ED Muskoka Physicians - Living the Dream

January Virtual Journal Club

I’ll post a more “official” article and review later in the month but I came across this article about abscesses and thought it was interesting. Skin abscesses are not the sexiest topic but we treat them frequently so it would be worth considering a practice change if it improved patient comfort and/or outcome.

The SGEM post and podcast (link below) summarizes the article and does a critical appraisal. Original article is posted here: https://onlinelibrary.wiley.com/doi/full/10.1111/acem.14106

Essentially they looked at treatment failure as a primary outcome after treatment of skin abscesses with the loop technique versus standard packing with ribbon gauze. Secondary outcomes were ease of procedure, pain at the time of treatment, ease of care at 36 hours, and pain at 36 hours.

Study conclusion was:

“The LOOP and packing techniques had similar failure rates for treatment of subcutaneous abscesses in adults, but the LOOP technique had significantly fewer failures in children. Overall, pain and patient satisfaction were significantly better in patients treated using the LOOP technique.”

A few thoughts/questions:

What is everyone’s usual practice? Packing vs. no packing vs. leaving a small wick? Has anyone tried this loop technique?

Do we even stock vessel ties in the ER?

Given the questionable evidence regarding packing, wouldn’t it be easier to just not pack at all (ie. no loop or standard packing)?

Aerosol Generating Procedures

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.15292

Journal of anesthesia 

Purpose of the Study  – Quantify the amount of aerosolization during aerosol generating procedures to inform risk assessment

Study Design

-They monitored aerosolization with continuous sampling with an optical particle sizer, which allowed characterisation of aerosol generation within the zone between the patient and anaesthetist

-The extent to which COVID is transmitted as airborne is controversial 

Problems with the study

-Small sample size – used 4 ORs in the UK

-Only 19 intubations and 14 extubations 

-During intubation they use BVM and not RSI

Conclusion

– Tracheal intubation including facemask ventilation produced very low quantities of aerosolized particles – 500x less than a cough (actually state that “this study does not support the designation of elective tracheal intubation as aerosol generating”.

-Extubation, particularly when the patient coughed, produced a detectable aerosol, 15 folds greater than intubation but 35 folds less than a volatile cough .

Questions– They just say “facemask ventilation” – I think they need to be more specific.  What type of facemask did they use, what was the flow rate?

Take away –

(1)If a break in PPE then chance of acquiring COVID is probably minimal during intubation.

(2) patients coughing on us is more risk than intubation, therefore patient’s properly wearing masks can reduce this.

HALT IT – TXA for GI Bleeds

For this month’s physically distanced Journal Club – a review of the HALT IT trial looking at TXA for GI Bleeds.

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. The Lancet. 2020; 395(10241):1927-1936.  https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30848-5/fulltext

TL;DR:

  • Tranexemic acid (TXA) did NOT reduce 5-day mortality in upper and lower GI bleed patients.
  • It did show small increase risk of VTE.
  • Well designed, large trial. Best evidence to date for TXA in GI bleed.

Background:

  • GI bleeds have a high mortality rate (10%)
  • TXA is an antifibrinolytic agent that has been shown to be effective at preventing bleeding complications in a variety of settings (surgery, trauma, epistaxis)
    • We love it for its low cost, minimal SE profile, and numerous indications in the ER
  • A 2012 Cochrane Review for UGIB showed a reduction in all-cause mortality with TXA for GI bleeds
    • However, individual trials were small and prone to biases making it difficult to draw definitive conclusions… but was the best evidence we had until now

Clinical Question:

  • Does IV tranexamic acid reduce 5-day death due to bleeding?

Methods:

  • International, multi-centre, randomized, double-blind, placebo controlled trial (15 countries, 164 hospitals)
  • Intervention:
    • 1g TXA IV over 10 min the 125mg/hr x 24 hours (3g) vs. Placebo

Patients:

  • Adults (>16/18 yo depending on country)
  • With “significant” acute GI bleeding
    • Risk of bleeding to death:  
      • Hypotension
      • Tachycardia
      • Signs of shock
      • Likely to need transfusion, urgent endoscopy or surgery
  • Treating clinician had to be “substantially uncertain” about whether to use TXA

Outcome:

  • Primary outcome: death due to bleeding at 5 days
  • Secondary outcomes:
    • Death due to bleeding at 24 h and 28 d randomization
    • All cause and cause specific mortality at 28d
    • Rebleed (24h, 5d, 28d)
    • Blood product transfusion
    • MI/CVA
    • VTE (DVT/PE)
    • Seizures
    • Days in the ICU
    • Functional status in-hospital or at 28d
    • Other (cardiac events, sepsis, pneumonia, resp failure, renal failure, liver failure)

Results:

