There are a variety of anorectal emergencies that present to the emergency department.  Recently, there were updated guidelines made by the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST).  In this post, we review some of the updated guidelines including for anorectal abscess, perineal necrotizing fasciitis (Fournier's gangrene), bleeding anorectal varices, complicated rectal prolapse (irreducible or strangulated), and retained anorectal foreign bodies.

These updated guidelines can be reviewed in their entirety free and open access through theWorld Journal of Emergency Surgery.   A PDF Version is also available at the bottom of this post.

Anorectal Abscess
Exam and labs:

• Perform a complete exam including a digital rectal exam.
• Recommended to check serum glucose, hemoglobin a1c, and urine ketones in order to identify for undetected diabetes mellitus.
• Assess for signs of systemic infection or sepsis including a CBC, serum creatinine, and inflammatory markers (CRP, procalcitonin, and lactate).

Imaging:

• MRI, CT, or endosonography depending on the availability of such imaging.
• Imaging is indicated for atypical presentations or in case of suspicion for occult supralevator abscesses, complex anal fistula, or perianal Crohn's disease.

Surgical management:

• In fit, immunocompetent patients with a small perianal abscess and without systemic signs of sepsis, consider outpatient management.
• Otherwise, surgical I&D is recommended with timing based on presence and severity of sepsis.
• No recommendations can be made regarding the use of packing after drainage.
• Further management such as fistulotomy may be needed in certain circumstances.

Antibiotics:

• Sampling of the drained pus in high-risk patients and/or in the presence of risk factors for multidrug resistance is recommended.
• In drained abscesses, it is recommended to administer antibiotics in the presence of sepsis, surrounding soft tissue infection, or in the case of disturbances of the immune response.

Perineal Necrotizing Fasciitis (Fournier's Gangrene)
Exam and labs:

• Perform a complete exam including a digital rectal exam.
• Recommended to check serum glucose, hemoglobin a1c, and urine ketones in order to identify for undetected diabetes mellitus.
• Assess for signs of systemic infection or sepsis including a CBC, serum creatinine, electrolytes, and inflammatory markers (CRP, procalcitonin, and lactate).
• It is also suggested to use theLaboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score for an early diagnosis and the Fournier's Gangrene Severity Index (FGSI) for prognosis and risk stratification.

Imaging:

• In stable patients with suspected Fournier's gangrene, consider performing a CT.
• Imaging should not delay surgical intervention.
• Recommend against obtaining imaging in patients with hemodynamic instability persisting after proper resuscitation.

Surgical management:

• Surgical intervention should be performed as soon as possible.
• Plan on repeat surgical revisions according to patient conditions.
• Seriated surgical revisions are needed until the patient is free of necrotic tissue.

Antibiotics:

• Start empiric antibiotics as soon as the diagnosis is suspected.
• Antibiotics should include coverage for Gram positive, Gram negative, aerobic and anaerobic, and anti-MRSA agents.
• Base antimicrobial de-escalation on clinical improvement, cultured pathogens, and results of rapid diagnostic tests (when available).

Bleeding Anorectal Varices​
Exam and labs:

• Perform a complete exam including a digital rectal exam.
• Recommended to check vital signs, hemoglobin, hematocrit, and coagulation to evaluate severity of bleeding
• In case of severe bleeding perform blood typing and cross-matching.

Imaging:

• Endosonography +/- Doppler as a second-line diagnostic tool, especially for deep rectal varices or when in doubt.
• Those with high-risk features or evidence of ongoing bleeding should have urgent colonoscopy (and upper endoscopy) within 24 hours of presentation.
• If risk factors for colon cancer or suspicion for a concomitant more proximal source of bleeding, full colonoscopy is suggested.
• Local procedures such as endoscopic variceal ligation, endoscopic band ligation, sclerotherapy, or endosonography-guided glue injection should be used to arrest bleeding in first instance where feasible.

Non-operative management:

• Multi-disciplinary management including early involvement of a hepatologist is recommended.
• For mild bleeding consider IV fluid replacement, blood transfusion if necessary, correction of coagulopathy, and optimal medication for portal hypertension.
• In severe bleeding, maintain a hemoglobin >7 g/dL during the resuscitation phase and a mean arterial pressure (MAP) >65 mm/Hg but avoid fluid overload.
• Endorectal placement of a compression tube as a bridging maneuver is suggested to help stabilization of the patient or to allow for transfer to a tertiary hospital.

Medications:

• Non-selective beta-adrenergic blockers for prevention/prophylaxis of first and/or recurrent variceal bleeding is suggested.
• In case of acute bleeding, temporarily suspend beta-blockers.
• Consider the use of vasoactive drugs such as terlipressin or octreotide to reduce splanchnic blood flow and portal pressure.
• Recommended to also use a short course of prophylactic antibiotics.

Angiography and surgery:

• If there is a failure of medical treatment and local procedures, suggested "step up" approach with radiological and then surgical procedures.
• Interventional radiology suggested to use embolization for short-term control of bleeding.
• Percutaneous TIPS, if not contraindicated, should be used to decompress the portal venous system and to reduce the risk of rebleeding.
• If these measures fail, "per anal" suture ligation by surgery to be considered.
• No recommendation regarding the role of Doppler-guided hemorrhoidal artery ligation and stapled anopexy in patients with persistent bleeding failing other techniques.

Complicated Rectal Prolapse (Irreducible or Strangulated)
Exam and labs:

• Perform a complete exam including visualizing the area of concern.
• Recommended to check a CBC, serum creatinine, and inflammatory markers (CRP, procalcitonin, and lactate).

