Archive for the Articles Worth Reading Category

Epistaxis and Tranexamic acid

A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial.

Author: Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M.

Reference: Am J Emerg Med. 2013 Sep;31(9):1389-92. doi: 10.1016/j.ajem.2013.06.043. Epub 2013 Jul 30.

Summary: This randomised controlled trial compared tranexamic acid with anterior nasal packing for patients with anterior epistaxis presenting to ED. 216 subjects with epistaxis were randomised to the injectable form of tranexamic acid (500 mg in 5 ml) applied topically, or anterior nasal packing with pledgets coated with tetracycline ointment. Outcome measures were time to cessation of bleeding, length of hospital stay (hours), and re-bleeding rates at 24 hours and 1 week. Patient satisfaction with treatment was rated on a 1-10 scale. Tranexamic acid was superior to anterior nasal packing for arresting bleeding at 10 minutes; 71 vs. 31.2% respectively (OR 2.28, 95% CI 1.68-3.09, p < 0.001) and discharge within 2 hours; 95.3 vs. 6.4% (p < 0.001). No difference was observed in between-group rates of re-bleeding at 24 hours; 4.7 vs. 11% (p = 0.128). Patient satisfaction with treatment was significantly greater for tranexamic acid compared to anterior nasal packing; 8.5 vs. 4.4 (p < 0.001).

Comment: The study showed good results, control of bleeding within 10 mins (71%) and discharged within 2hours(95%). More studies required for confirmation.

Airway management in obesity

This article from Stuart relates to our recent M&M case of an obese patient with respiratory failure

Airway management in bariatric patients Annals 2010

Two nice articles from EMA (if you don’t get it or don’t read it)

Metoclopromide and DIA EMA 2013

Diagnostic utility of VE EMA 2013

I have added two articles from June EMA. Both are neat little studies with good methodology and a simple bottom line. The first challenges the belief that that bolus metoclopromide is associated with akathisia. The second that vaginal examination helps in 1st trimester bleeding. In this study, clinical assessment was correct in only half the cases and did not correctly diagnose ectopic pregnancy at all. None of the six cases diagnosed as ectopic, had an ectopic and none of the four who had an ectopic were diagnosed clinically. VE made no difference. A good argument for bedside ultrasound.

Two new articles posted

I have posted a couple of new articles

WCC, CRP & PCT remain tests we love ordering, but recent systematic reviews show they have a limited ability to identify serious infection over and above our clinical assessment. The attached editorial gives a balanced assessment.

The second article again shows the risks of ICH in patients who sustain a minor head injury whilst on clopidogrel. A liberal use of CT is recommended.


Clopidogrel in Minor Head Injury

Risk of ICH in Patients on Clopidogrel

Another article on the risks of ICH in patients on Clopidogrel (10% risk) and Warfarin (4% risk) who sustain a minor head injury. The authors could not identify a low risk group, so recommend liberal use of CT in all these patients, even if assymptomatic.


PCT & CRP Moran Editorial Annals EM 2012

PCT & CRP Yo Annals EM 2012

For those of you who attended the recent Paediatric day at CHW, there was discussion of the value of CPR and PCT. The articles above are one of the ones referenced from Annals of Emergency Medicine and the accompanying editorial. Neither have strong enough LRs to be game changers in a febrile child.

CMAC versus direct laryngoscopy

CMAC versus Direct Laryngoscopy Sakles Ann EM 2012

A timely article about CMAC as we are about to introduce it at Nepean


Right-Sizing Testing for PE

A thoughtful editorial on  the approach to testing low risk PE patients. It argues that any testing (even D’dimer) for PERC negative patients does more harm than good.


 Right Sizing Testing for PE Green & Yealy Annals EM 2012

Intracranial Haemorrhage in Patients on Anticoagulation

This prospective study of patients with blunt head trauma showed that patients on clopidogrel had a higher rate of intracranial haemorrhage (12%) than those on Warfarin (5%), but warfarin had a small rate (0.6%) of delayed haemorrhage.  In this study, 97 % of patients were mild head injury with only 18% having a history of loss of consciousness or amnesia. The implication is that like patients on warfarin, you should have a very low threshhold for scanning patients on clopidogrel.

