Prospective observational study of peripheral intravenous cannula utilisation and frequency of intravenous fluid delivery in the emergency department-Convenience or necessity?

BACKGROUND: Peripheral Intravenous Cannulas (PIVCs) are frequently utilised in the Emergency Department (ED) for delivery of medication and phlebotomy. They are associated with complications and have an associated cost to departmental resources. A growing body of international research suggests many of the PIVCs inserted in the ED are unnecessary. METHODS: The objective of this study was to determine the rates of PIVC insertion and use. This was a prospective observational study conducted in one UK ED and one Italian ED. Adult ED patients with non-immediate triage categories were included over a period of three weeks in the UK ED in August 2016 and two weeks in the Italian ED in March and August 2017. Episodes of PIVC insertion and data on PIVC utilisation in adults were recorded. PIVC use was classified as necessary, unnecessary or unused. The proportion of unnecessary and unused PIVCs was calculated. PIVCs were defined as unnecessary if they were either used for phlebotomy only, or solely for IV fluids in patients that could have potentially been hydrated orally (determined against a priori defined criteria). PIVC classified as unused were not used for any purpose. RESULTS: A total of 1,618 patients were included amongst which 977 PIVCs were inserted. Of the 977 PIVCs, 413 (42%) were necessary, 536 (55%) were unnecessary, and 28 (3%) were unused. Of the unnecessary PIVCs, 473 (48%) were used solely for phlebotomy and 63 (6%) were used for IV fluids in patients that could drink. CONCLUSIONS: More than half of PIVCs placed in the ED were unnecessary in this study. This suggests that clinical decision making about the benefits and risks of PIVC insertion is not being performed on an individual basis.

AWAreness during REsuscitation - II: A multi-center study of consciousness and awareness in cardiac arrest.

INTRODUCTION: Cognitive activity and awareness during cardiac arrest (CA) are reported but ill understood. This first of a kind study examined consciousness and its underlying electrocortical biomarkers during cardiopulmonary resuscitation (CPR). METHODS: In a prospective 25-site in-hospital study, we incorporated a) independent audiovisual testing of awareness, including explicit and implicit learning using a computer and headphones, with b) continuous real-time electroencephalography(EEG) and cerebral oxygenation(rSO2) monitoring into CPR during in-hospital CA (IHCA). Survivors underwent interviews to examine for recall of awareness and cognitive experiences. A complementary cross-sectional community CA study provided added insights regarding survivors' experiences. RESULTS: Of 567 IHCA, 53(9.3%) survived, 28 of these (52.8%) completed interviews, and 11(39.3%) reported CA memories/perceptions suggestive of consciousness. Four categories of experiences emerged: 1) emergence from coma during CPR (CPR-induced consciousness [CPRIC]) 2/28(7.1%), or 2) in the post-resuscitation period 2/28(7.1%), 3) dream-like experiences 3/28(10.7%), 4) transcendent recalled experience of death (RED) 6/28(21.4%). In the cross-sectional arm, 126 community CA survivors' experiences reinforced these categories and identified another: delusions (misattribution of medical events). Low survival limited the ability to examine for implicit learning. Nobody identified the visual image, 1/28(3.5%) identified the auditory stimulus. Despite marked cerebral ischemia (Mean rSO2 = 43%) normal EEG activity (delta, theta and alpha) consistent with consciousness emerged as long as 35-60 minutes into CPR. CONCLUSIONS: Consciousness. awareness and cognitive processes may occur during CA. The emergence of normal EEG may reflect a resumption of a network-level of cognitive activity, and a biomarker of consciousness, lucidity and RED (authentic "near-death" experiences).

Short-term neurocognitive and symptomatic outcomes following mild traumatic brain injury: A prospective multi-centre observational cohort study.

OBJECTIVE: To determine the short-term cognitive and symptomatic outcome following mild traumatic brain injury. METHODS: Setting: Emergency Departments of two UK tertiary referral hospitals. PARTICIPANTS: Adult patients presenting to the Emergency Departments of the Royal London Hospital and Salford Royal Hospital with suspected traumatic brain injury within 24 hours and Glasgow Coma Score > 8. A non-TBI comparison group included adult patients with no head or neck injury. DESIGN: Prospective multi-centre cohort study. MAIN MEASURES: The Standardized Assessment of Concussion (SAC), the Concussion Symptom Inventory (CSI) and total number of symptoms, measured at baseline and 72 hours. RESULTS: This study enrolled 189 patients with and 51 patients without TBI. Patients with TBI had marked cognitive impairment which persisted at 72 hours (SAC score at baseline = 25 [23-27] vs 72 hours = 25 [22-27]; p = 0.1). Patients with TBI had persistent high symptom severity, although this had decreased at 72 hours (CSI score at baseline = 9 [4-22] vs 72 hours = 5 [1-19], p = 0.002). A similar pattern was observed with the total number of symptoms (baseline = 4 [2-8] vs 72 hours = 0 [0-4]; p < 0.001). Patients with TBI had worse neurocognitive function, higher overall symptom severity and higher total number of symptoms compared with patients without TBI. Patients without TBI' neurocognitive function and symptom severity remained constant, but the number of symptoms reduced between baseline and 72 hours. CONCLUSION: There is a cognitive deficit and symptom burden in patients with mild TBI presenting to the Emergency Department which persists at 72 hours.

