Classic Journal Club: TXA for Epistaxis

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?

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

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?

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

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.

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

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.

Antacid Monotherapy vs GI Cocktail: Are You On or Off the Wagon?

This post first appeared on REBEl EM blog. Background: Dyspepsia and epigastric pain are common emergency department (ED) complaints affecting one in four adults annually. Twenty percent of these patients have an organic cause while 80% have functional dyspepsia (Moayyedi 2017). Antacids are often a first-line treatment in relieving the discomfort of dyspepsia and epigastric pain (Salisbury 2021). Antacids can be paired with other medications to create the “GI cocktail.”

Are You Pausing Too Long During CPR?

Outside of early defibrillation and high-quality CPR, little has been shown to improve outcomes in out-of-hospital cardiac arrest (OHCA). In theory, rapid identification of the underlying cause of arrest can be beneficial. Point-of-care ultrasound (POCUS) has been adopted into cardiac arrest care by many emergency clinicians for this reason.

Retrospective Validation of High-Sensitivity Troponin with 5 Clinical Decision Instruments

This post first appeared on REBEl EM [Link is here] Background: Chest pain is the second most common reason for presentation to the emergency department (ED) and accounts for nearly 6.5 million visits each year. [1] Management often requires the utilization of clinical gestalt, laboratory analysis, diagnostic imaging, and clinical prediction rules.  Clinical decision instruments (CDIs) …

Tox Box Journal Club

In this installment of the Tox Box Journal Club we are going over three articles reviewed at the NYC Poison Control Center in Manhattan last week. Two of the articles discuss utility of lipid emulsion therapy in animal models and a third on the deleterious effects of methotrexate dosing errors in Australia.