 Intracranial Haemorrhage with Anticoagulants Annals EM 2012


Contrast Induced Nephropathy with CTPA

An interesting article in light of our recent journal club looking at the use of NAC to prevent CIN. The article shows more patients suffered CIN than were found to have PE. The PE story only gets murkier.

CIN following CTPA AEM 2012

Recent Staffing Changes – Clarification from Dr Bishop

1. Recent Staffing Changes

Just some further discussion and clarification re the medical staffing
You may have noticed that we are now rostering a registrar to EMU/WRAC/FT. The aim of this is to give the registrars some exposure to EMU and assist the staff specialists in managing this load which is likely to increase with the 4 four target. Similarly this registrar will be the first port of call for clinical advice etc from the NPs in Fast Track. Again this gives the registrars some exposure to this case mix and allows the WRAC staff specialist to concentrate on patient flow through WRAC.
There are still some CMO shifts in Fast Track. When they are there they will obviously bethe fisrt port of call for the NPs. Also,just to clarify, the Fast Track shift times aren’t fixed to the shift times for acute care, but could be varied in conjunction with Arlene and Jayshri.
However there will be some shifts when we are short staffed on the registrar roster, and depending on workload, the FT CMO should also help out with WRAC – Jayshri may even roster this as a WRAC/FT shift.
At night, all fast track patients should be seen through WRAC – there will be no nursing staff in FT. You may ofcourse take patients into FT to use the eye room, plaster trolley etc. The oncoming night staff should start seeing patients between 2200 and 2300. Check with the evening staff specialists as to where the greatest need is. Picking up a couple of patients before the 2300 handover and getting a handle on what is waiting will help to ensure most patients are seen and have some plan before the staff specialist finish at midnight.
And yes the staff specialists are there until midnight  – the aim being that they have time after the handover to sort out issues identified at the handover, clear patients for EMU and ring VMOs as necessary, instead of having to do this at 0100 as has been the practice.
Finally we are making some more changes to WRAC including the development of an internal waiting room in Room 33 for patients to sit after their initial assessment. Tracey is developing some guidelines and we will undertake some further education etc prior to implementation in February.


Fluid Resuscitation in Trauma

Couple of articles worth reading.

The first paper is an evidence based review of fluid management of traumatic hemorrhagic shock. Take home points:

1.    How little we really know, how bad the science is, and that some conventional dogma is incorrect.

2.    In the bleeding patient, lost time is lost blood. Minimise delays (pre-hospital and in-hospital) prior to definitive control of hemorrhage. A common statement is that the best pre-hospital fluid is a bolus of diesel to the engine of the ambulance (ie get moving).

3.    Fluid choice doesn’t seem to have any significant impact on morbidity or mortality.

a.    No advantage to colloid. The best study here is SAFE, which concludes that crystalloids and colloids should be considered equivalent. There may be a minor logistic advantage to colloid in remote or military environments (when someone has to carry the IV fluids on their back).

b.    No clear advantage to either Saline or Hartmanns. Theoretical considerations favor Hartmanns, and some studies suggest that Hartmanns may be better (these studies are poor quality however).

c.    No advantage to hypertonic saline. Theoretically you would expect hypertonic saline to be of greatest benefit in head injuries (due to its ability to reduce ICP). However the best study addressing this (from Melbourne) failed to find a benefit.

4.    Trend towards using less fluid and less “resuscitation” than previously.

a.    Theoretical concerns of large volumes of IV fluid include increased bleeding due to hydrostatic disruption of hemostasis (“popping the clot”), dilution of hemoglobin (reduced oxygen transport), dilution of clotting factors and platelets (more bleeding), hypothermia (more bleeding) and tissue edema (including lung injury, pulmonary edema, and intra-abdominal compartment syndrome).

b.    The most famous study here is 1994 US study by Bickell et al. This showed significantly higher mortality in patients who got aggressive prehospital fluids. Note the setting of this study – inner-urban USA (= short prehospital times), and lots of penetrating trauma (ie big holes in big vessels). Care therefore needs to be taken extrapolating this data to all trauma patients.

c.    However minimizing fluids has become accepted practice. Our thinking now is that a patient does not immediately require fluid resuscitation if he has normal mentation (and therefore presumably normal tissue perfusion).

