The DownEast Emergency Medicine Podcast
Tranexamic Acid Beyond Trauma

Tranexamic Acid Beyond Trauma

March 16, 2020

Tranexamic acid (TXA) is a synthetic lysine derivative that binds with the lysine site on plasminogen, inhibits fibrinolysis and stabilizes clot. While it has been around since the 1960’s, its popularity for major trauma has gained a lot of steam in recent years. This has also resulted in creative emergency providers finding novel uses for it at the bedside. In this podcast, Dr. Tim Fallon discusses some of the more novel bedside uses of TXA including epistaxis, hemoptysis, post tonsillectomy bleeding, and dental trauma.

Click Here for the Show Notes on Downeastem.org

References

  1. Zahad, R. A new and rapid method for espistaxis treatmetn using injectable form of tranexamic acid topically: a randomized controlled trial. AJEM. 31 (2013)1389-1392.[Pubmed]

  2. Wand, O. Inhaled Tranexamic Acid for Hemoptysis Treatment. Chest. 2018; 154(6):1379-1384.[Pubmed]

  3. Schwarz, W. Nebulized tranexamic Acid Use for Pediatric Secondary Post-Tonsillectomy Hemorrhage. Annals of Emerg Med. in Press. [Pdf]

  4. Dietrich, S. Trick of the Trade: Topical Tranexamic Acid Paste for Hemostasis. ALiEM. https://www.aliem.com/category/clinical/tricks-of-the-trade/

  5. Mason, J. Epistaxis TXA Pack. EMRAP HD. May 2018

  6. Rezaie, S. TXA for Everyone: Inhaled TXA for Hemoptysis. RebelEM.

  7. Rezaie, S. Topical Tranexamic Acid for Epistaxis or Oral Bleeds. RebelEM

You passed out, Eh?- the Canadian Syncope Risk Score and its use in the ED

You passed out, Eh?- the Canadian Syncope Risk Score and its use in the ED

February 15, 2020

Syncope is an incredibly common presentation to the Emergency Department with a broad differential diagnosis from the benign (vasovagal) to the lethal (arrhythmia). Because of this, the care and disposition of these patients can be challenging. In this podcast we sat down with Dr. Mike Burla to talk through the details of a new(er) decision aid- the Canadian Syncope Risk Score.

 

The paper we discuss can be found HERE

Thiruganasambandamoorthy V et al. Duration of Electrocardiographic Monitoring of Emergency Department Patients With Syncope. Circulation. 2019 Mar 12;139(11):1396-1406.

 

 

Check out our post on the Down East EM blog for shownotes, references, and more.

 

When listening to this post, please consider the following questions (and follow us on twitter for spaced retrieval of this material @downeastem):

1. How long did the CSRS study investigators observe patients for major arrhythmic outcomes after presentation to the ED? 

2. Approximately what percentage of the study cohort was classified as low risk by the CSRS?

3. What proportion of serious arrhythmic outcomes occurred within 6 hours of ED arrival, regardless of CSRS score? 

4. According to the study authors, what is the recommended time for observation of a low risk patient by CSRS? How about for Medium and High Risk Patients? 

5. Based on the study results, what risk stratification category are the recommendations most applicable to? What is the recommendation for electrocardiographic monitoring of this group? 

 

Authors: Mike Burla MD and Jason Hine MD

Peer Review: Lauren Wendell MD

FOAM (free open access medical education) & How to Use It with Matt Delaney

FOAM (free open access medical education) & How to Use It with Matt Delaney

January 26, 2020

FOAM [free open access medical education] is growing at an amazing rate (we are actually using FOAM now to talk about FOAM). Like most powerful tools, this resource has both its pro and cons. To review FOAM and its use in Graduate Medical Education, we sat down with Matt Delaney.

 

Check out our post on the Down East EM blog for shownotes, references, and more.

 

To hear more on FOAM, check out Dave Mackenzie's talk at the Sugarloaf Conference

 

Author: Jason Hine MD

Peer Review: Jeff Holmes MD

 

Blood Pressure Pearls for Neuro Emergencies with Evie Marcolini

Blood Pressure Pearls for Neuro Emergencies with Evie Marcolini

January 8, 2020

We have a lot of numbers to remember when it comes to the care of the brain injured patient. From subarachnoid hemorrhage to traumatic brain injury, it can be hard to keep all the numbers straight. We sat down with neuro-intensivist Dr. Evie Marcolini to discuss blood pressure targets for these different disease processes.

Check out our post on the Down East EM blog for more

  

SUMMARY OF RECOMMENDATIONS AND ASSOCIATED LITERATURE

Subarachnoid Hemorrhage (SAH)

Systolic blood pressure (SBP) to <160 (AHA recs) [1]

Neurosurgeons/neurointensivists like it <140 to decrease rebleed risk.

Evie Pearl: SAH often happens in younger, healthy women who can tolerate a lower BP and so if you go below 140 even, and the patient tolerates it, that is ok.

 

Intracerebral Hemorrhage

SBP <180 (Atach 2) [2]

Evie Pearl: BP goal depends on baseline for patient.

 -Elderly, comorbid with baseline elevated BP aim higher (<180)

 -Younger healthy patients without pre-existing hypertension, aim lower (ex <160)

 

Acute Ischemic Stroke

TPA Candidate  <185/110 (AHA recs) [3]

Non-TPA Candidate <220

Evie Pearl 1: remember we are trying to keep BP on the higher side to perfuse the penumbra, but the larger the core infarct the higher the risk of reperfusion hemorrhage. 

