February 2019

Authors:

Andy Neill
Dave McCreary

Clinical Question

– Is TXA effective in treating haemoptysis?

Title

– Inhaled Tranexamic Acid for Hemoptysis Treatment A Randomized Controlled Trial
PMID [30321510](https://www.ncbi.nlm.nih.gov/pubmed/30321510)
DOI: [10.1016/j.chest.2018.09.026](https://doi.org/10.1016/j.chest.2018.09.026)

Author:

– Wand, 2018, Chest

Background:

– Just like fluoride, TXA is now added to the tap water in most emergency departments and is creeping up to take the crown from Ketamine as the drug you would most want to have on a desert island. We now use it for epistaxis, for oral mucosal bleeding as a mouth wash and I have used it for substantial upper GI bleeds. I had heard of nebulising it for haemoptysis anecdotally and it made sense but now we have a trial

Methods:

– Patients in an Israeli respiratory unit within the first 24 hrs of presentation. So not ED patients.
– Excluded massive haemoptysis and anticoagulation which is a shame because i’d be really interested i this group
– Two primary outcomes (NO!!!) complete resolution in 5 days and volume of blood expectorated
– Ridiculous sample size estimation based on apparently nothing where they assumed 90 v 55% resolution. This happens to be close to what they found which makes me a touch suspicious they did the sample size retrospectively.
– Powered for 60 but stopped at 47 cause it was so overwhelmingly wonderful (which again seems silly, when the numbers are this small just finish the damn trial)

Results

– 47 patients ~35% malignancy, most had some lung disease
– They say half had anticagulation or antiplatetlets which is a bit weird cause they say anticoagulation was an exclusion (presumably these were DOACs as technically their exclusion was INR>2)
– 96% resolution in TXA v 50% in placebo
– Mainly patients with COPD and malignancy as you might expect
– Very little interventional bronchoscopy needed or angioembolisation

Thoughts

– Not a great trial but if you need low level data then go for it…
– Would love to see if simply taking it orally would work as well. It works for women with heavy periods and we don’t have to give that as a pessary…

Authors:

– Andy Neill
– Andrew Tabner
– Graham Johnston

Look out for the new EMJ podcast coming soon

Capacity in the ED

Published in October 2018 this guideline review isnt specifically one for ED but its one we use every single day!
It looks at people over the age of 16 their decision making when they may lack capacity or may lack it in the future.

The first principles in this guidance are that practitioners should be trained and have ongoing training around the mental health act

Remember….

1) A person must be assumed to have capacity unless it is established that he lacks capacity.
2) A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success
3) A person is not to be treated as unable to make a decision merely because he makes an unwise decision

You have to remember that a consultation with patients who may lack capacity does not involve trying to persuade or coerce a person into making a particular decision, and must be conducted in a non-discriminatory way.

Record the information that is given to the person during decision-making. Give the person an opportunity to review and comment on what is recorded and write down their views

Practitioners should be aware that people can be distressed by having their capacity questioned, particularly if they strongly disagree that there is a reason to doubt their capacity. This is an easy way to escalate a slightly disgruntled patient into an angry, shouting patient in the middle of a busy ED. Be sensitive!!

When making best interests decisions, explore whether there are less restrictive options that will meet the person’s needs

References:

www.nice.org.uk
nhs.uk making decisions for someone else
www.legislation.gov.uk
www.england.nhs.uk

Authors

– Dave McCreary
– Andy Neill

Clinical Question:

Does pre-medication with midazolam or haloperidol decrease recovery agitation after adult ketamine sedation?

Title of Paper:

Premedication With Midazolam or Haloperidol to Prevent Recovery Agitation in Adults Undergoing Procedural Sedation With Ketamine: A Randomized Double-Blind Clinical Trial
PMID: [30611640](https://www.ncbi.nlm.nih.gov/pubmed/30611640)
DOI: [10.1016/j.annemergmed.2018.11.016](https://doi.org/10.1016/j.annemergmed.2018.11.016)

Journal and Year:

Annals of Emergency Medicine. 2018.