Imaging:

• In hemodynamically stable patients, perform an urgent contrast enhanced CT of the abdomen and pelvis to detect for associated complications and to assess the presence of colorectal cancer.
• If hemodynamically unstable, do not delay appropriate and timely management with imaging.

Surgical management:

• If presenting with signs of shock or gangrene/obstruction of the prolapsed bowel, immediate surgical treatment is recommended.
• In cases with acute bowel obstruction or failure of non-operative management, urgent surgical treatment is suggested.

Medications:

• Administer empiric antibiotics because of the risk of intestinal bacterial translocation.
• A specific regimen should be based on the clinical condition of the patient, risk of MDRO, and local resistance patterns.

Retained Anorectal Foreign Bodies
Exam and labs:

• Perform a complete exam including a digital rectal exam.
• It is suggested to perform the digital rectal exam after obtaining abdomen X-ray whenever possible to prevent accidental injury from sharp objects.
• Routine laboratory testing is not recommended if there are no signs of bowel perforation, but if there is failure of manual extraction or it is not feasible then routine preoperative labs can be obtained.
• If there is a suspected bowel perforation, obtain a CBC, serum creatinine, and inflammatory markers (CRP, procalcitonin, and lactate).

Imaging:

• Obtain lateral and anteroposterior plain X-rays of the chest, abdomen, and pelvis to identify the foreign body position, shape, size, and location as well as to evaluate for pneumoperitoneum. 
• With a suspected perforation, obtain a CT of the abdomen and pelvis with contrast.
• If hemodynamically unstable, do not delay surgical treatment to perform imaging.

Non-operative and endoscopic management:

• In low lying retained foreign bodies without signs of perforation, attempt extraction at bedside.
• If unsuccessful, a pudendal nerve block, spinal anesthesia, IV conscious sedation, or general anesthesia may be used to improve chances of extraction.
• If the foreign body is high-lying, attempt at endoscopic extraction is first-line.
• Should drug concealment be suspected, avoid any maneuvers that can disrupt the drug packaging such as endoscopic retrieval.
• Evaluate the bowel wall status after foreign body removal by protoscopy or flexible sigmoidoscopy.
• Do not perform transanal extraction if there are signs of hemodynamic instability or perforation.

Surgical management:

• When there is failure of transanal extraction, a "step up" approach is recommended starting with downward milking and proceeding to colotomy only when milking/transanal extraction has failed.
  
• If skills and tools are available, consider a laparoscopic approach if there is no perforation.
  
• Primary suture only in case of small and recent perforation if the colonic tissues appear healthy and well vascularized with said approximation being without tension.
  
• If primary suture is not feasible, resection with primary anastomosis with or without diverting stoma should be used in clinically stable patients without risk factors for anastomic leakage.
  
• In critically ill patients, selected patients with extensive peritoneal contamination and risk factors for anastomic leakage it is suggested to perform a Hartmann's procedure.
  
• Patients that are hemodynamically unstable should have emergent laparotomy and damage control surgery approach. 

Antibiotics:

• Antimicrobial therapy generally not recommended.
• However, if there are signs of hemodynamic instability or bowel perforation, broad spectrum antibiotic therapy according to the WSES guidelines on intra-abdominal infections is recommended.

​Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on Apple Podcasts.  If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.

We are back to providing our ATLS content and we are picking up where we left off.  Our last ATLS podcast was on spine and spinal cord trauma.  Somewhat similar in nature is musculoskeletal trauma.  This is a very common form of trauma.  However, delayed recognition and  treatment can result in life-threatening hemorrhage or limb loss.

It is important to remember though that while these injuries often appear dramatic, they infrequently cause immediate threat to life or limb.  However, they can distract team members from more urgent resuscitation priorities.   This is due to the dramatic nature of certain wounds (such as open fractures or amputations). 

With that being said, we must still treat massive hemorrhage quickly.  Long-bone fractures can be significant, and femoral fractures in particular often result in significant blood loss into the thigh.  Major arterial hemorrhage warrants the use of a tourniquet.  While there are risks of placing a tourniquet, the risks increase with time.  However, tourniquets for short periods of time are appropriate and safe.  The Texas Tourniquet Study Group published a study in 2018 that demonstrated that there was nearly a 6-fold increase in death when tourniquets were not used.  Another study in 2019 demonstrated that tourniquet use resulted in better systolic blood pressure on arrival to the emergency department, less blood products being used, and decreased incidence of limb related complications.

A patient with multiple injuries who requires intensive resuscitation and/or emergency surgery for extremity or other injuries is not a candidate for replantation.

Also be careful with patients who have bilateral femur fractures.  These require significant force and should alert you to the possibility of associated injuries.  Knee dislocations (not meaning patellar) can reduce spontaneously and may not present with external or radiographic abnormalities until a physical exam of the joint is performed and instability is detected clinically.  An ankle/brachial index of less than 0.9 indicates abnormal arterial flow secondary to injury or peripheral vascular disease.

Crush syndrome is the sequelae to a crush injury.  It is also known as traumatic rhabdomyolysis.  If left untreated, it can lead to acute renal failure and shock.  Look for amber-colored urine in the presence of a serum creatine kinase of 10,000 U/L or more to help indicate rhabdomyolysis when urine myoglobin levels are not available.  Rhabdomyolysis can lead to metabolic acidosis, hyperkalemia, hypocalcemia, or disseminated intravascular coagulation (DIC).  