5.    Above all else, significant head injuries require normal BP. A single episode of hypotension doubles the mortality in head injury. In the setting of traumatic brain injury, the need to give fluids to maintain BP outweighs concerns about increased bleeding from a co-existing splenic injury.

6.    There is a trend to using more and earlier FFP and platelets in trauma resuscitation. There is a lot of evidence favoring this approach, although the studies are not perfect (mostly US military from Iraq and Afghanistan. However the believers are firm believers, and we are increasingly using FFP and platelets pre-emptively rather than waiting until clotting times become abnormal. Hospital based massive transfusion protocols recommending agreed fixed ratios of red cells:FP:platelets have been shown to be helpful in achieving this goal of early and more FFP and platelets.

7.    Tranexamic acid is definitely in following CRASH-2.


The second paper by Brohi is interesting in view of the current trend towards minimum volume fluid resuscitation. This paper is hard going unless you have a particular interest in coagulation! However the conclusion is that hypotension has been shown to induce activation of Protein C, and hence lead to anticoagulation! This happens very quickly (hence “acute”), and is frequently present by the time the patient has arrived in Emergency. This process has been termed “Acute Coagulopathy of Trauma”. This ACT appears to be more important than other traditional explanations for coagulopathy in trauma (eg dilutional, hypothermia). It seems strange that we would have a mechanism to initiate endogenous anti-coagulation when in a state of hemorrhagic shock. If there is an evolutionary rationale for this, it presumably lies in avoiding widespread sludging, thrombosis and ischemia when in a low perfusion state.

So we seem to be saying that excessive fluids can increase bleeding, and that insufficient fluids and uncorrected shock can induce a coagulopathy which will presumably increase bleeding. A delicate balance, especially in the early management of a seriously injured patient with lots of unknowns. What is this patients normal BP? Where is he bleeding? Does he have a significant brain injury, or is he just intoxicated?

Bottom line: Trauma is a complex entity, and we don’t know it all. Treatment decisions (including resuscitation strategy) need to be individualized taking into account the patient’s particular circumstances and competing priorities.

You can download the articles below for further reading.

Paper 1: Fluid Management in Traumatic Hemorrhagic Shock

Paper 2: Acute Coagulopathy of  Trauma (ACT)

Happy reading,

Steve Walker

Intralipid for Calcium Channel Blocker Overdose

Read this interesting article; its just a case report not a recommendation.

Lipid Rescue of Massive Verapamil Overdose. A Case Report.

Conrad W Liang1, Sarah J Diamond2 and Daniel S Hagg2* 

1Department of Neurology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, Oregon, 97201, USA. 2Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, Oregon, 97201 USA. Posted: 10/12/2011; J Med Case Reports. 2011;5(399)

Read Abstract [expand title=”Open” swaptitle=”Close”] Introduction: Massive intentional verapamil overdose is a toxic ingestion which can cause multiorgan system failure and has no currently known antidote.
Case Presentation: The patient is a 41-year-old Caucasian woman who ingested 19.2 g of sustained release verapamil in a suicide attempt. Our patient became hypotensive requiring three high-dose vasopressors to maintain arterial pressure. She also developed acute respiratory failure, bradycardic ventricular rhythm necessitating continuous transvenous pacing, and anuric renal failure. Our patient was treated with intravenous calcium, bicarbonate, hyperinsulinemic euglycemic therapy and continuous venovenous hemodialysis without success. On the fourth day after hospital admission continuous intravenous lipid therapy was initiated. Within three hours of beginning lipid therapy, our patient’s vasopressor requirement decreased by half. Within 24 hours, she was on minimal vasopressor support and regained an underlying junctional rhythm. After three days of lipid infusion, she no longer required inotropic agents to maintain blood pressure or pacing to maintain stable hemodynamics.
Conclusions: Intravenous fat emulsion therapy may be an effective antidote for massive verapamil toxicity. [/expand]

New Paediatric Stroke Scale Validated

The objective of this study was to evaluate IRR (Inter rater reliability) of a pediatric modification of the NIHSS, the Pediatric NIHSS (PedNIHSS). This is a MCT conducted at 15 sites in the United States and Canada from January 2007 through October 2009. Reported to have excellent IRR among child neurologists.

