Kong at the time of the 2003 epidemic. Of 910 patients who were managed without hospitalization, 6 patients had serologic evidence of SARS. Five of the 6 patients had normal chest radiographs, and 4 patients had symptoms such as myalgia, chills, coughing, and feeling feverish. Cautions Although this study suggests few cases of subclinical SARS during the 2003 outbreak, patients were self-referred rather than identified through community surveillance. The Editors Severe acute respiratory syndrome (SARS) is a rapidly progressive, atypical pneumonia (1-3) that is caused by a novel coronavirus (4-8) and has spread throughout the globe (9). The epidemiology (10), clinical features (11-15), and progression (16) of patients with confirmed SARS have recently been described and have shown a spectrum of clinical presentation and severity of disease (16). However, published data are insufficient to clarify whether patients have subclinical and milder forms of SARS that do not result in pneumonia. Strategies were devised for screening patients who attended our emergency department (15, 17) and for clinically confirming SARS in the Hong Kong outbreak (13, 18), but these strategies have never been evaluated by using a gold standard diagnostic test for SARS coronavirus infection. Virus isolation, molecular detection for viral RNA, and serologic tests have recently been developed for detecting SARS coronavirus infection (4-8). Among these, serologic testing on paired serum samples is regarded as both sensitive and specific (19). We studied the spectrum of clinical presentation in patients screened at a SARS screening clinic with paired serologic test results, investigated whether a subset of mildly symptomatic or asymptomatic patients exists, and evaluated the accuracy of clinical assessment of SARS. Methods Study Design and Setting This study was conducted in the newly opened SARS clinic located in the emergency department of the Prince of Wales Hospital, Hong Kong. This teaching hospital and tertiary referral center for the New Territories of the Hong Kong Special Administrative Region serves a mainly urban catchment area of 1.5 million people. Because of the severity of the crisis, pursuing normal channels of approval and consent was not possible. However, all patients received a questionnaire to complete, and they understood that the data would be used for surveillance, analysis, and research. The chief executives and associated institutional review boards of the Hospital Authority of Hong Kong and Prince of Wales Hospital approved the collection of clinical data and use of blood tests for surveillance, analysis, research, and reporting. Many of these patients have been described in previous reports (13, 15). Patients were included if they attended the clinic between 12 March 2003 and 12 May 2003. People would attend the emergency department of their own volition as per normal practice and were triaged either to fever or nonfever areas depending on whether they reported fever or had a temperature greater than 37 C. The SARS clinic was operated by emergency physicians and nurses. The clinic was initially located in the emergency department but was later moved outside the main building. All staff or patients from the community catchment area with suspected SARS were referred to the clinic. There are 14 hospitals with emergency departments in Hong Kong, and patients with suspected SARS would present to and be hospitalized in all of these during the outbreak. The Prince of Wales Hospital SARS clinic received a high proportion of hospital staff; thus, this study may not fully represent the spectrum in the community. We previously described in detail the process of care through the clinic (15). Patients were followed up daily after first attendance if they had a contact history, were symptomatic, had a body temperature greater than 38 C, had a normal or indeterminate chest radiograph, or had abnormal results on laboratory investigations (for example, leukopenia, lymphopenia, monocytosis, or thrombocytosis). Patients were given hygiene advice, advised to isolate themselves, and followed up the next day. Patients were hospitalized to a clearing ward if they met the case definition for probable SARS. Patients were discharged from the clinic after first attendance if they were asymptomatic, did not have a fever, and had a normal chest radiograph and normal results on laboratory investigations. They were given hygiene advice and advised to return if they experienced a fever. Patients who were followed up daily were discharged after 48 hours of remaining asymptomatic and afebrile and with normal chest radiographs and laboratory test results. Patient Assessments and Investigations All patients were seen by an emergency specialist; completed a health questionnaire that documented contact history and