When feasible, proper splint application can control blood loss, reduce pain, and prevent further neurovascular compromise as well as soft-tissue injury.  Be careful with open fractures, particularly open joint injuries.  CT can be effective, but asaline load test can also be performed if indicated.  Open fractures should also receive weight-based dosing antibiotics as early as feasible.  Cefazolin is the preferred antibiotic but with an allergy to this (or more conservatively beta-lactams like penicillin in general), use clindamycin or gentamicin if the soft tissue damage is more severe or there is substantial contamination.  In the setting of farmyard, soil, or standing water use piperacillin-tazobactam.  See the table below for details.  Remember to also update the patient's tetanus immunization if out-of-date or uncertain in any patient with wounds including open fractures.

When splinting an injury, make sure it does appropriately immobilize the extremity.  Also make sure it is padded and smooth enough to prevent secondary injury.  Certain injuries are splinted in a position of function or otherwise to reduce tension.  Make sure to assess and document the neurovascular status of the patient both before and after splinting (or basically any procedure).

Pain control is a common issue with these injuries.  Often, a short course of opioids may be needed.  Some may only need acetaminophen and/or NSAIDs.  This may also be limited by the patient's allergies.  Also, consider regional nerve blocks as they can also play an important role in pain control and can be very beneficial when patients require high doses or opioids or do not want any opioid medications.  However, keep in mind the potential risk in compartment syndrome as a nerve block can mask this condition and lead to a delay in diagnosis.

Finally, we should warn patients of the possibility of occult injuries.  Imaging is not perfect and sometimes occult fractures or other injuries may be missed.  Carefully assess and reassess patients, but also assure appropriate follow-up to help them catch such occult injuries. 

Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on Apple Podcasts.  If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.

Cluster headaches are often considered one of the most painful human experiences.  They are short (lasting usually 15-180 minutes), frequent (up to 8 a day), unilateral headaches behind or around the eye often with ipsilateral autonomic symptoms and restlessness.  While migraines and tension headaches are seen frequently in the emergency department, cluster headaches are much less frequently seen and often are harder to identify as a result.  There are certain points to remember with patients that are experiencing cluster headaches and we list 10 of them here.

These pearls come from a recent BMJ article title Recent Advances in the Diagnosis and Management of Cluster Headache by Emmanuelle Schindler and Mark Burish. 

1. Suicidal ideation (SI) occurs in 55-64% of patients and self-injurious behavior is often seen.
2. Cluster headaches are associated with smoking, but cessation does not alter the disease.
3. There are episodic and chronic types:
   1. Episodic occurs only during a period of weeks to months often in an annual cycle and accounts for approximately 80% of cases.
   2. Chronic accounts for the other approximately 20% and occurs throughout the year without remission.
4.  There are certain clinical features that can help distinguish and identify cluster headaches:
   1. Preattack "shadows" with symptoms present shortly prior to the actual attack (ipsilateral aching, lacrimation, and nasal congestion often seen minutes before) and further out (such as an hour) there are generalized symptoms including difficulty concentrating and mood changes.
   2. Mild symptoms may remain between these attacks.
   3. There is often restlessness which helps differentiate it from migraines.
   4. Self injurious behaviors are often seen (but unrelated to SI) such as hitting or rubbing head, punching walls, and cutting or piercing skin.
   5. Dysautonomia is also seen where there are changes in autonomic tone including bradycardia, altered tilt table testing, and nocturnal lipolysis.
5. Approximately 80% of patients can predict when attacks occur (often around 2-3 AM), have an annual rhythm (often less common in summer months), and daylight hours are associated in general with fewer attacks.
6. There are common triggers (chemical, environmental, and physiologic) that are often noted, but it may not have effect outside of the attack cycle:
   1. The most common chemical trigger is alcohol (EtOH) which usually occurs within an hour, nitroglycerin, PDE5 inhibitors, and strong smells (such as cleaners or perfumes).
   2. Environmental triggers often include high altitude, weather changes, or bright sunlight.
   3. Physiologic triggers include sleep, circadian rhythm disruption (such as shift work, jet lag, and time changes), stress, relaxation, menstruation, menopause, postpartum, and low testosterone. 
7. Brain MRI can help rule out secondary causes and if refractory consider other testing such as MRA of the head and neck, pituitary lab tests, sleep study for obstructive sleep apnea, and if Horner syndrome is present image the lung apex.
8. Acute treatment includes sumatriptan, oxygen (often 6-12 L/min), and noninvasive vagus nerve stimulation.
9. Transitional treatments include steroids (including occipital nerve injection) and dihydroergotamine.
10. Preventative treatments include a variety of medications that can be used if chronic cases or before typical period of episodes which includes verapamil, lithium, melatonin, capsicum, topiramate, baclofen, and galcanezumab. 

You can learn more by clicking on the link above or downloading the PDF listed below.

Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on Apple Podcasts.  If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.

The use of tranexamic acid (TXA) has expanded with growing evidence in its use for a variety of clinical situations.  However, not all evidence is created equal and not all applications show benefit.  In this blog and podcast we discuss the various uses of TXA and the surrounding evidence.

There are certain drugs in emergency medicine that feel like they can be used for almost everything.  One such example is ketamine, but another frequent favorite is tranexamic acid (TXA).  There is evidence in its use for trauma, hemorrhagic stroke, postpartum hemorrhage, upper gastrointestinal bleeding, epistaxis, hemoptysis, and post-tonsillectomy bleeding.  However, we must ask ourselves what is the evidence for each of these applications?

