Important Studies in Emergency Medicine

Below are some important studies in Emergency Medicine. There certainly are more, however these are the most recent and relevant. More will be added to this page regularly.

TRAUMA

Sherren PB et al. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service. Critical Care 201317(Suppl 2):P281

The authors here looked at the differences between traumatic and medical cardiac arrest anda proposed a new algorithm for management.

Roberts I. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013 Mar;17(10):1-79

Randomised Placebo controlled trial, conducted on an international level. 20211 patients were given 1g Tranexamic Acid over 10 minutes then 1g over 8 hours.

The study found that Tranexamic Acid given in < 1 hour had a 32% reduction in deaths due to bleeding. There was a significant reduction in death due to bleeding up to 3 hours. If given at > 3 hours it increased the risk of death due to bleeding.

There were some criticisms of this study, the greatest of which were that a substantial number i.e.., over 50% of the patients were recruited from centres whose ability to provide the level of care needed may not have been possible.

Morrison et al Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012 Feb;147(2):113-9.

A retrospective Observational Study of 896 patients that found a lower mortality in the Tranexamic Acid Treatment Group.

Morrison et al Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury: findings from the MATTERs II Study. JAMA Surg. 2013 Mar;148(3):218-25

This study had 1332 patients and compared those receiving Tranexamic acid, or tranexamic acid with cryoprecipitate, compared with cryoprecipitate alone or neither. The groups containing the tranexamic acid demonstrated the lowest mortalities.

Holcomb JB et al The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study. JAMA Sure. 2013;148(2):127-136

This study looked at mortality in trauma and how it relates to plasma and platelets. It concluded, that although there was no overall improvement in survival, the early use of plasma and platelets decreased mortality in the first 6 hours after admission( when most haemodynamic deaths occur)

Holcomb JB et al. Transfusion of Plasma, Platelets and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients with Severe Trauma. The PROPPR Randomised Clinical Trial. JAMA 2015;313(5):471-482.

The study looked at what would happen if platelets were also added to blood and plasma in trauma. The overall conclusion was that a 1:1:1 ratio achieved better haemostasis and there were fewer deaths due to exsanguination in the first 24 hours. What this meant was: 1(6U RBC : 1(1U Platelets):1(6U Plasma)

MEDICINE

Baharoglu MI et al. Platelet Transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with anti platelet therapy(PATCH):a randomised, open ;label, phase 3 trial. The Lancet Volume 387, No. 10038, p2605–2613, 25 June 2016.

This was a randomised trial in the Netherlands France and UK, that looked at the effect of platelet transfusion in those patients with intrcerebral haemorrhage associated with anti platelet therapy use. It was found that platelets increased mortality and adverse neurological outcome.

Appelboam A et al. Postural modification to the standard Valsalva manoeuvre for emergency medicine treatment of supra ventricular tachycardias(REVERT):a randomised controlled trial. The Lancet. Volume 386, No 10005, p1747-1753, 31 October 2015

This was a randomised control trial of 433 patients in SVT that found that 15 seconds of sitting up and performing valsalva, followed by 15 seconds of having head down and legs raised and then 1 minute of sitting up resulted in a reversion to sinus rhythm in 43% of cases as compared to 17% in the control group.

Than M et al. 2-Hour Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponin as the Only Biomarker. The ADAPT Trial. JACC Vol 59, No 23, 2012. The ADAPT Trial

This was a accelerated diagnostic protocol using a serial troponin at ) and 2 hours, associated with a TIMI score. It demonstrated that a low risk group i.e. normal troponin and TIMI=0 had a negative predictive value of 99.7% in predicting major adverse cardiac events.

Stub D et al. A randomized controlled trial of oxygen therapy in acute myocardial infarction Air Verses Oxygen In myocarDial infarction study (AVOID Study).Am Heart J. 2012 Mar;163(3):339-345

A Multicenter randomised controlled trial in the pre-hospital environment. It compared supplemental oxygen 8L/min with no oxygen in patients with STEMI. Supplemental oxygen, i.e. in patients that were not hypoxic, was found to increase early myocardial injury and result in larger myocardial infarct size when assessed at 6 months.

SURGERY

Anderson CS et al. Rapid Blood-Pressure Lowering in Patients with Acute Intracerebral Hemorrhage. NEJM 2013:368:2355-2365 INTERACT- 2 Trial

This study randomised 2839 patients to blood pressures of < 140mmHg and < 180mmHg. The results:

• NO reduction in death or severe disability
• No early neurological deterioration or advese event when BP <140mmHg
• Subgroup trend towards improved functional outcome at 90 days when BP<140mmHg