Lead Author:

Narjes Akhlaghi

Background:

– Generally ketamine is a well-loved, well-used agent for procedural sedation in the ED, especially in kids
– Some are more reluctant to use it in adults, mainly because of the increased risk of recovery agitation / emergence reactions in grown-ups
– Benzos have been proposed to reduce this, as long ago as 1973 in a study entitled The taming of ketamine.
– Other studies have suggested haloperidol may have the same benefit

Study Design:

– Randomised, double-blind, placebo-controlled, multi-arm trial

Patients Studied:

– Patients >18 years requiring procedural sedation in the Emergency Department
– Excluded patients with contraindications to the study drugs

Intervention:

– Premedication with:
– 0.05mg/kg IV midazolam OR

– 5mg IV Haloperidol

– then 1mg/kg IV ketamine

– Randomisation packs had three syringes:
– Blinded midazolam/placebo (distilled water) syringe
– Blinded haloperidole/placebo syringe (distilled water) syringe
– Non-blinded ketamine syringe

Comparison:

– Placebo or the alternative study drug
– Then 1mg/kg IV ketamine

Outcomes:

– Primary:
– Recovery agitation on [Richmond Agitation-Sedation Scale](https://www.mdcalc.com/richmond-agitation-sedation-scale-rass) (RASS) at 5, 15 and 30 minutes post ketamine
– Maximum observed [Pittsburgh Agitation Scale](https://www.cambridge.org/core/journals/international-psychogeriatrics/article/pittsburgh-agitation-scale/90FDE4277BD438D75A8D994CFE7B8CFB)score
– 3 considered disruptive behaviours and so threshold for clinically important for this study

– Secondary:
– Clinician satisfaction
– Questionnaire

– Recovery duration
– Time from administration of first syringe to the time the patient was alert and easily aroused by minimal stimulation

Summary of Results:

– 185 patients enrolled (sample size calc was minimum 59 per group, 177 total)
– 182 completed follow up and analysis

– Incidence of ketamine induced agitation (Pittsburgh score >0):
– Control: 63.9%
– Clinically important” = 26.2%

– Midazolam: 25% (relative risk reduction 60.9%)
– “Clinically important = 5%

– Haloperidol: 19.7% (relative risk reduction 69.2%)
– Clinically important = 1%

– Median recovery time (minutes):
– Control: 18
– Midazolam: 35
– Placebo vs midazolam: -17 [95% CI -24.95 to -9.05]

– Haloperidol: 50
– Placebo vs haloperidol: -32 [95%CI -38.81 to -25.19]
– Midazolam vs haloperidol: -15 [95%CI -23.01 to -6.99]

– No difference in clinician satisfaction
– Episodes of severe agitation (PAS >8):
– Control: 9.8%
– Midazolam and haloperidol: 0%

Authors Conclusion:

In adult patients undergoing procedural sedation in the ED, premedication of ketamine by either midazolam or haloperidol significantly reduces ketamine-induced recovery agitation while delaying recovery.

Clinical Bottom Line:

– As the authors say, there is definitely need for a larger, multi centre trial to truly assess this, but in the meantime I personally already use midazolam as a premedication in both adults and kids when giving ketamine sedation, and I think this study encourages continuation of that practice.

– Haloperidol is an interesting alternative (and its a decent anti-emetic, too) but maybe not worth the much longer recovery time. Personally I think, based on this studys results, midazolam is a nice middle ground.

– Maybe haloperidol is something to keep in mind if you are sedating a patient that might be higher risk for recovery agitation such as patients with a psychiatric history (though excluded from this study).

**Other #FOAMed Resources / References:**

– [Simon Carly](https://twitter.com/@EMManchester) has a [St Emlyns journal club](https://www.stemlynsblog.org/jc-should-we-premedicate-for-ketamine-sedation-st-emlyns/) if youd like his take on the paper
– You can follow the author on twitter [@pooya_mehr](https://twitter.com/pooya_mehr)

Capacity in the ED

Published in October 2018 this guideline review isnt specifically one for ED but its one we use every single day!
It looks at people over the age of 16 their decision making when they may lack capacity or may lack it in the future.

The first principles in this guidance are that practitioners should be trained and have ongoing training around the mental health act

Remember….

1) A person must be assumed to have capacity unless it is established that he lacks capacity.
2) A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success
3) A person is not to be treated as unable to make a decision merely because he makes an unwise decision

You have to remember that a consultation with patients who may lack capacity does not involve trying to persuade or coerce a person into making a particular decision, and must be conducted in a non-discriminatory way.