Polytrauma:
We will start our discussion with one of the most well studied applications: polytrauma.  It makes sense that in polytrauma we lose blood and factors, develop hypothermia, undergo an inflammatory cascade, and develop acidosis.  These leads to hyperfibronlysis which makes hemostasis challenging.  TXA is a synthetic derivative of lysine.  It inhibits fibrinolysis resulting in stabilizing the clots that are formed.  It is a medication that has been around for a long time and is inexpensive.

In many ways, the study that started it all was theCRASH-2 study.  Published in 2010, this randomized controlled trial (RCT) enrolled 20,211 patients from 274 hospitals in 40 countries.  1 gram of TXA was administered as a loading dose infused over 10 minutes and another 1 gram was infused over 8 hours.  It found an absolute reduction in all cause mortality of 1.5% with TXA.  The evidence points to the most benefit in reducing death from hemorrhage which is the most common cause of mortality in polytrauma without increasing a rate of mortality in other causes.  There was not an increase in thromboembolic events helping demonstrate the safety and efficacy of this treatment in patients with hemorrhagic shock in trauma to help reduce mortality.  The thromboembolic events that were assessed included stroke, myocardial infarction, pulmonary embolism (PE), or clinic evidence of deep venous thrombosis (DVT).  There was no significant different in the rate of surgical intervention or number of units of blood products transfused in this clinical trial.

The Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study was published in February 2012  which further looked at the use of TXA.  It was a single center, retrospective, observational study at a regional hospital in Afghanistan comparing patients who received TXA versus no TXA in patients receiving at least 1 unit of packed red blood cells (PRBCs).  Additionally, study authors evaluated patients receiving a massive transfusion defined as 10 or more units of PRBCs.  There was an overall reduction in mortality with the use of TXA especially during massive transfusions.  The number needed to treat (NNT) for benefit was 13 for overall 48 hour mortality and 15 for 30 day mortality.  That NNT was reduced to 8 and 7, respectively, in the setting of a massive transfusion.  The number needed to harm (NNH) with TXA for PE was 42 and for DVT was 46, but there were no fatalities from such events.

It is worth noting that a single-center study in the United States from a level 1 trauma center was published in May 2020 regarding mortality and complication rates in adult trauma patients that received TXA.  This was a much smaller and retrospective study that included 273 patients.  It found all cause mortality of 12.8% with thromboembolic events being 6.6% which is much higher than that of the CRASH-2 study.  While this is concerning, it does not appear to be enough to change practice on this study alone.

Yet another study was published in October 2020, the Study of Tranexamic Acid During Air Medical and Ground Prehospital Transport (STAAMP).   This was a multicenter RCT that was placebo-controlled and a superiority study.  927 patients were eligible and after exclusions the intention to treat study comprised of 903 patients.  The study did not result in a significantly lower 30-day mortality, but it also did not result in a  higher incidence of thrombotic complications or adverse events.  It is worth noting the study was underpowered due to time and financial constraints.  While this is the case we can still a pattern similar to previous trials including CRASH-2.  There was also some signal of potential benefit when larger amounts (2 or 3 grams of TXA) was given, but this requires further studying.

Overall, in the setting of polytrauma TXA does appear to have benefit in reducing mortality especially in the more severe cases of trauma.  It does also appear to have the most benefit when given earlier in a resuscitation and is recommended to be given within the first 3 hours of injury.  This makes it an ideal medication to be used in rural and remote settings including for the prehospital arena with EMS.

Traumatic Brain Injury:
The evidence for traumatic brain injury (TBI) is different from that of polytrauma and warrants a separate discussion.  While waiting for the results of the CRASH-3 trial, there was a systematic review and meta-analysis on TXA for TBI published in 2014.  While 1,030 references were identified, only 2 were high quality RCTs that met inclusion criteria.  The pooled results demonstrated a statistically significant reduction in intracerebral hemorrhage (ICH) progression with TXA but not a significant improvement in clinical outcomes.  While a signal for benefit, further data was needed.

CRASH-3 was published in October 2019.  A total of 12,737 patients were enrolled from 175 hospitals in 29 countries.  Of those enrolled, 9,202 were treated within 3 hours of injury.  The overall effect size of TXA on ICH was not statistically significant in this trial.  What effect was potentially seen appeared to be in those that received treatment within the first 3 hours, had a mild to moderate TBI (Glasgow Coma Scale of 9-15), and with ICH on baseline head CT.  Based on these results of a secondary analysis with a subgroup that was underpowered, there was an absolute reduction of 1.7% in mortality (5.8% versus 7.5%).

Another study published in September 2020 looked at prehospital TXA in patients with moderate to severe TBI.  They looked specifically in this study at 6 month functional neurologic outcomes.  966 patients from 12 sites, 20 trauma centers, and 39 EMS agencies located in the United States and Canada were enrolled.  This RCT had three arms: a bolus and maintenance group, bolus only group, and placebo group with patients treated within 2 hours of injury.  The study can be a bit challenging to interpret.  Technically, it is negative because the 3.5% difference in mortality (favoring TXA) was not statistically significant but CRASH-2 had only a 1.5% mortality benefit.  It is likely that the real difference in mortality is lower than the 3.5% shown, but would still be clinically important.  Even a 1% reduction in mortality would be important in an overall safe and effective drug like TXA.  There was also a large number of patients that would not have a potential for benefit due to no ICH on CT or having a nonsurvivable injury (43%).  This could potentially dilute the results.

