Archive | August, 2014

transexamic acid for epistaxis?

29 Aug

recent article on use of transexamic acid (which binds plasminogen and prevents it turning into plasmin):


Randomized trial for anterior bleeding:

using soaked cotton pledgets with TXA in one group vs. cotton pledget with epinephrine + lidocaine for ten minutes and packing with several cotton pledgets covered with tetracycline.  Nasal packing was removed after 3 days.


  • significantly higher rate of bleeding arrest in TXA group (71% to 31%)
  • significantly higher discharge with TXA at 2 hours or less (95% vs 6.4%),
  • non-significant rates of rebleeding at 24 hours (4.7% TXA vs 11% ANP).
  • higher patient satisfaction in the TXA group. 


However, it should be noted that this is not compared to rapid rhino or other commercially available products, simply to anterior nasal packing with cotton pledgets in place for ten minutes. No mention of holding pressure was noted.



Submitted by J. Stone. 


References: Zahed R 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. PMID: 23911102.; picture

septic arthritis: quick hits

26 Aug


Your next patient is a 54 y.o. male who presents to with complaints of swelling in the right elbow while he was at a party a few days prior.  

He also feels feverish since the onset of swelling, though he denies any pain in the elbow or any recent injury.  

Do you want to tap the joint?  What are you looking for?



the most common organisms involved in septic arthritis:

  • The most common overall cause of septic arthritis is Staphylococcus aureus 
  • Neisseria gonorrhea is the most common organism in young sexually active adults. 
  • Special populations and their common organisms include:
    • History of leukemia – Aeromonas spp.
    • IV drug users – Serratia spp (especially sternoclavicular and SI joints).
    • Sickle cell — higher Salmonella spp osteoarthritis 

Common characteristics of septic arthritis include

  • fever,
  • limited range of motion of the joint,
  • erythema
  • tenderness of the joint,
  • warmth over the joint.

Joint aspiration should usually show greater than 50K WBCs but sensitivity is only 64%.

ESR has sensitivity of 96% but is non specific.

Culture is definitive but is often negative in gonococcal septic arthritis.

Treatment is with vancomycin and and 3rd generation cephalosporin most commonly.


Submitted by J. Stone.


References: (Tintinalli’s Emergency Medicine, Ch 281 – Acute disorders of the joints and bursae); picture

Anterior Epistaxis: When compression isn’t enough

25 Aug

Usually patients come back from triage with some form of compression, be it fingers, tongue-blades, clothespin… Compression should be held for at least 20-30 minutes


If still actively bleeding, first thing is to clean out the nose. Have them blow out all clots (ONCE.  Not every 5 minutes)

Take a look to make sure an anterior bleed, and where exactly that bleed is.

If compression not working, here are some options:


Afrin:  Afrin or phenylephrine is a vasoconstrictor which usually does the trick


LET or 4% Lidocaine:  the UVA ER is stocked with Epistaxis kits which have nasal cannula, cotton balls, small plastic cup. 

Put 5-10cc 4% Lidocaine into cup, Dab cotton or gauze in the lidocaine, squeeze excess and apply to bleeding site.

Alternatively, using LET (lidocaine 4%, epinephrine 0.1%, and tetracaine 0.4%)


Silver nitrate:  If site dry, can apply Chemical cautery with silver nitrate. Roll on site.epi1


Surgicel:  Surgicel is fast-acting absorbable hemostat material. Cut to fit and place over site. Absorbs in
7-10 days.


Nasal packing or Rapid Rhino: Rapid Rhino is an inflatable balloon coated with a compound that eip2acts as a platelet aggregator and also forms a lubricant upon contact with water. Different sizes available.


Extra Pearls:

  • Once bleeding stopped, make sure the patient walks, bends down, squats to make sure no re-bleeding.
  • ENT follow-up if persistent problem.
  • Admit if cannot get it under control.



Submitted by Joran Sequeira, MD.


References: Gilman, Charles. “Focus on: Treatment of Epistaxis”. June 2009. ACEP News.

EtCO2 Monitoring for procedural sedation

21 Aug

Potential complications of procedural sedation include hypoventilation, aspiration, and respiratory failure capnowith hypoxic brain injury.

Capnography -> the non-invasive measurement of the partial pressure of carbon dioxide in exhaled breath.

Capnometer -> a device that displays what numeric value for end tidal carbon dioxide (ETCO2).


Hypoventilation always precedes hypoxia during procedural sedation, either due to airway obstruction or diminished respiratory drive.