upper and lower respiratory tract, gastrointestinal, and systemic symptoms; and had pulse rate, systolic and diastolic blood pressure, respiratory rate, tympanic temperature, and oxygen saturation at room air recorded daily. All patients underwent daily frontal plain chest radiography until their symptoms subsided or pneumonic change appeared. If fever (temperature > 38 C) persisted for more than 2 days, standard and high-resolution computed tomography was requested for high-risk patients (those with contact history, persistent symptoms, and persistent fever) who had normal chest radiographs to confirm or exclude occult pneumonia. Chest radiographs were initially evaluated by a specialist emergency physician who had knowledge of clinical details and then by a radiologist without reference to clinical information. Case Definition and Viral Detection The World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) have described current case definitions for SARS (2, 3). In our study, patients with a probable case of SARS during the outbreak that would result in hospitalization included those with 1) a contact history; 2) systemic, respiratory, or gastrointestinal symptoms; and 3) pneumonic change on chest radiograph or computed tomography scan (Table 1). Table 1. Case Definitions for Severe Acute Respiratory Syndrome Before SARS coronavirus serologic tests were available, SARS was diagnosed clinically if the patient followed a typical 3-phase clinical course during the outbreak (Table 1). After SARS coronavirus serologic tests were available, SARS was confirmed by serologic evidence of SARS coronavirus (18). Phase 1 of the clinical course is a viral replication phase and involves an initial presentation of high fever and myalgia that last a few days and then resolve (symptoms resolve and temperature < 37 C). Phase 2 involves presumably immune-mediated lung injury and includes a recurrence of fever and progression of pneumonia. This phase begins about 8 days after fever onset. Most patients will improve after pulse steroid therapy and enter a third phase of rehabilitation. However, 20% may enter phase 3: severe lung injury characterized by the acute respiratory distress syndrome and need for ventilatory support (13, 16, 18). The level of anticoronavirus IgG antibody was measured by an immunofluorescence assay on the basis of Vero cells infected with coronavirus isolated from a patient with SARS (20). The full genome sequence of this SARS coronavirus strain is available at GenBank (GenBank accession number AY278554) (7, 8). According to the CDC, laboratory criteria for SARS may be used to classify cases as confirmed, negative, or undetermined status (3, 19). Severe acute respiratory syndrome is confirmed if any 1 of 3 criteria is met: 4-fold increase in SARS coronavirus antibody titer between acute-phase serum (measured within 7 days after the onset of fever) and convalescent-phase serum (measured >21 days after the onset of fever), detection of antibody to SARS coronavirus in specimens during acute illness, or detection of antibody to SARS coronavirus in specimens obtained from convalescent serum. Cases were classified as negative if there was no serologic evidence of SARS coronavirus, defined by the absence of antibody to SARS coronavirus in convalescent serum obtained more than 21 days after symptom onset (3, 18). Undetermined status includes patients in whom laboratory testing was either not performed or not complete (that is, discharged patients who declined to return to provide convalescent serum or patients who did not have serologic evidence of SARS coronavirus but had convalescent samples taken 21 days after onset of symptoms). For this study, convalescent or acute SARS coronavirus serologic status was considered the reference standard for SARS. Two experienced technicians cross-checked all results. The primary clinical outcome measure was a case with serologic evidence of SARS coronavirus. Controls were patients with no serologic evidence of SARS coronavirus. Cases of undetermined status are reported but are excluded in sensitivity analyses. Statistical Analysis Data are presented as means (SD) or absolute numbers (percentages), unless otherwise specified. Continuous variables were analyzed by using the unpaired 2-tailed t-test, and categorical data were analyzed by using the chi-square test or Fisher exact test. Data were analyzed by using Statview for Windows, version 5.0 (SAS Institute, Inc., Cary, North Carolina), and MedCalc, version 7.0 (MedCalc Software, Mariakerke, Belgium). Both SARS coronavirus serologic findings and clinical determination of SARS were binary (yes or no), categorical data. Sensitivity is the proportion of patients with the disease (serologic evidence of SARS coronavirus) and positive test results (that is, were hospitalized), while specificity is