Given the evidence, it is reasonable to give TXA in ICH especially if within the first 3 hours of injury.  We must recognize that this evidence is limited.  However, it does not appear to cause significant harm.  While TXA may be used, it should not necessarily be considered standard practice at this point.

Hemorrhagic Stroke:
The Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2) trial published in May 2018 assessed whether TXA reduced hematoma expansion and improved outcomes in adults with stroke due to ICH.  This can be particularly beneficial since sometimes we are unable to clearly identify if the ICH is from TBI or stroke, especially during the initial assessment such as in the prehospital arena.  2,325 patients were recruited from 124 hospitals in 12 countries in this RCT.  The primary outcome was functional status at 90 days and it did not differ significantly despite fewer deaths by day 7 in the TXA group.  However, fewer patients had serious adverse events after TXA compared to placebo at days 2, 7, and 90.  Part of the limitations may be the fact that the trial chose to use 8 hours as their treatment window versus the typical 3 hours and its overly broad inclusion criteria.

Based on the limited evidence, TXA cannot be recommended for spontaneous ICH but does not seem to cause harm.  This may be helpful for now if TBI has not been excluded when trying to differentiate it versus hemorrhagic stroke.

Postpartum Hemorrhage:
The WOMAN trial was published in May 2017 to assess the effects of TXA on death, hysterectomy, and other relevant outcomes in women with postpartum hemorrhage (PPH).  A total of 20,060 women from 193 hospitals in 21 countries were enrolled whether they had a vaginal birth or caesarean section.  The authors found a reduction in death due to bleeding with no adverse effects.   Some limitations were that women were only enrolled if the benefit of TXA was uncertain (possibly underestimating the benefit), had a primary endpoint that was altered after initiation, and the diagnosis of PPH was made clinically without an assessment of inter-rater reliability in making such a determination.  While the primary endpoint was changed, it was reasonable.  The decision to perform a hysterectomy was most commonly made at the time of randomization meaning that this was not affected by the intervention.  However, the endpoint was changed prior to data analysis and unmasking.

Like the studies mentioned above, it appears the benefit is when the medication is given early.  The NNT to prevent a death in general due to PPH was 250 but reduced to 200 when TXA was given within the first 3 hours.  At this time, for PPH we can consider TXA but carefully recognize the limitations of the data (as with the other studies mentioned).

Upper GI Bleeding:
A Cochrane Review was published in November 2014 as a systematic review and meta-analysis  that looked at the effects of TXA on gastrointestinal bleeding (GIB).  A total of 8 RCTs were found.  As an interesting note, studies use TXA as IV, oral, or as a combination.  These studies were small making it difficult to draw absolute conclusions with the median number of patients per study being 204.  The review did find that TXA appears to have a benefit on mortality, but more research was recommended.

Enter the HALT-IT Trial published in June 2020.  Their trial looked at IV TXA to reduce mortality at 5 days for those with acute upper GIB when compared to placebo.  1 gram of TXA in 100 mL was infused over 10 minutes similar to other studies with another 3 grams given as 125 mg/hour for 24 hours.  A total of 12,009 patients were randomized which is a significantly larger study compared to others for GIB.  The RCT did have a change in primary outcome to death from bleeding at 5 days as it was observed halfway through the trial that over half of all deaths were due to non-bleeding causes.  Variceal bleeding due to liver disease accounted for approximately 75% of deaths.  It also appears these patients had an increased risk of venous thromboembolic events with TXA.  Interestingly, there was no statistically significant difference in mortality if the TXA was administered within or after 3 hours.  This is good since only 16% of patients were randomized within 3 hours of the bleeding onset.  However, this was a negative trial which did not find a benefit of TXA in reducing death from GIB.

Given the large HALT-IT trial and the limited findings from the Cochrane Review based on much smaller studies, it seems most reasonable that TXA would not be recommended for GIB at this time.  However, this can readily change with more evidence since there has been some signal for potential benefit.
​
Epistaxis:
Topical TXA was compared to anterior nasal packing of epistaxis for patients taking antiplatelet drugs in a RCT that was published in December 2017.  124 patients from two emergency departments taking aspirin, clopidogrel, or both were randomized to receive topical TXA as a 500 mg in 5 mL solution.  A pledget soaked in TXA was placed when TXA was used.  73% of patients in the TXA group versus 29% in the anterior packing group had cessation of bleeding within 10 minutes (primary outcome) with a NNT of 2!  Epistaxis recurrence was only 5% with TXA versus 10% with anterior packing.  Recurrence at a week was also 5% in the TXA group and 21% in the anterior packing group.  Length of stay in the emergency department was less than 2 hours in 97% of TXA patients versus only 13% in the anterior packing group.

​The NoPAC Trial was published in June 2021 and used TXA 200 mg in 4 mL applied to a cotton wool dental roll which was held in place for 10 minutes with pressure.  The control group soaked a cotton wool dental roll in sterile water and held in place for 10 minutes with pressure.  This difference in dosing along with some other changes (not excluding posterior epistaxis, using phenylephrine versus oxymetazoline for initial attempts alongside simple first aid measures, and potential underpowering) may have impacted the results which demonstrated no benefit when using TXA.

The differences in the studies using TXA for epistaxis fails to leave a clear understanding of how to best approach this particular situation.  While TXA may be of benefit, there is also now evidence that points the other direction.  It is an approach worth considering, but may not necessarily be a standard practice in all patients that present with epistaxis.