Letter in Response to 'Classification of Traumatic Brain Injury Severity Using Informed Data Reduction in a Series of Binary Classifier Algorithms'.

Presents letters to the editor.

A comparison of measurements of sodium, potassium, haemoglobin and creatinine between an Emergency Department-based point-of-care machine and the hospital laboratory.

Blood gas analysers provide electrolyte and metabolic data. In the author's institution, these values were not used clinically because of the risk of inaccuracy. To discover whether this approach was warranted, we compared values from our Radiometer point-of-care (POC) analyser and the laboratory. A total of 207 patients from an urban Emergency Department received venepuncture for sodium, potassium, creatinine and haemoglobin. Two samples were drawn; one analysed in the laboratory, the other on the POC machine. The results were: sodium: n=182, mean difference (MD) (lab-POC) 3.36, 95% limits of agreement (LOA) 0.18-6.54; potassium: n=171, MD 0.46, 95% LOA -0.12 to 1.03; creatinine: n=183, MD 1.6, 95% LOA -16.2 to 18.7; haemoglobin: n=191, MD -0.29, 95% LOA -1.71 to 1.12. Thus, sodium and potassium showed negative bias on the Radiometer compared with the laboratory. Creatinine and haemoglobin agreed well. We advocate the clinical use of POC values when taken in clinical context.

The role of venous blood gas in the emergency department: a systematic review and meta-analysis.

The aim of this study is to provide a systematic review of the literature reporting agreement between arterial and venous pH, partial pressure of carbon dioxide (PCO2), bicarbonate (HCO3⁻), base excess and lactate; and to perform a meta-analysis of the differences. Medline and Embase searches using Eduserv Athens from 1950 to present were conducted using the terms 'VBG', 'ABG', 'arterial', 'venous', 'blood', 'gas', 'lactate', 'emergency' and 'department'. References of the published papers were hand searched and full-text versions of those deemed helpful to the question were obtained. Mean difference (MD) and 95% limits of agreement (LOA) were either reported or calculated from the published data. Pooled MDs with 95% confidence intervals (CIs) were calculated for differences between arterial and venous pH, PCO2, bicarbonate and lactate. Thirteen articles relevant to pH, 12 relevant to PCO2, 10 relevant to bicarbonate and three relevant to lactate were found. The pooled MD (venous-arterial) for pH was -0.033 pH units (95% CI -0.039 to 0.027) with narrow 95% LOA, the pooled MD for PCO2 was 4.41 mmHg (95% CI 2.55-6.27) with 95% LOA ranging from -20.4 to 25.8 mmHg, the pooled MD for bicarbonate was 1.03 mmol/l (95% CI 0.56-1.50) with 95% LOA ranging from -7.1 to 10.0 mmol/l and the pooled MD for lactate was 0.25 mmol/l (95% CI 0.15-0.35) with 95% LOA ranging from -2.0 to 2.3 mmol/l. Venous and arterial pH and bicarbonate agree reasonably at all values, but the agreement is highest at normal values. Arteriovenous agreement for PCO2 is poor and PvCO2 cannot be relied upon as an absolute representation of PaCO2. However, normal peripheral PvCO2 has a good negative predictive value for normal arterial PCO2, and a normal PvCO2 can be used as a screen to exclude hypercapnic respiratory disease. There may be a poor agreement between arterial and venous lactate at abnormal values; however, if the venous lactate is normal, it is likely the arterial values of this parameter will also be normal.

Surviving atlanto-occipital dislocation.

Traumatic atlanto-occipital dislocation carries a significant mortality and morbidity. We present the clinical and radiological features of a case of traumatic skeletal and central nervous system disunion. Thanks to a combination of early resuscitation and luck, the patient survived an improbably severe injury to leave hospital and enjoy a degree of independent life. Such severe injuries are usually fatal and the literature on such extensive cervical disruption is often confined to postmortem evidence.