The CANBACK trial: a randomised, controlled clinical trial of oral cannabidiol for people presenting to the emergency department with acute low back pain.

OBJECTIVE: To assess the analgesic efficacy and safety of single-dose oral cannabidiol (CBD) as an adjunct to standard care for patients presenting to an emergency department with acute low back pain. DESIGN: Randomised, double blinded, placebo-controlled clinical trial. SETTING: The tertiary emergency department of Austin Hospital, Melbourne. PARTICIPANTS: Patients who presented with acute, non-traumatic low back pain between 21 May 2018 and 13 June 2019. INTERVENTION: One hundred eligible patients were randomised to receiving 400 mg CBD or placebo in addition to standard emergency department analgesic medication. MAIN OUTCOME MEASURES: Pain score two hours after administration of study agent, on a verbal numerical pain scale (range, 0-10). Secondary outcomes were length of stay, need for rescue analgesia, and adverse events. RESULTS: The median age of the 100 participants was 47 years (IQR, 34-60 years); 44 were women. Mean pain scores at two hours were similar for the CBD (6.2 points; 95% CI, 5.5-6.9 points) and placebo groups (5.8 points; 95% CI, 5.1-6.6 points; absolute difference, -0.3 points; 95% CI, -1.3 to 0.6 points). The median length of stay was 9.0 hours (IQR, 7.4-12 hours) for the CBD group and 8.5 hours (IQR, 6.5-21 hours) for the placebo group. Oxycodone use during the four hours preceding and the four hours after receiving CBD or placebo was similar for the two groups, as were reported side effects. CONCLUSION: CBD was not superior to placebo as an adjunct medication for relieving acute non-traumatic low back pain in the emergency department. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12618000487213 (prospective).

Prediction of tracheostomy in critically ill trauma patients: a systematic review.

BACKGROUND: Tracheostomy is relatively common in mechanically ventilated patients in the intensive care unit (ICU). The prediction of which patients will receive a tracheostomy is crucial to both clinical decision making and the design of targeted interventional trials of its timing. OBJECTIVES: We aimed to systematically review the literature to ascertain whether useful predictors of eventual tracheostomy can be identified, with a particular focus on trauma patients. DATA SOURCES AND REVIEW METHODS: We searched three electronic databases to identify all studies of any design evaluating potential predictors of tracheostomy in mechanically ventilated ICU patients. Bias was assessed using the Quality in Prognosis Studies tool. RESULTS: Of 140 potentially eligible studies, we identified 12 relevant observational studies recruiting a total of 119 945 mechanically ventilated patients, of whom 14 080 (11.7%) received a tracheostomy. Seven studies were performed in trauma populations and included 24 858 patients, of whom 6140 (24.7%) received a tracheostomy. Factors predictive of receiving a tracheostomy in the trauma population included patient factors (age and comorbidities), diagnostic factors (injury type and injury severity score), and intervention factors (craniotomy or laparotomy). Profound clinical and methodological heterogeneity prevented meaningful metaanalysis. Significantly, more predictors were present on the day of admission in trauma populations than in non-trauma patients with brain injury and in other populations (89.7% v 73.3% v 25.0%). CONCLUSION: There are a number of clinical factors associated with subsequent tracheostomy in mechanically ventilated patients, in particular trauma patients. Given the need to prevent patients from receiving an unnecessary tracheostomy, these findings indicate that better predictive models are needed before the conduct of interventional trials. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO registry no. CRD42018084987.

Epidemiology of early Rapid Response Team activation after Emergency Department admission.

BACKGROUND: Rapid Response Team (RRT) calls can often occur within 24h of hospital admission to a general ward. We seek to determine whether it is possible to identify these patients before there is a significant clinical deterioration. METHODS: Retrospective case-controlled study comparing patient characteristics, vital signs, and hospital outcomes in patients triggering RRT activation within 24h of ED admission (cases) with matched ED admissions not receiving a RRT call (controls). RESULTS: Over 12 months, there were 154 early RRT calls. Compared with controls, cases had a higher heart rate (HR) at triage (92 vs. 84 beats/min; p=0.008); after 3h in the ED (91 vs. 80 beats/min; p=0.0007); and at ED discharge (91 vs. 81 beats/min; p=0.0005). Respiratory rate (RR) was also higher at triage (21.2 vs. 19.2 breaths/min; p=0.001). On multiple variable analysis, RR at triage and HR before ward transfer predicted early RRT activation: OR 1.07 [95% CI 1.02-1.12] for each 1 breath/min increase in RR; and 1.02 [95% CI 1.002-1.030] for each beat/minute increase in HR, respectively. Study patients required transfer to the intensive care in approximately 20% of cases and also had a greater mortality: (21% vs. 6%; OR 4.65 [95% CI 1.86-11.65]; p=0.0003) compared with controls. CONCLUSIONS: Patients that trigger RRT calls within 24h of admission have a fourfold increase in risk of in-hospital mortality. Such patients may be identified by greater tachycardia and tachypnoea in the ED.