BNP Testing and the Accuracy of Heart Failure Diagnosis in the Emergency Department

Background—It is often difficult to diagnose heart failure (HF) accurately in patients presenting with dyspnea to the emergency department (ED). This study assessed whether B-type natriuretic peptide (BNP) testing in these patients improved the accuracy of HF diagnosis. Methods and Results—Patients presenting to the Alfred and the Northern Hospital EDs with a chief complaint of dyspnea were enrolled prospectively from August 2005 to April 2007. Patients were randomly allocated to have BNP levels tested or not. The diagnostic gold standard for HF was determined by 1 cardiologist and 1 emergency or respiratory physician who, blinded to the BNP result, independently reviewed all available information. The ED diagnosis of HF in the non-BNP group showed a sensitivity, specificity, and accuracy of 65%, 92%, and 81%, respectively. The BNP group had a similar sensitivity, specificity, and accuracy of 66%, 90%, and 78%, respectively, for the diagnosis of HF in the ED. There was no significant difference between the BNP and non-BNP groups in any of the measures of diagnostic accuracy for HF. Conclusion—In the clinical setting of EDs, availability of BNP levels did not significantly improve the accuracy of a diagnosis of HF. Clinical Trial Registration—clinicaltrials.gov. Identifier: NCT00163709.

The association between time to disposition plan in the emergency department and in-hospital mortality of general medical patients.

Background:  A perceived risk of time‐limited emergency department (ED) assessment of patients is inadequate workup leading to inappropriate disposition. The aim of this study was to examine the association of time to disposition plan (TDP) on ED length of stay (LOS) and correlate this to mortality.

Presentation and management of aural foreign bodies in two Australian emergency departments

Objective:  To survey and compare the type and management of foreign bodies found in adult and paediatric ears presenting to an Australian otorhinolaryngology and a general ED.

Acupuncture as analgesia for low back pain, ankle sprain and migraine in emergency departments: Study protocol for a randomized controlled trial

BackgroundPain is the most common reason that patients present to an emergency department (ED) and is often inadequately managed. Evidence suggests that acupuncture is effective for pain relief, yet it is rarely practiced in the ED. The current study aims to assess the efficacy of acupuncture for providing effective analgesia to patients presenting with acute low back pain, migraine and ankle sprain at the EDs of four hospitals in Melbourne, Australia.MethodThe study is a multi-site, randomized, assessor-blinded, controlled trial of acupuncture analgesia in patients who present to an ED with low back pain, migraine or ankle sprain. Patients will be block randomized to receive either acupuncture alone, acupuncture as an adjunct to pharmacotherapy or pharmacotherapy alone. Acupuncture will be applied according to Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA). Pain after one hour, measured using a visual analogue scale (VAS), is the primary outcome. Secondary outcomes measures include the following instruments; the Oswestry low back pain disability questionnaire, 24-hour Migraine Quality of Life questionnaire and Patients Global Assessment of Ankle Injury Scale. These measures will be recorded at baseline, 1 hour after intervention, each hour until discharge and 48 ± 12 hours of ED discharge. Data will also be collected on the safety and acceptability of acupuncture and health resource utilization.DiscussionThe results of this study will determine if acupuncture, alone or as an adjunct to pharmacotherapy provides effective, safe and acceptable pain relief for patients presenting to EDs with acute back pain, migraine or ankle sprain. The results will also identify the impact that acupuncture treatment may have upon health resource utilisation in the ED setting.Trial registrationAustralia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000989246

RESPOND—a patient-centred programme to prevent secondary falls in older people presenting to the emergency department with a fall: protocol for a multicentre randomised controlled trial

Introduction Participation in falls prevention activities by older people following presentation to the emergency department (ED) with a fall is suboptimal. This randomised controlled trial (RCT) will test the RESPOND programme, an intervention designed to improve older persons’ participation in falls prevention activities through delivery of patient-centred education and behaviour change strategies. Design and setting A RCT at two tertiary referral EDs in Melbourne and Perth, Australia. Participants 528 community-dwelling people aged 60–90 years presenting to the ED with a fall and discharged home will be recruited. People who require an interpreter or hands-on assistance to walk; live in residential aged care or >50 km from the trial hospital; have terminal illness, cognitive impairment, documented aggressive behaviour or a history of psychosis; are receiving palliative care or are unable to use a telephone will be excluded. Methods Participants will be randomly allocated to the RESPOND intervention or standard care control group. RESPOND incorporates (1) a home-based risk factor assessment; (2) education, coaching, goal setting and follow-up telephone support for management of one or more of four risk factors with evidence of effective interventions and (3) healthcare provider communication and community linkage delivered over 6 months. Primary outcomes are falls and fall injuries per person-year. Discussion RESPOND builds on prior falls prevention learnings and aims to help individuals make guided decisions about how they will manage their falls risk. Patient-centred models have been successfully trialled in chronic and cardiovascular disease; however, evidence to support this approach in falls prevention is limited. Trial registration number The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000336684).