Podcast #352: TXA for Epistaxis
Author: Chris Holmes, M.D.
- TXA: tranexamic acid; used in control of bleeding in major trauma, postpartum hemorrhage, etc.
- In study of 216 patients with epistaxis, TXA placed on a pledget was compared to anterior cotton nasal packing.
- The TXA group had faster time to bleeding control, quicker time to discharge, better patient satisfaction, and lower rates of re-bleeding.
Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013 Sep;31(9):1389-92. doi: 10.1016/j.ajem.2013.06.043.
Author: Pete Bakes, MD
- AICD: Automated Implantable Cardioverter-Defibrillator.
- Can be placed for secondary prevention of cardiac arrest (i.e. history of cardiac arrest not from reversible cause).
- Also indications for primary prevention: EF 35% or less; ventricular tachycardia with underlying structural heart disease; Brugada; genetic-induced prolonged QT-syndromes.
Al-Khatib SM et. al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2017 Oct 30. pii: S1547-5271(17)31249-3. doi: 10.1016/j.hrthm.2017.10.035.
Author: Nick Hatch, MD.
- A common concern using vasopressors is the risk of digital and mesenteric ischemia.
- The absolute risk of digital ischemia and/or mesenteric ischemia is pretty low. Norepinephrine at its highest doses carries a 5% digital ischemia rate and a 2% mesenteric ischemia rate.
- The studies demonstrating this complication were predominately patients with pre-existing liver disease.
- Providers commonly mistake purpura fulminans, a common complication of sepsis, for digital ischemia.
Brown, SM. et al. Survival After Shock Requiring High-Dose Vasopressor Therapy. Chest. 2013. 143(3), 664?671. http://doi.org/10.1378/chest.12-1106.
Malay MB et al. Heterogeneity of the vasoconstrictor effect of vasopressin in septic shock. Critical Care Medicine. 2004. 32(6), 1327-31.
Author: Sue Chilton, MD
- Triad of fat emboli syndrome is a petechial rash, AMS, and respiratory distress.
- Petechiae usually start in the axilla.
- 90% of patients with long bone fractures will shed fat.
- May see ground-glass opacities on imaging, but perfusion defects will not be seen on CTA or V/Q scan
- Patients with a PFO can have cerebral involvement.
Newbigin K, Souza CA, Torres C, Marchiori E, Gupta A, Inacio J, Armstrong M, Peña E. Fat embolism syndrome: State-of-the-art review focused on pulmonary imaging findings. Respir Med. 2016.113:93-100. doi: 10.1016/j.rmed.2016.01.018.
Kosova E, Bergmark B, Piazza G. Fat embolism syndrome. Circulation. 2015. 20;131(3):317-20. doi: 10.1161/CIRCULATIONAHA.114.010835.
Author: Don Stader, MD
- Steakhouse syndrome is an impacted esophageal food bolus.
- Occurs because they have an esophageal stricture (schatzki ring, scarring, esophagitis).
- Classic treatments have consisted of effervescents, glucagon, and/or sublingual nitroglycerin (NTG).
- Recent case series has shown oral 400mcg tablet of NTG dissolved in 10cc tap water was 100% successful.
- Complications of NTG are hypotension and headache.
Kirchner GI, Zuber-Jerger I, Endlicher E, et al. (2011) Causes of bolus impaction in the esophagus. Surgical Endoscopy. 25:3170.
Willenbring BA, et al. (2018). Oral Nitroglycerin Solution May Be Effective for Esophageal Food Impaction. Journal of Emergency Medicine. 54(5):678-680.
Author: Sam Killian, MD
- Recent study examining fasting and adverse events during procedural sedation found no association between fasting duration and any type of adverse event.
- Of the 6,183 children in the study, about 6 vomited during the procedure, and about 300 vomited recently after the procedure, and there were no episodes of aspiration.