Record the information that is given to the person during decision-making. Give the person an opportunity to review and comment on what is recorded and write down their views

Practitioners should be aware that people can be distressed by having their capacity questioned, particularly if they strongly disagree that there is a reason to doubt their capacity. This is an easy way to escalate a slightly disgruntled patient into an angry, shouting patient in the middle of a busy ED. Be sensitive!!

When making best interests decisions, explore whether there are less restrictive options that will meet the person’s needs

References:

www.nice.org.uk
nhs.uk making decisions for someone else
www.legislation.gov.uk
www.england.nhs.uk

Authors:

Andy Neill
Dave McCreary

Clinical Question

– Can you safely clear a c-spine in a patient with a distracting injury?

Title:

– Clearing the Cervical Spine in Patients with Distracting Injuries: An AAST Multi-Institutional Trial
PMID [30188422](https://www.ncbi.nlm.nih.gov/pubmed/30188422)
DOI: [10.1097/TA.0000000000002063](https://doi.org/10.1097/TA.0000000000002063)

Author:

– Khan 2018, Journal Trauma Acute Care Surgery

Background:

– Since Jerry Hoffman’s original NEXUS study we have had some great clinical decision instruments for clearing the c-spine clinically. There has always been some concern as to clearing a c-spine in the “distracted patient”. Many have been unclear as to what a distracting injury was. Was it a broken femur or a simple laceration on the hand? Jerry Hoffman has repeatedly said that a distracting injury is any injury that a decent clinician thinks is distracting the patient – it was always meant to be a subjective decision on the part of the physician. That being said people have tried to come up with lists of what might be a distracting injury and for whom you would need imaging no matter what the clinical exam said. Most of us realise that often that’s a bit silly and this paper is one of a number of excellent big studies looking at the c-spine from US trauma surgeons.

Methods

– 8 level 1 centres in USA
– Aimed to look at patients with a distracting injury
– They have a reasonable list of what they might consider a distracting injury but it completely neglects the idea that this is deliberately a subjective thing as people will be very different in terms of what distracts them
– They had a standardised algorithm for clinical assessment (which is heavily indebted to NEXUS and Canadian) but you weren’t allowed any neck pain at all if you were going to pass clinically (which isn’t really how many of us practice)
– GCS >13 and blunt trauma the only inclusion criteria (but you have to remember they got a trauma activation call so they are probably different than every patient we see with neck pain)
– Everyone in this study got a CT regardless!!
– They compared those with distracting injuries with those without with CT as a gold standard to see if they could be safely clinically cleared
– There are all kinds of issues with that methodology as distraction was defined retrospectively but the clinical exam was prospective. If you think someone is distracted or not it may well impact how you interpret the clinical exam but this trial can’t account for that.
– They also don’t define which CT findings are considered significant which is a big downfall for me as many C-spine injuries are not clinically significant

Results

– 3000 pts
– 70% with a distracting injury
– 7.5% c-spine injury on CT (which is high enough to be honest)
– Clinical exam missed 0.8% of injuries and there was no difference if they were distracted or not. Of the 0.8% missed clinically (25 pts) only 1 needed an operation and overall the operative rate for c-spine injuries was 20%. This is as good a proxy for “significant” c-spine injuries that I could find
– They conclude that clinical exam is sufficient even in distracting injury
– Importantly no mention of intoxication here so be careful with that. If they’re intoxicated then this paper can’t help you clear them clinically.

Thoughts

– It’s not a wonderful paper and the key diagnostic features were that sensitivity was poor but NPV was great (low sensitivity impacted by probably non significant c-spine fractures most likely but they don’t parse that out)
– Either way it seems that whether you were “distracted” or not then it shouldn’t affect clinical clearance.

[Bush 2016 JAMA Surg] and [Martin 2017 J Trauma] are useful to read alongside this as they include drunk folk in those papers with slightly different clinical questions

– Bush L, Brookshire R, Roche B, Johnson A, Cole F, Karmy-Jones R, et al. Evaluation of Cervical Spine Clearance by Computed Tomographic Scan Alone in Intoxicated Patients With Blunt Trauma. JAMA Surg. 2016 Jun 15;:17.

– Martin MJ, Bush LD, Inaba K, Byerly S, Schreiber M, Peck KA, et al. Cervical spine evaluation and clearance in the intoxicated patient. Journal of Trauma and Acute Care Surgery. 2017 Dec;83(6):103240.