  • Patients:
    • 12 009 patients enrolled
    • 65% male, mean age 58
    • the mean time from bleeding onset to randomization was 22 hours
      • only 16% of patients presented within 3 hours
    • 89% had upper GI bleeding
    • 45% suspected to have variceal bleeds
    • 60% showed NO signs of shock at enrolment
  • NO BENEFIT
  • Primary outcome:
    • Death due to bleeding at 5 days = 3.7% (n=222) of TXA group and 3.8% (n=226) of placebo group (RR 0.99, 95% CI 0.82-1.18)
  • Secondary outcomes:
    • All cause mortality at 28 days (9.5% of TXA group and 9.2% of placebo group, RR 1.03, 95% CI 0.92-1.16)
    • No difference in rebleeding, surgery, endoscopy, need for transfusion, or total blood products transfused
    • RISKS – doubling of venous thromboembolic events (0.4% placebo and 0.8% TXA (RR 1.85, 95% CI 1.15-2.98)
    • NNH = 250

Limitations:

  • The authors changed the primary outcome from “all-cause mortality” to “death due to bleeding at 5d”
    • Not entirely sure why, as “all cause mortality” is clinically more relevant to us, “death” vs “death from bleeding” are one and the same when talking to family members
    • However, the change of this primary outcome forced the authors to increase their sample size by 4000, and still powered the study to detect a difference in the original outcome
  • The majority of patients in the trial had variceal bleeding due to liver disease and accounted for 75% of deaths, but also increased risk of VTE was more pronounced in patients with liver disease
  • Only 9% of patients were on anticoagulants, so unsure of applicability of data to that group

Thoughts:

  • Overall really well done study, very few protocol violations, excellent follow up
  • Time to randomization was high (mean ~ 22hrs)
    • Looking back at CRASH-2 showed mortality benefit (>20 000 pts, 4.9% vs 5.7% (p = 0.0077)) when 1g TXA given <3 hrs, but not after that.
    • Perhaps we would have been benefit it TXA was administered earlier in GI bleed patients
    • However, if these patients don’t present to us within that time frame, there is no point seeing if TXA works for GI bleeds if given in <3hrs
  • Since CRASH2 there has been lots of interest in TXA, but multiple studies since this positive publication have failed to show similar benefit from TXA
    • TICH -2 – no difference in mortality or neurological outcomes with TXA and ICH (Sprigg 2018)
    • WOMAN no difference in mortality or hysterectomy in PPH (WOMAN 2017) (*revised primary outcome, “death due to PPH” showed small benefit, NNT 267, but fragility index 0…, so overall not a resounding “positive study” in my opinion)
    • CRASH3 – no difference in mortality or neurologic outcomes in TBI (CRASH 2019)
    • Important to have these negative studies published given the well known publication bias of only positive studies
  • Not entirely clear why they had the inclusion criteria of “clinician substantially uncertain whether to use TXA”
    • How do we know if our gestalt is correct if we eliminated those patients from the trial?
    • Perhaps this is mostly to include obvious criteria such as allergy, or for ethical reasons for clinicians to be able to treat patients to the best of their ability, but it is hard to know how many patients were not included and if that would have had any effect on the outcome

Take Home Thoughts:

  • Despite some of the study weaknesses, this is a very well-designed, large trial, and a “negative” trial of this magnitude is clinically important.
  • Based on the current evidence, I will not be using TXA in the management of the GI bleed patients
  • What are you thoughts? Does this change your clinical practice?

References:

  1. Crash-2 Collaborators. (2011). The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. The Lancet377(9771), 1096-1101.
  2. Dewan, Y., Komolafe, E. O., Mejía-Mantilla, J. H., Perel, P., Roberts, I., & Shakur, H. (2012). CRASH-3-tranexamic acid for the treatment of significant traumatic brain injury: study protocol for an international randomized, double-blind, placebo-controlled trial. Trials13(1), 1-14.
  3. Gluud, L. L., Klingenberg, S. L., & Langholz, E. (2012). Tranexamic acid for upper gastrointestinal bleeding. Cochrane Database of Systematic Reviews, (1).
  4. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. The Lancet. 2020; 395(10241):1927-1936. 
  5. Justin Morgenstern, “TXA for GI bleeds”, First10EM blog, March 9, 2020. Available at: https://first10em.com/txa-for-gi-bleeds/.
  6. Roberts, I., Shakur-Still, H., Afolabi, A., Akere, A., Arribas, M., Brenner, A., … & Jairath, V. (2020). Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. The Lancet395(10241), 1927-1936.
  7. Salim Rezaie, “REBEL Cast Ep85: The HALT-IT Trial – TXA in Acute GI Bleeds”, REBEL EM blog, June 27, 2020. Available at: https://rebelem.com/rebel-cast-ep85-the-halt-it-trial-txa-in-acute-gi-bleeds/.
  8. Shakur, H., Elbourne, D., Gülmezoglu, M., Alfirevic, Z., Ronsmans, C., Allen, E., & Roberts, I. (2010). The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials11(1), 40.
  9. Sprigg, N., Flaherty, K., Appleton, J. P., Salman, R. A. S., Bereczki, D., Beridze, M., … & Dineen, R. A. (2018). Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. The Lancet, 391(10135), 2107-2115.