Abstract of the study,
[expand title=”Open” swaptitle=”Close”] Interrater Reliability of the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) in a Multicenter Study. Rebecca N. Ichord, MD et al.

Background and Purpose—Stroke is an important cause of death and disability among children. Clinical trials for childhood stroke require a valid and reliable acute clinical stroke scale. We evaluated interrater reliability (IRR) of a pediatric adaptation of the National Institutes of Health Stroke Scale.

Methods—The pediatric adaptation of the National Institutes of Health Stroke Scale was developed by pediatric and adult stroke experts by modifying each item of the adult National Institutes of Health Stroke Scale for children, retaining all examination items and scoring ranges of the National Institutes of Health Stroke Scale. Children 2 to 18 years of age with acute arterial ischemic stroke were enrolled in a prospective cohort study from 15 North American sites from January 2007 to October 2009. Examiners were child neurologists certified in the adult National Institutes of Health Stroke Scale. Each subject was examined daily for 7 days or until discharge. A subset of patients at 3 sites was scored simultaneously and independently by 2 study neurologists.

Results—IRR testing was performed in 25 of 113 a median of 3 days (interquartile range, 2 to 4 days) after symptom onset. Patient demographics, total initial pediatric adaptation of the National Institutes of Health Stroke Scale scores, risk factors, and infarct characteristics in the IRR subset were similar to the non-IRR subset. The 2 raters’ total scores were identical in 60% and within 1 point in 84%. IRR was excellent as measured by concordance correlation coefficient of 0.97 (95% CI, 0.94 to 0.99); intraclass correlation coefficient of 0.99 (95% CI, 0.97 to 0.99); precision measured by Pearson  of 0.97; and accuracy measured by the bias correction factor of 1.0.

Conclusions—There was excellent IRR of the pediatric adaptation of the National Institutes of Health Stroke Scale in a multicenter prospective cohort performed by trained child neurologists. (Stroke. 2011;42:613-617.)[/expand] Download Full Article in PDF,
[expand title=”Open” swaptitle=”Close”] PedNIHSS

EMA Courses 2012

EMA courses schedule for the year 2012 has been published and early bird registration available. Click here. For more conferences and handy TESL documents check the “Education” menu.



Formulating Clinical Questions and Literature Searching

[box]This is a quick guide to searching for evidence for clinical questions which you may encounter.

For example you may be wondering whether diazepam is effective in the treatment of back pain.

The clinical question should be structured in the PICO format :

  Patient population or clinical problem  =   back pain

   Intervention(study factor/exposure)  = diazepam

C  Comparator (control ) =   placebo

O  Outcome factor           =   pain

Your search terms would be the bold terms, although you could add other search terms if you were comparing other interventions eg. Paracetamol/codeine etc.

Databases and methods

All the following databases available through CIAP :

1) Cochrane database (under evidence-based practice tab in CIAP)– for systematic reviews

a) on the opening page, click the tab Advanced search

b) enter search term back pain

c) enter search term diazepam

d) combine with AND

e) under restrict search by product – tick ‘systematic reviews’ limit


2) Medline database – usually choose 1948-present

a)click on Advanced  Search tab

b) enter back pain – will be mapped to Medical Subject Heading(MeSH) term

c)Tick explode box to widen search, then continue

d) do not choose any subheadings, click continue

e) enter 2nd search term diazepam

f) click explode, continue, on the next page click continue

g)combine searches 1+2 by ticking boxes next to them and clicking AND

h) click on limits, then additional limits and select evidence based medicine reviews

i) click on search

Useful articles and links

Haynes RB, Wilczynski NL. Optimal search strategies for retrieving scientifically strong studies of diagnosis from Medline : analytical survey. BMJ 2004 : 328 (7447) : 1040

Haynes RB. McKibbon KA. Optimal search strategies for retrieving scientifically strong studies of treatment from Medline : analytical survey. BMJ 2005 : 330 (7501) : 1179[/box]