Pigtail Catheter vs Large Bore Chest Tube for Pneumothorax

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Written by Jessica DiPeri, MD
This post first appeared on REBEL EM

Background: Pneumothorax management is a common clinical condition in the emergency department (ED) occurring in patients of varying ages and caused by multiple etiologies, including spontaneous, traumatic, and iatrogenic pneumothorax. Regardless of the cause, a thoracostomy is often required for treatment (Currie 2007). Traditionally, all pneumothoraces were treated with large bore chest tubes (LBCT) defined as any tube > 14 F. The benefits of a small bore catheter (ie a pigtail catheter (PC) include less trauma to the chest wall and less patient pain. Additionally, small-bore catheter placement is performed via the Seldinger technique;’ a skill possessed by all Emergency Physicians (Bauman 2018). The decision to use a LBCT vs. a PC in the treatment of pneumothorax has been widely studied over the last decade, yet clinical practice still varies.

Article: Chang, Su-Huan et al. “A Systematic Review and Meta-Analysis Comparing Pigtail Catheter and Chest Tube as the Initial Treatment for Pneumothorax.” Chest vol. 153,5 (2018): 1201-1212. PMID: 29452099 Prospero: CRD42017078481

Clinical Question: Is a pigtail catheter (PC) more effective than a large bore chest tube (LBCT) for treating pneumothorax?

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Classic Journal Club: TXA for Epistaxis

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Written by Amanda Hall, DO
This post first appeared on REBEL EM

Background: Epistaxis is a common ailment experienced by millions worldwide. While most of these cases can be managed by patients at home, some will require medical attention. Initial interventions include local pressure, ice, and forward head positioning for persistent bleeds. When simple maneuvers fail, we proceed to topical agents such as lidocaine with epinephrine, oxymetazoline, anterior nasal packing, and electrical or chemical cauterization. 

Tranexamic acid (TXA) is an antifibrinolytic drug that inhibits the enzymatic breakdown of fibrin blood clots. Essentially, it increases blood clot stability. TXA has been studied extensively over the last 10 years for various conditions, including trauma, hemophilia, bleeding related to pregnancy, and other uncontrolled bleeding. However, the benefit vs. harm of using TXA topically for epistaxis is unclear. 

TXA has become the standard practice in the ED based on small RCTs, though larger trials have not demonstrated the same benefit (REBEL EM review). Here, we explore one of the original trials which formed the basis of care and moved TXA into standard practice.

Paper:  Zahed R, Moharamzadeh P, Alizadeharasi S et al. 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. Epub 2013 Jul 30. PMID: 23911102.

Clinical Question: Does the topical application of standard injectable tranexamic acid in adult patients presenting to the ED with persistent epistaxis reduce the need for anterior nasal packing?

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Gun Laws and Mass Shootings: A Call to Action

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Written by Sarah Aly, DO
This post first appeared on REBEL EM

Background: Rob Elementary. Columbine. Sandy Hook. Pulse Night Club. Tops Grocery Store. Irvine Taiwanese Presbyterian Church. Virginia Beach. The Tree of Life Synagogue. Santa Fe High School. The New York City Subway. The Las Vegas Harvest Music Festival. Aurora Movie Theater. The El Paso Walmart. Tulsa. The list goes on.

The United States has a unique epidemic: mass shootings. There is no universal definition of a mass shooting but it is often referred to as an event where greater than four individuals are killed by a single perpetrator (Everytown Research & Policy, 2022). Outside of the US, mass shootings are rare events (Bloomberg 2022, Snopes 2018).

In the United States, we continue to have an average of 19 mass shootings per year (Everytown Research & Policy, 2022). Medical providers, especially Emergency Physicians, bear witness to the toll of mass shootings as we sit on the interface between the community and the hospital. As a result, it is important for us to understand the role of public policy in this epidemic.

Clinical Question: Do states with permissive gun laws have more mass shootings than states with restrictive gun laws?

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REBEL Core Cast – Basics of EM – Introduction

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Written by EJ Wright, MD
This post first appeared on REBEL Cast

Welcome to the EMRA Basics of Emergency Medicine Podcast. I am your host EJ Wright, and the following series is an all encompassing approach to the most common chief complaints in the ED based on the well known EMRA Basics of Emergency Medicine, A Chief Complaint-Based Guide. Each cast will highlight myself and a guest attending physician as we take new learners through the differentials, red flags, physical exam findings, and a sample presentation that you need to know to treat patients in the ED.

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Massive Acetaminophen Overdose: Are We Giving Enough N-acetyl-cysteine?

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Written by Christopher Hart, DO
This post first appeared on REBEL EM

Introduction: Acetaminophen, N-acetyl-p-aminophenol, or APAP, is one of the most commonly used medications worldwide. While it is generally safely used, overdose can result in the development of liver failure due to APAP’s hepatotoxic metabolites. Hepatic necrosis is preventable in overdose with timely administration of N-acetyl-cysteine (NAC) which restores glutathione reserves, allowing for safe excretion of these hepatotoxic metabolites. NAC use is based on plotting APAP levels, on the Rumack-Matthew nomogram.

Intravenous NAC therapy includes: 
1. An initial dose of 150 mg/kg over 1 hour, 
2. A second dose of 50 mg/kg over 4 hours, 
3. And a final infusion of 100 mg/kg over 16 hours.

