EM Quick Hits 21 TXA in GI Bleed, Pediatric DKA, POCUS for Shoulder Dislocations, Lisfranc Injuries, Dexamethasone for COVID Pneumonia, Consultation Tips

Topics in this EM Quick Hits podcast

Salim Rezaie on HALT-IT trial for TXA in unstable GI bleed (0:30)

Sarah Reid on pediatric DKA update in fluid management and cerebral edema (8:32)

Hans Rosenberg on POCUS in shoulder dislocations via CJEM (15:30)

Arun Sayal on Lisfranc injury pearls and pitfalls (23:57)

Justin Morgenstern on RECOVERY Trial for Dexamethasone in COVID pneumonia (32:48)

Walter Himmel on getting what you need from consultants (38:41)

Podcast: Play in new window | Download (Duration: 52:20 — 48.0MB)

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Podcast production, editing and sound design by Anton Helman

Podcast content by Salim Rezaie, Sarah Reid, Hans Rosenberg, Tara Dahn, Arun Sayal, Justin Morgenstern, Walter Himmel and Anton Helman

Written summary & blog post by Graham Mazereeuw, edited by Anton Helman

Cite this podcast as: Helman, A. Rezaie, S. Reid, S. Rosenberg, H. Dahn, T. Sayal, A. Morgenstern, J. Himmel, W. EM Quick Hits 21 – The HALT-IT Trial for TXA in Unstable GI Bleed, Pediatric DKA Update in Fluid Management and Cerebral Edema, POCUS in Shoulder Dislocations, Lisfranc Injury Pearls and Pitfalls, the RECOVERY Trial for Dexamethasone in COVID Pneumonia, Consulting Tips. Emergency Medicine Cases. August, 2020. https://emergencymedicinecases.com/em-quick-hits-august-2020/. Accessed [date].

HALT-IT Trial for TXA in Unstable GI Bleed

• Largest trial yet: international, multicenter RCT, 12,000 adults with significant GI bleeding (90% upper GI bleed)
• Intervention: TXA 1g IV infusion followed by 3g maintenance infusion over 24 hours vs. placebo
• No difference in 5-day mortality due to bleeding between TXA (4%) and placebo (4%) (risk ratio 0.99, 95% CI 0.82 to 1.18)
• TXA did not reduce the need for transfusion or surgical intervention; no benefit from early administration (< 3 hours)
• Small, but significant increase in VTE risk with TXA (NNH=250)

Bottom line: TXA should not be routinely recommended for management of acute GI bleeds

Pediatric DKA Update on Fluid Management and Cerebral Edema

• A practice changing PECARN study compared two fluid protocols in 1,389 cases of DKA
  • Fast protocol: 10 mL/kg bolus + 10 mL/kg bolus (both with NS) followed by replacement of a 10% fluid deficit + maintenance over 36 hours with either NS or 0.45 NS
  • Slow protocol: 10 mL/kg bolus (with NS) followed by replacement of a 5% fluid deficit + maintenance over 48 hours with either NS or 0.45 NS
• No difference between the fluid protocols in worsening mental status, cerebral injury, or post-DKA cognitive function

Bottom line: we don’t have to be so judicious with fluids in pediatric DKA; it’s almost always safe to start your resuscitation with 10mL/kg NS bolus regardless of fluid status and repeat if still hypoperfused

pediatric DKA algorithm

POCUS for Shoulder Dislocations – CJEM ‘Just the Facts’

• Up to 70% of posterior shoulder dislocations may be missed on initial exam
  • Posterior dislocations are uncommon and present less obviously compared to anterior shoulder dislocations (no shoulder squaring)
  • Standard x-ray views usually have subtle findings and the axillary view x-rays, which are very helpful to detect a posterior shoulder dislocation, are often difficult to obtain as pain may impede the necessary shoulder positioning; CT scans are not always available as a backup
  • Missed posterior dislocation can delay diagnosis and predispose patients to the need for surgical reduction

• Shoulder POCUS
  • Posterior approach, transverse orientation, at the lateral edge of scapular spine
  • Linear probe (ideal for thin patients) or curvilinear probe (ideal for larger or muscular patients)
  • Sensitivity 99.1-100%, specificity 99.9-100% for dislocation

Figure 2. Shoulder POCUS with normal appearance (above) and dislocations (below) anteriorly and posteriorly

Bottom line: there might be a role for POCUS in the diagnosis and reduction of posterior shoulder dislocation; but usually the reason we miss this diagnosis is a lack of thorough history and physical (see EM Cases podcast on shoulder injuries ); a block to external rotation of the shoulder is highly suggestive of posterior shoulder dislocation.

Lisfranc Injuries Pearls and Pitfalls

Fleck sign for avulsion fracture in Lisfranc injury

• History and physical exam are keys to this diagnosis
• Scrutinize x-rays with a keen eye, but avoid reliance on imaging; some Lisfranc injuries are radio-occult
• Displaced injury = unstable = operative management; undisplaced Lisfranc injuries – including ligamentous injuries – can also be unstable, so speak to your orthopaedic surgeon to help guide management

For more on Lisfranc injuries: EM Cases Digest, Volume 1: MSK & Trauma

RECOVERY Trial for Dexamethasone in COVID Pneumonia

• Design: 6,425 hospitalized patients with suspected or confirmed COVID-19 pneumonia in 176 hospitals in the United Kingdom; 2,104 patients randomized to dexamethasone with 4,321 controls
• Intervention: dexamethasone 6 mg daily PO or IV vs. usual care (unblinded)
• Dexamethasone might save lives! All-cause mortality was lower among patients treated with dexamethasone (21.6%) compared to controls (24.6%) (RR 0.65, 95% CI 0.51 to 0.82, NNT=33)
• Greatest benefits of dexamethasone were in ventilated patients > oxygenated patients > patients on room air

Bottom line: for patients with presumed COVID-19 pneumonia requiring ventilation or oxygen, even with an oxygen saturation of 92 to 94%, dexamethasone is probably your best bet for medical treatment

None of the authors have any conflicts of interest to declare