Post-Tonsillectomy Bleeding:
A systematic review and meta-analysis regarding the use of TXA in post-tonsillectomy bleeding was published in September 2012.  It look at 2,444 patients from 7 studies (3 RCTs and 4 case control trials) to determine if there was a benefit.  TXA dosing, mode of delivery, and timing of administration varied significantly limited the interpretability of the evidence.  None of these looked at the post-operative period and instead was TXA for prophylaxis.  While TXA led to a significant reduction in blood loss volume, it did not impact the rate of patients with post-tonsillectomy hemorrhage.

It is difficult to draw much from this study, but TXA could be considered to help reduce or stop bleeding.  A nebulized form may be beneficial, but the evidence is very limited.

Hemoptysis:
Inhaled TXA for hemoptysis has seen a RCT which was published in December of 2018 after multiple case reports had been published.  This was a small study of 47 patients with 25 received nebulized TXA and the other 22 receiving nebulized normal saline.  9 patients in each group had a lung malignancy and more than half were treated with anticoagulants or antiplatelet medications.  Resolution of hemoptysis within 5 days of admission was 96% in the TXA group and 50% in the placebo group creating a NNT of 2!  The quantity of expectorated blood was also significantly reduced by day 2 of admission.  None in the TXA group died or required invasive procedures.  There was a 10% mortality rate in the placebo group and 18.2% required invasive procedures to control bleeding such as bronchoscopy or angiographic embolization. 

This RCT is the first prospective RCT to assess the effectiveness of nebulized TXA in patients with hemoptysis.  It does seem to demonstrate benefit but given the small size this is a limited study.  It would be great to see larger studies moving forward, but this therapy should be considered in these situations.

IM Administration:
There was a very small study 30 patients that received intramuscular (IM) TXA in bleeding trauma patients that was published in January 2021.  It reviewed the pharmacokinetics of IM TXA and found that it does appear to be a potentially reasonable option for administration.  It would be of most benefit in low resource, rural, or combat settings where IV access is challenging.  The limited evidence demonstrated the rapid absorption of TXA to reach therapeutic concentrations within 15 minutes.  Blood lactate and signs of shock had no apparent impact on the rate of absorption.

IM TXA is potentially beneficial in certain settings, but again more evidence would be extremely beneficial to look at its effects in a larger population.

​Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on Apple Podcasts.  If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.

For decades, there has been a major name debate regarding the appropriate title for PAs.  However, on May 24, 2021 the American Academy of PAs (AAPA) House of Delegates (HOD) came to a vote.  Over 100 possible titles were considered, but ultimately the winning vote was for "physician associate" which has led to a significant amount of discussion.  What is the history behind this decision and why now?  What has been the response?  We discuss this and more in this new blog and podcast.

When it was announced thatAAPA's HOD voted to change the name of the profession from "physician assistant" to "physician associate" it was by a vast majority of those present at 198 to 68.  It is worth noting that the AAPA Board of Directors (BOD) will now begin the process of how to implement the HOD policy which willcost an estimated $21.6 million based on the final Title Change Investigation report.  However, AAPA recommended that PAs refrain from representing themselves as "physician associates" at this time based on recommendations from their legal counsel until legislative and regulatory changes can be made.

The process first started in May 2018 when the AAPA HOD met and passed a resolution requesting the AAPA BOD to create a new professional title for PAs.  This has been seen as a necessary step for a variety of reasons but ultimately surrounds the many problems connected with the term "assistant" when most PAs are not necessarily fulfilling such a role.  However, PAs are closely associated with and collaborate with physicians which is part of the reason for changing the title to "physician associate" as this better represents the typical functions of a PA clinically.

It is worth noting the history of the PA title.  When PAs were first developed under the guidance of Dr. Eugene Stead at Duke University in 1965, it was with the title "physician's assistant" but later discussed how he saw them more as the role of an associate versus assistant.  This was even more important as there were three kinds of physician assistants seen (A, B, and C) with the current version of PAs being the A-type.  In 1971, the same time the American Medical Association (AMA) recognized the PA profession, the title of "physician associate" was also being recognized.  However, the AMA and others then pushed the title back to "physician assistant" which is where it has been up until recently.  

Additionally, "physician associate" is used in other parts of the world such as the United Kingdom and the Republic of Ireland.  This was done very specifically to avoid the confusion with other professions.  This includes the difficulty the public has (and even some in healthcare) from distinguishing a "physician assistant" and a "medical assistant" (which is a common issue even in the United States).  PAs also have graduate level education and the "assistant" term is not well translated versus "associate" which is frequently used across occupations include in academia.  However, the "associate" term is still not perfect by any means and still is not specific to the exact role of a PA in healthcare.

Ultimately, there have been some very vocal physician groups that have spoken out since the vote for the change in the PA title.  This includes the American Osteopathic Association (AOA) and ajoint statement from the American College of Emergency Physicians and Emergency Medicine Residents' Association (EMRA).  While it is disappointing to read these statements, it is important to recognize why this change has been made.

Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on Apple Podcasts.  If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.

There are countless guides and references that can be used in emergency medicine.  However, some books prove to be better resources than others and it is vital to identify them.  In this post, we review one of the books you should seriously consider having if you work in emergency medicine.