Evie Pearl 2: do a neuro exam on the patient sitting up, then lie them flat and repeat the exam. If it improves, the stroke is BP dependent and you may want the patient to run on the higher side, let them lie flat, or give some gentle fluids.

 

Traumatic Brain Injury

SBP >110 age 15-49 or >70 (Brain Trauma Foundation) [4]

SBP > 100 age 50-69

Evie Pearl: These numbers are based on the fact that we do not have robust data on specific BP parameters. Newer data (Spaite paper [5]) is showing that not only is avoiding hypotension necessary, but allowing BPs to run higher (up to 130) may be of benefit. 

 

 

References

1. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P; American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012 Jun;43(6):1711-37. doi: 10.1161/STR.0b013e3182587839. Epub 2012 May 3.

 

2. Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, Moy CS, Silbergleit R, Steiner T, Suarez JI, Toyoda K, Wang Y, Yamamoto H, Yoon BW; ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016 Sep 15;375(11):1033-43. doi: 10.1056/NEJMoa1603460. Epub 2016 Jun 8.

 

3. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418. doi: 10.1161/STR.0000000000000211. Epub 2019 Oct 30.

 

4. Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15. doi: 10.1227/NEU.0000000000001432.

 

5. Spaite DW, Hu C, Bobrow BJ, Chikani V, Sherrill D, Barnhart B, Gaither JB, Denninghoff KR, Viscusi C, Mullins T, Adelson PD. Mortality and Prehospital Blood Pressure in Patients With Major Traumatic Brain Injury: Implications for the Hypotension Threshold. JAMA Surg. 2017 Apr 1;152(4):360-368. doi: 10.1001/jamasurg.2016.4686.

 

Author: Jason Hine MD

Peer Review: Jeff Holmes MD

Coding in the Community- Keeping It Real with Really Limited Resources

Coding in the Community- Keeping It Real with Really Limited Resources

December 18, 2019

Coding cardiac arrest patients is tough. There's lots to do- from getting access, to doing ultrasounds, to analyzing rhythms, the tasks really add up! This is especially true in a low-staffing, low-resource setting. In this post we review how to code someone well with limited resources.

 

Check out our post on the Down East EM blog for shownotes, references, and more.

 

Author: Jason Hine MD

Peer Reviewer: Jeff Holmes MD

Fentanyl Hysteria with Ryan Marino

Fentanyl Hysteria with Ryan Marino

December 3, 2019

In this podcast we sit down the ED toxicologist Ryan Marino to talk about this phenomenon in the media of "fentanyl hysteria"- a trend of fear-mongering, exaggerated reporting, and misinformation. 

 

Check out our post on the Down East EM blog for shownotes, references, and more.

 

Examples of Fentanyl Hysteria reporting:

San Fran Chronicle Article on Police OD

CNN Article on Deputy and EMT exposure

 

Author: Jason Hine MD

Peer Review: Jeff Holmes MD

Neuroimaging Update: The Studies and Sequences You Should Know

Neuroimaging Update: The Studies and Sequences You Should Know

November 18, 2019

The world of emergency neuroimaging is evolving and increasingly influencing time-sensitive treatment decisions. A basic understanding of the imaging studies and sequences you may be asked to obtain in the ED may help you better manage your patients. In this post, Dr. Matthew Siket reviews the four major neuroimaging modalities (CT, CTA, Perfusion, and MRI).

For the full show notes on our DownEast EM blog

https://www.downeastem.org/downeastem/2018/6/29/neuroimaging

 

References:

  1. Smith AG and Hill CR. Imaging assessment of acute ischaemic stroke: a review of radiological methods. Br J Radiol. 2018;91:1083.[Pubmed]

  2. Albers GW et al. New Engl J Med 2018;378:708-18.[Pdf]

  3. Thomalla G et al. New Engl J Med 2018; 379(7):611-22.[Pdf]

Author Matt Siket, MD and Jeff Holmes, MD

Peer Reviewed by Andrew Perron, MD

Emergency Mansplaning- Gender Equality in your ED

Emergency Mansplaning- Gender Equality in your ED

November 1, 2019

Gender equity (or in truth, inequity) in medicine has come under the spotlight with an increasing focus on a culture of fairness, improving female practitioners' access to leadership roles, and moving away from the "good ol' boys club" medicine is prone to being. 

In this guest lecture we have Dr. Kimon Ioannides talking on Mansplaining in the ED.

Check out our post on the Down East EM blog for shownotes, references, and more.

 

 

Author: Jason Hine MD and Kimon Ioannides MD

Peer Review: Jeff Holmes MD

Buprenorphine, the Opioid Epidemic, and the Emergency Provider

Buprenorphine, the Opioid Epidemic, and the Emergency Provider

October 16, 2019

Check out our post on the Down East EM blog for shownotes, references, and more.

 

The reality of America’s opioid addiction and overdose problem has reached the lay press. As overdose deaths begin to outpace car accidents as the #1 cause of accidental deaths, the Opioid Crisis has people’s attention.

How we deal with this epidemic in the Emergency Department has been a topic of hot debate, both in publication and in the Free Open Access Medical Education (FOAM) world.

To dive into these topics, we sat down with Dr. Ken Starr, an Emergency and Addiction medicine specialist, to review buprenorphine. 

 

Author: Jason Hine MD and Ken Starr MD

Peer Review: Jeff Holmes MD

Marble Mouth- Oropharyngeal Foreign Bodies in Kids

Marble Mouth- Oropharyngeal Foreign Bodies in Kids

October 1, 2019

Check out our post on the Down East EM blog for shownotes, references, and more.

In this podcast we review the complexity of the oral foreign body (FB) in kids and why this disease process is so tough to handle.

 

 

 

Other helpful links!