However, it is unclear if this dosing regimen is adequate for the treatment of massive overdoses (>32g or concentrations >300 mcg/mL).

Clinical Question: Will increasing the third dose of IV NAC decrease the risk of hepatotoxicity in massive APAP overdose?

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Race Multiplier in the eGFR Equation: What’s the impact for African-Americans?

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Written by Amanda Russo, DO
This post first appeared on REBEL EM

Background: Race is a sociological construct that affects how clinicians deliver health care to various racial/ethnic groups.  This in turn affects clinical outcomes.  Thus, African Americans with chronic kidney disease have worse outcomes with respect to hypertension control, timely nephrology referral, dialysis fistula/graft placement, adequate dialysis treatment, and access to transplantation. The precise reason for this difference is unclear but one proposed cause is the race multiplier term in estimated glomerular filtration rate (eGFR) equations.

The MDRD and CKD-EPI studies developed the equations most commonly used for eGFR in hospitals today. This article aims to illuminate how the race multiplier in the eGFR equations impacts care for African Americans with chronic kidney disease. 

Clinical Question: What is the impact of the race multiplier for African-Americans in the CKD-EPI eGFR equation on CKD classification and healthcare delivery?

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The INSPIRATION Trial: Intermediate Dose Anticoagulation in Critically Ill Patients with COVID-19

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Written by Jessica DiPeri, MD
This post first appeared on REBEL EM

Background: COVID-19 infection increases the risk of thrombosis due to multiple factors. (Rico-Mesa, 2020). Over the last 2 years, researchers have published 12 RCTs investigating various anticoagulation strategies among patients diagnosed with COVID-19 in multiple clinical settings. To date, only a multiplatform trial in noncritically ill patients, the HEP-COVID trial, and the MICHELLE trial have shown a benefit.

Severely ill patients with COVID-19 in the intensive care setting have an increased risk of thromboembolism, with an incidence reported as high as 31% (Klok, 2020). It remains unclear what the optimal prophylactic anticoagulation strategy is in critically ill patients.

Does intermediate-dose anticoagulation improve clinical outcomes compared to standard prophylactic anticoagulation in patients with COVID-19 treated in the intensive care unit?

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The MICHELLE Trial: Anticoagulation Post-Discharge in Patients Hospitalized Secondary to COVID-19

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Background:Patients diagnosed with COVID-19 have an increased risk of thromboembolic events, including pulmonary embolism and deep vein thrombosis (DVT). In addition, COVID-19 patients with increased coagulation parameters such as D-dimer, fibrin degradation products, prothrombin time, and activated partial thromboplastin time are at higher risk of morbidity and mortality.
Several RCTs have investigated the benefit of anticoagulation in patients with COVID-19 in various clinical settings. The INSPIRATION Trial investigated outcomes with an intermediate vs. standard prophylactic dose of anticoagulation in ICU patients. A multiplatform trial and HEP-COVID Trial investigated therapeutic anticoagulation in critically ill and non-critically ill hospitalized patients. The ACTIV-4B Trial investigated anticoagulation in symptomatic COVID-19 patients who did not require hospitalization. Currently, there is some evidence in support of therapeutic anticoagulation in non-critically ill hospitalized patients. However, there is no evidence to support the use of full dose anticoagulation in either the ICU or outpatient setting.

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The ACTIV-4b Trial: Antithrombotics For Treatment of Outpatient COVID-19

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Background: Severely ill patients diagnosed with COVID-19 have an increased risk of cardiovascular complications, especially thromboembolic events (Bikdeli 2020). The overall incidence of developing venous thromboembolism (VTE) is approximately 17% in patients diagnosed with COVID-19, with a significantly higher rate in the ICU setting (Jiménez 2021). Multiple studies have investigated the use of antithrombotic agents in patients with COVID-19 admitted to various hospital settings (Talasaz 2021). Some of these papers have been reviewed on REBEL EM. However, there is currently no evidence to support the use of antithrombotics in stable patients who are treated in the outpatient setting. Some clinicians have extrapolated inpatient data and are using antithrombotics in the outpatient setting without evidence. How should we manage those symptomatic but stable patients with COVID-19 that are discharged home without an inpatient stay? Investigators of the ACTIV-4b trial sought to answer this question.

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PECARN Blunt Abdominal Trauma: Is A Clinical Decision Instrument Better Than Clinician Gestalt?

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This post first appeared on REBEL EM Blog. Background: Unintentional injuries remain the leading cause of mortality in children. While traumatic brain injuries and thoracic traumas are the top two causes of mortality and morbidity, abdominal traumas are the third most common cause. Additionally, children are at higher risk for clinically significant intra-abdominal (IAI) injuries as a result of their anatomy in comparison to adults. Therefore, it is critical that emergency clinicians accurately diagnose IAI that requires intervention. Given the sensitivity of abdominal CTs for detecting IAI, emergency clinicians may be susceptible to overuse. Unfortunately, CTs expose patients to high doses of ionizing radiation, placing children at increased risk of developing radiation-induced malignancies. The data now shows that solid organ cancers occur in one out of every 300 to 390 girls and one out of every 670 to 690 boys undergoing abdominal CT.

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