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
HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020;395(10241):1927-1936.
Bennett C, Klingenberg SL, Langholz E, Gluud LL. Tranexamic acid for upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2014;(11):CD006640.
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
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
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.
Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.