Bhatt, M, et al. (2018). Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children. JAMA Pediatrics, doi: 10.1001/jamapediatrics.2018.0830. [Epub ahead of print]
Author: Chris Holmes, MD
- There is a risk of cerebral edema in pediatrics with DKA if over resuscitated.
- Recent study comparing normal saline vs. ½ normal saline showed no difference in rates of cerebral edema regardless of rate of infusion.
- Recommend sticking with a fluid resuscitation protocol you are familiar with (i.e., 2 rounds of 10cc/kg bolus of NS).
Glaser, N. S., Ghetti, S., Casper, T. C., Dean, J. M., & Kuppermann, N. (2013). Pediatric Diabetic Ketoacidosis, Fluid Therapy and Cerebral Injury: The Design of a Factorial Randomized Controlled Trial. Pediatric Diabetes, 14(6), 435?446. http://doi.org/10.1111/pedi.12027
Author: Sue Chilton, MD
- IV drug use and spinal procedures are major risk factors.
- Classic triad of back pain, focal neurological deficit and fever. However, presence of fever is highly variable. Neurologic deficits may not present until later, but then they can have a rapid progression of neurological decline.
- MRSA is most common organism, but GNR and MSSA are also possible.
Chen WC, Wang JL, Wang JT, et al. (2008). Spinal epidural abscess due to Staphylococcus aureus: clinical manifestations and outcomes. Journal of Microbiology, Immunology and Infection. 41:215.
Danner RL, Hartman BJ. (1987).Update on spinal epidural abscess: 35 cases and review of the literature. Review of Infectious Disease. 9:265.
Pfister H-W, Klein M, Tunkel AR, Scheld WM. Epidural abscess. In: Infections of the Central Nervous System, Fourth Edition, Scheld WM, Whitley RJ, Marra CM (Eds), Wolters Kluwer Health, Philadelphia 2014. p.550.
Author: Aaron Lessen, MD.
- When foley is stuck, balloon may not have deflated.
- Make sure balloon is not in the urethra, which can block drainage.
- Cut off the port as it may be obstructed.
- If still not draining, pass guide wire through port to unclog catheter.
- Other techniques have been described using mineral oil to dissolve, rupturing the balloon through over-inflation, and transcutaneous guided drainage.
- Crystallization can be a cause of catheter obstruction – sterile water may be a better solution to inflate the ballon than saline when it is first placed.
Khan SA, Landes F, Paola AS, Ferrarotto L. Emergency management of the nondeflating Foley catheter balloon. Am J Emerg Med. 1991 May;9(3):260-3. PubMed PMID: 2018599.
Hollingsworth M, Quiroz F, Guralnick ML. The management of retained Foley catheters. Can J Urol. 2004 Feb;11(1):2163-6. PubMed PMID: 15003159.
- Snake bites commonly occur between April and October.
- Rattlesnake bites are the most common.
- Venom contains proteins/enzymes that cause local inflammation, coagulopathy, and systemic effects (hypotension, angioedema, renal failure, etc.) along with neurotoxins may cause fasciculations, ptosis, drooling, or hyporeflexia.
- Mark site for swelling.
- Monitor progression.
- Elevate and immobilize injured limb and treat pain.
- Check basic labs including coagulation studies, and update tetanus.
- Antidote is CroFab and use if patient has systemic symptoms. Anaphylaxis is a known complication of CroFab
- Avoid: ice, tourniquets, and incision and drainage.
Hifumi T et. al.. Venomous snake bites: clinical diagnosis and treatment. J Intensive Care. 2015 Apr 1;3(1):16. doi: 10.1186/s40560-015-0081-8.
Warrell DA. Snake bite. Lancet. 2010. 375(9708):77-88. doi: 10.1016/S0140-6736(09)61754-2.
Warrell DA. Envenoming and injuries by venomous and nonvenomous reptiles worldwide. In: Wilderness Medicine, 6th Edition, Auerbach PS (Ed), Elsevier Mosby, Philadelphia 2012. p.1040.