Atrial Fibrillation: Pharmacological vs Electrical

Hey guys. Hopefully better late than never! I am on virtual Journal Club this month. Thanks Pierre for the reminder.

In the busy Muskoka ED department. Patients coming in with atrial fibrillation requiring cardioversion. Chemical vs Electrical vs combination of both. Which option allows for the best outcome and what allows for me to keep the best flow in the department?

Electrical versus pharmacological cardioversion for emergency department patients with acute atrial brillation (RAFF2):
a partial factorial randomised trial

Lancet 2020; 395: 339–49

The Question:

  1. compare the sinus conversion of pharmacological cardioversion followed by electrical cardioversion to electrical cardioversion along
  2. effectiveness anteroposterior vs anterolateral pad placement

Methods:
Group 1: procainamide 15mg/kg (max 1500mg over 30min) wait 30minutes and then electrical cardioversion vs placebo infusion and then electrical cardioversion. Around 200 patients assigned to each group.

Results:
96% of patients in drug-shock group converted vs 92% in the shock group. 52% in the drug shock group converted after infusion (in the drug-shock group) and 9% after the placebo infusion.

Adverse events: transient hypotension more common in the drug-shock group (resolved with fluids) and one cardiac arrest in the shock only group (not synchronized cardioversion)

Time in the ED:
Similar in both groups (however, electrical cardioversion received placebo infusion, so likely not accurate representation)

For Pad placement: no different between anteroposterior vs anterolateral.

For more intense analysis of the article check out RebelEM: https://rebelem.com/raff2-electrical-vs-pharmacological-cardioversion-for-ed-patients-with-acute-atrial-fibrillation/

Question:
So… would you use procainamide infusion and potentially save 50% of the Afib procedural sedations in the department?

travel

Hey gang,

Anyone travel within the last 14 days out of country….the new isolation guidelines that came out today do apply…

give me a call or text if you have and I will walk you through it!

!

conference call

call in number for conference calls – for ED group

always the same 705-704-9984

PIN 0001255

communication

Hi all, good group chat this am. Sorry if you couldn’t make it.

If you have questions please ask one of us that was on the call (Evan, Kelly, Deb, Emma, Adam, Heather, Nelson, Jeff, Mike, Kirsten, Stacey) as we can share group brain with you.

Tuesday – heads up – a patient with COVID intubation sim – Dr Jewell and Dr Smith…!! Great SIM . Thank you both in advance.

Allyson Snelling just resent the simcoe muskoka update and the MAHC community test site info about again this am to the emails she has for all Md’s. If you didn’t; get from her please contact with what email you want on these…then you should get all future updates.

Just spoke to Allyson some are easy fixes and some are not.

MD conference call

COVID CHAT for MAHC ED docs tomorrow at 8:30 am.

call 705-704-9984

pin:0001255

Intention is to discuss our updated local plan, answer questions of each other about the covid 8 update from MAHC and community test sites info just sent out. Most of us are Type A ( hint , hint) and no one has all the answers or do we need to micro manage others but lets brainstorm, feel we are all on the same page, and support each other and our care of our community and our nurses/teams, etc. Max time 30 mins.

Update

So – although I am signed out as director the next 9 days I just cancelled our family trip to the USA. Bummer. I know a couple of you who have done the same.

So many of us will be around when we weren’t gonna be before.

Hard times for us all. But safety is likely in numbers for our groups as some of us may get sick and not be able to work. Hopefully not…but likely. And if we aren’t leaving the country then no automatic quarantine or risk of being caught in another country.

Please is you feel sick consider calling me ( or the acting director) to plan what to do with some support. Please be ready as the back up doctor . Also if we are dropping like flies I will be reaching out to community MD’s to back up us and the hospital.

We need to be healthy as a team and help each other ( insert group hug here with a one meter distance between each of us for social isolation)!

I propose we start having “opt in” conference calls as a way to ask questions of each other as MD’s and see what is happening on the front line ( practical stuff ). More info to come.

Hep A

Final update on Hep A issue in Muskoka as public health information I circulated and Liz sent out to all Muskoka Md’s…

If you have questions about a patient in front of you around this issue and need help Angela Hollingshead is happy o help. She has had lots of discussions with public health around this…