Many resources are simply too wordy  to be beneficial when seconds count.  Dave Borshoff, an Australian anesthesiologist and former pilot, developed theAnesthesia Crisis Manual.  While some may like this particular book even in emergency medicine, a newer book has been created with emergency medicine and critical care in mind called the Resuscitation Crisis Manual (RCM).  This book was co-authored by both Dave Borshoff and Scott Weingart.  The latter is well known for his EMCrit blog and podcast which also includes a post covering this book.

What makes this book so special?  Why should you bother looking into having it for your shifts?  This book in particular is set up as a quick reference handbook (QRH) similar to what a pilot keeps in their cockpit for an emergency.  The idea is that the QRH provides bold face actions for emergency situations.  These are meant to be incredibly brief.  They tell the pilot what must be done (in order), to address the immediate threat.  Usually, on the other side, the QRH contains additional details (see pictures below for an example on ejection).

The format is very similar in the RCM.  Below is an example for status epilepticus.  On the left side are the bold face actions.  These actions are meant to be performed in order.  In the example below, you may not how there are small boxes with numbers.  These refer to other references.  For example, the intubation checklist mentioned in step 7 is found under section 43 (note how status epilepticus is section 22).  On the right side of the example includes further details such as drugs and dosages, causes, and recommended labs among many other details.  The right side is meant more to provide additional details where they may be needed.

You may be thinking to yourself that you do not need such resources.  While it is possible, checklists provide an additional layer of safety and can act to cognitively offload you in an emergency.  Use your bandwidth for other components which must require your focus and use tools such as the RCM to provide you with additional and methodical support.

In addition to a physical book, there is an e-book that can be purchased.  When purchasing the physical book, the e-book is included.  However, an e-book alone may be purchased if desired.  It is worth noting that the books are designed in a way to withstand many of the demands in the emergency department.  It is also reasonably priced and written by experts in their fields.

Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on Apple Podcasts.  If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.

Last year, the American Heart Association (AHA) provided updates to their basic life support (BLS), advanced cardiac life support (ACLS), and pediatric advanced life support (PALS) programs.  Mike Sharma is helping again by reviewing some of the key updates and changes to guidelines.  We also provide some additional feedback and information to consider with these new guidelines.

Layout of Post and Podcast:

• The full guidelines, their updates, and the cited evidence can be found with THIS LINK.
• They can also be accessed in PDF form through THIS LINK.
• Algorithms and other visuals from the AHA are placed throughout this post primarily after a related section has been discussed.
  
• Additional commentary with links (including to older podcasts), are also included.
  

Key BLS Updates:

• Chain of survival has been updated.
  • For each chain, there is now a new link for recovery.
  • Think of return of spontaneous circulation (ROSC) as the end of the beginning.
  • The adult chains of survival are below in red and the pediatric is purple.

Final Thoughts:​

• One of the mainstays is that high-quality CPR is key.
  • Compressing between a rate of 100-120 beats per minute.
  • Adequate compression depth and chest recoil.
  • High chest compression fraction (no more than 10 seconds off of the chest being key).
  • Early defibrillation if the patient is in a shockable rhythm.
• CPR Coaching is another common consideration and now encouraged.
  • Allows cognitive offloading from the team leader.
  • Can help improve the components of high-quality CPR as described above.
  • A metronome or similar device can be used to help ensure adequate compression rate.

Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on Apple Podcasts.  If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.

March is Women's History Month and we wanted to celebrate some of the accomplishments of women in medicine.  While there are countless women that could be mentioned, we wanted to focus on a few that have been seen as pioneers in medicine.

Elizabeth Blackwell, MD (1821-1910)
In 1849, Elizabeth Blackwell became the first woman in the United States to earn her MD.  The journey reportedly began after a deathly ill friend said she would have received better care from a female physician.  While she was turned away from more than 10 medical schools, she refused to disguise herself as a man despite one professor's suggestion.  She was able to finally attend at Geneva Medical College and would later co-found the New York Infirmary for Indigent Women and Children.  She also worked to support and encourage other women hoping to pursue a career in medicine.

Rebecca Lee Crumpler, MD (1831-1895)
The first African American woman to receive her MD in the United States was Rebecca Lee Crumpler.  She attended the New England Female Medical College in Boston, Massachusetts and graduated in 1864.  In the period following the Civil War, she would move to Richmond, Virginia.  There, she treated formerly enslaved people despite severe racism and sexism and would later write about those experiences.

Mary Putnam Jacobi, MD (1842-1906)
A prolific writer, Mary Putnam Jacobi received her MD from the Female Medical College of Pennsylvania in 1864.  She wrote about a variety of topics including pediatrics, pathology, and neurology.  However, one unique claim to fame was her argument against a reported claim in a book by a Harvard professor that exertion, including studying, during menstruation, was dangerous.  She was able to prove the stability of women's strength throughout their cycle and won Harvard's Boylston Prize.

Virginia Apgar, MD (1909-1974)
Moving up in time, we recognize an achievement still well known today.  In 1953, Virginia Apgar devised a tool to assess a neonate's health risk and need for potentially life-saving observation.  It became a backronym when it started to be used as a memory tool for the five criteria of the Apgar Score (Appearance, Pulse, Grimace, Activity, and Respiration).

Joyce Nichols, PA-C (1940-2012)
The first formally educated female physician assistant (PA) was Joyce Nichols.  She graduated from Duke University Medical Center in 1970 after first being a licensed practical nurse (LPN).  Dr. Eugene Stead (the "father" of the PA profession) encouraged her to attend even though prior to that point it had only been men, especially those with military experience (such as Navy corpsmen) prior to that point.  She did suffer hardships including her house burning down in 1969 while in PA school.  She was well known for her advocacy and in 1996 was named the AAPA Paragon "Humanitarian of the Year" a year after she retired from clinical practice.

Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on Apple Podcasts.  If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.

Recently there was commentary in a forum that suggested the Pulmonary Embolism Rule-Out Criteria (PERC Rule) was essentially useless for detecting a pulmonary embolism (PE).  It started with an anecdote, which is a logical fallacy (post hoc ergo propter hoc) and went wild from there.  This led to the realization that many still do not understand how to use the Wells' Criteria for Pulmonary Embolism (referred to from here simply as the Wells' Criteria) and the PERC Rule.

For those not familiar with the Wells' Criteria or the PERC Rule, they are shown below.  Both screenshots are taken from MDCalc which is a fantastic tool for medical calculations including acting as a reminder for scores and criteria frequently used in medicine.

Originally, the PERC Rule was recommended to be used when patients were considered to be low risk based on clinical gestalt ("trusting your gut" it was low risk).  However, some wanted to objectively be able to determine who was low risk.  It has been recommended by some experts to use the Wells' Criteria and then if they are considered low risk to apply the PERC Rule as a combination.  Note how some of these are redundant and patients would already be PERC Rule positive based on even one Wells' Criteria being positive.  The main two are the heart rate and hemoptysis.  It is also worth noting that older individuals (patients 50 and older), automatically will need a d-dimer to evaluate risk because of age.

However, some common concerns have come up with using the PERC Rule.  The less common concern is with elevation.  However, this has been addressed with the relatively new Altitude-Adjusted PERC Rule which allows for a lower oxygen saturation at 4,000 feet (1219.2 meters).  In the original PERC Rule, oxygen saturations <95% led to someone having a positive PERC Rule and needing a d-dimer, but at over 4,000 feet this will be the same result only if the oxygen saturation are <90% (a clever idea).

The more common concern becomes the d-dimer itself being positive in older individuals.  However, there is another clever way to go around this issue.  An age-adjusted d-dimer can be used when there is concern for a venous thromboembolism (VTE) for pulmonary embolism or deep vein thrombosis (DVT).  Now, for individuals over the age of 50 we can adjust based on their age their risk.  For example, if the normal cutoff was 500 ug/L but the patient is 60 years old, the cutoff allowed would be 600 ug/L instead.  Again, this helps us safely avoid unnecessary testing in otherwise low-risk situations.

Keep in mind, these criteria are not meant to be perfect.  This was the argument incorrectly made in the aforementioned forum.  However, they are quite helpful in identifying the vast majority of cases while avoiding over-testing.  As with every patient encounter, a certain amount of shared decision making and education should occur and can make a monumental difference in our patient management.

Hopefully, this brief post will help you better understand how these criteria were meant to be used and how to use them effectively.  While not perfect, they do carry many benefits and can help objectively measure and discuss risk with patients (and lead to better management).

Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on Apple Podcasts.  If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.

Injuries to the spine can occur both in blunt and penetrating trauma.  They can also be with or without neurological deficits.  For this reason, they should be considered in all patients with multiple injuries.  In this podcast, Chip Lange and Mike Sharma review the pearls and pitfalls of this disease process.

It is worth remembering key dermatomes (pictured left) and myotomes (pictured right) as seen in the two images below.  Dermatomes are areas of skin innervated by the sensory axons within a particular segmental nerve root.  Myotomes are essentially the equivalent for muscles but most muscles are innervated by more than one root (usually two).

Neurogenic shock results in the loss of vasomotor tone and sympathetic innervation to the heart. Injury to the cervical or upper thoracic spinal cord (T6 and above) can cause impairment of the descending sympathetic pathways. The resultant loss of vasomotor tone causes vasodilation of visceral and peripheral blood vessels, pooling of blood, and, consequently, hypotension.

Spinal shock refers to the flaccidity (loss of muscle tone) and loss of reflexes that occur immediately after spinal cord injury. After a period of time, spasticity ensues.

Neurogenic shock and spinal shock were discussed recently on EMCrit and it is worth listening to that podcast by Scott Weingart.  We also covered how there may be a benefit in trauma in Podcast #216.  In general, vasopressin should at least be considered especially after volume resuscitation.

We did cover spinal cord syndromes and there is some additional information in the infographic below that can be very helpful in understanding the differences.  However, the website that it comes from is no longer functional.

When it comes to evaluation, there is a way to help us risk stratify cervical spine injuries.  However, the thoracic and lumbar portions of the spine do not benefit from rule out criteria.  There are also certain injuries to watch for specifically as discussed in the podcast.  

The Canadian C-Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) are widely used.  The CCR is used more frequently now than the NEXUS criteria, but both are specifically mentioned in this ATLS chapter.

Simple compression fractures are usually stable and often of the thoracic and lumbar spine are usually stable and often treated with a rigid brace.  Burst fractures, Chance fractures, and fracture-dislocations are extremely unstable and nearly always require internal fixation.  Chance fractures can be associated with retroperitoneal and abdominal visceral injuries.  Given the narrow relation to the spinal cord and canal a the level of the thoracic spine means that fracture-dislocations (or subluxations) can commonly result in complete neurological deficits.  Finally, thoracolumbar junction fractures (T11 through L1) are due to immobility of the thoracic spine compared with the lumbar spine and are often considered unstable due to their vulnerability to rotational movement so be careful in logrolling these patients.

Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on Apple Podcasts.  If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.