July 2022

Authors:

– Andy Neill
– Dave McCreary

Background

– Chest pain is really common. We have lots of tools for risk stratifying people at the front door but it’s really difficult to get people to a level of comfort that the patient can go home and not have a potential bad outcome. We would love a test that tells us about the anatomy of the coronary arteries but we can’t and shouldn’t send everyone for an invasive angiogram. CT scans have dramatically improved over the past 20 years and we’re at the stage where we can fairly reliably outline the coronary anatomy with CT. But does doing this help the patient?

Paper

– Early computed tomography coronary angiography in patients with suspected acute coronary syndrome: randomised controlled trial

Author

– Alasdair Gray, BMJ, 2021

Methods

– Randomised trial 37 centres across UK
– Included not just patients with potential ACS but could also have a raised trop abnormal ECG or piror coronary artery disease. They consider the group as intermediate risk which I think is reasonable. These aren’t the youngish, low heart score patients with 2 negative trops.
– Randomised to usual care (dictated by the caring team)
– Outcome was all cause death or non fatal MI within a year. I think this is a very reasonable outcome as that’s what we worry about when sending people home
– The trial was open label for obvious reasons but the outcome assessors were apparently blinded
– powered to look for a 3.5% absolute reduction in that primary outcome

Results

– 1750 patients
– a third had known CAD and half had a +ve trop or abnormal ECG so as mentioned these are well into the intermediate risk category
– 90% of those randomised to CTCA got it. Presumably the other 10% went straight to angio. CTCA done witihn 4 hrs for most
– 50% of those in the CTCA group has obstructive disease
– 6% met the primary outcome in both groups
– slightly less angio in the CTCA group (presumably clinicians felt reassured not to do it)
– no difference in length of stay at 2 days each

Thoughts

– it is very hard to prove that a diagnostic test saves lives so it’s hardly surprising that this was a negative trial.
– i don’t really think for most of us in EM in Ireland or the UK this is going to be an EM test. There is likely a role for risk stratification almost in an observation medicine type thing with input from Cardiology. In my ED all of these patients are likely getting admitted – certainly the +ve trops and ECGs. Once admitted then there may well be a role for the CTCA to direct care from there. If it provides the reassurance to patient and provider not to test further than it probably still is helpful.
– important to note how this is different from the low risk chest pain population where this has been previously looked at. CTCA in those patients tends to find a lot more coronary disease and increase interventions but again does not seem to improve outcomes.

www.hsib.org.uk

Authors

– Andy Neill
– Dave McCreary

Clinical Question

– can we use small 14F drains for haemothorax drainage in trauma patients

Paper

– The small (14 Fr) percutaneous catheter (P-CAT) versus large (2832 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial https://pubmed.ncbi.nlm.nih.gov/33843831/

Author

– Kulvatunyou, 2021, Journal Trauma Acute Care Surgery

Background

– Traditional teaching is that you need big (eg >28F) tubes for traumatic haemothoraces as things just clot and don’t drain if you use smaller. We have lots of trials over past 10 years looking at drains in a variety of settings all of which suggest less is more. For PTX we can just not drain at all and for bigger PTX we can just use pig tails or small catheters and the same for medical type effusions – smaller is better. The surgical, open chest drain is dying a death for many specialties.
– trauma has been a bit of a hold out and this trial asks can we use small drains here

Methods

– Multi centre RCT (all good words) of major trauma patients in the states.
– roughly at least 300mls blood on a CT to get into the study
– importantly excluded unstable patients.
– those randomised to a big drain got a 28-32F drain placed in the usual manner
– those randomised to small drains got a 14F pig tail placed with a wire. They make no mention of US guidance which i found a bit odd.
– primary outcome was retained blood on CT or if an intervention was needed. Pain would be another reasonable outcome but that was secondary here.
– It was designed as a non inferiority trial which seems reasonable when you’re trying a less invasive intervention against an established more invasive one. They set a non inferiority margin of 15% which seems very generous that you could easily quibble with.

Results

– like many trials in the past few years this was ended early due to COVID before it reached its sample size.
– they got 120 patients out of their planned 160.
– they found a failure rate of ~15% in both groups which is similar to prior data though higher than other centres have reported which was one of the criticsms of the study
– the rate of drainage by volume was higher in the pig tail group and as expected pain was less.

Thoughts

– important to note that these are pig tails with the little curly tip of the drain that maintains a gap in the pleural space so the drainage holes remain open. These are different from those small seldinger chest drains with the straight tip that we have. There are some subtle differences to the equipment and technique.
– These were the stable post CT scan patients. A big hole in the chest with a finger remains the treatment of choice in the primary survey phase. Then is not the time to fiddle around with wires and pig tails
– I’d love to know a bit more on their technique – ie US use and did they flush the drains, things like that.

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