ETCO2 monitoring provides an early warning signal to provide time to intervene before the onset of hypoxia.


The evidence:

132 subjects undergoing procedural sedation with Propofol (1 mg/kg then 0.5 mg/kg boluses using ideal body weight) were randomized to intervention (standard monitoring + capnography measuring ETCO2 via nasal cannula using the Capnostream 20™) or control (standard monitoring alone) groups.

All patients received 3L/minute oxygen and 0.5 μg/kg fentanyl or 0.05 mg/kg of morphine at least 30-minutes prior to the procedure.

The primary outcome was hypoxia, as defined by an oximetry reading of ≤ 93%. Respiratory depression was defined as ETCO2 ≥ 50 mm Hg, an absolute increase or decrease from baseline ETCO2 ≥ 10%, or loss of the waveform for > 15 seconds.

Capnography-defined respiratory depression was 100% sensitive and 64% specific in predicting hypoxia with the loss of a waveform being the most likely finding to precede hypoxia.

In patients with hypoxia, the median time from onset of respiratory depression to hypoxia was 60 seconds (range 5 to 240 seconds). 


A few things to consider:

-insufficient demographic variables were identified (history of obstructive sleep apnea, comorbidities, etc.)

-the Capnostream 20™ costs $4,950 per unit


Submitted by Kelly Estes.


Reference: Dietch K, Miner J, Chudnofsky CR, et al. Does end tidal CO2 monitoring during emergency department sedation and analgesia with Propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med 2010; 55: 258-264.


Peritonitis in peritoneal dialysis

19 Aug


Due to contamination with pathogenic skin bacteria or catheter-related infection;

less commonly secondary peritonitis due to underlying GI tract pathology (cholecystitis, appendicitis, etc.)



  • Abdominal pain (79-88%),
  • cloudy peritoneal effluent (84%),
  • fever (29-53%),
  • nausea (31-51%)

Patient with secondary peritonitis are more likely to have systemic manifestations of sepsis


Laboratory Findings

Peritoneal fluid cell count > 100 cells/mm3

*approximately 10% of patients with bacterial peritonitis have WBC counts below 100…among this group, >50% PMN strongly suggests peritonitis, independent of the WBC

Peripheral WBC often elevated as well

80-95% of cases have positive peritoneal fluid cultures, blood cultures are generally negative



Typical organisms:

  • E. coli (43%)
  • Other strep (19%)
  • Klebsiella pneumonia (11%)
  • Miscellaneous (10%)
  • Streptococcus pneumonia (9%)

Antibiotic of choice = cefotaxime 2g IV q 8 hours (or other third generation cephalosporin)

Second line = Levofloxacin (doesn’t penetrate into ascites fluid to the same extent)


Submitted by Kelly Estes.


Reference:; picture

Understanding Insulin Pumps

14 Aug

Basic function:pump1

~200-300 units of short acting insulin is in the insulin reservoir. This connects through the tubing to be infused via the cannula to the subcutaneous tissue of the patient.

Frequent BG monitoring is still required.  In fact more these patients check more frequently than patients without pumps d/t the possibility of pump problems.

-Patients have a basal rate they get continuously and then type in their desired bolus amount with meals.

-Patients need to move the needle site every 2-3 days (otherwise increased risk of infection and decrease in glycemic control)



  1. Local reactions to adhesive or insulin preparation
  2. Lipohypertrophy or lipoatrophy
  3. Cellulitis at the needle insertion site
  4. Pump failure. Any part of the device can fail- dead batteries, kinked/cracked tubing, depleted or broken reservoir…
  5. Air in tubing causing missed insulin
  6. Insulin leakage (at insertion site or infusion set connection site causing missed insulin


* Pumps frequently will not given any indication that there is a problem

* As the patient is getting only short-acting insulin, device failure can rapidly lead to DKA. 


Submitted by Heather Groth.



Academic Life in Emergency Medicine

Pickup, John. “Insulin-Pump Therapy for Type I Diabetes Mellitus” N Engl J Med 2012; 366:1616-1624

UCSF Website:

Treatment of Primary Spontaneous Pneumothoraces

12 Aug


Primary= No apparent lung disease   vs   Secondary= Underlying lung disease

 –Spontaneous= No precipitating event (no traumatic/iatrogenic cause)

-The definition of a “small” pneumothorax can vary. For the most part, this means the distance between the lung and chest wall on CXR is <3cm. 


3 Senarios:

  1. Stable patient, small pneumothorax

-Give supplemental O2

-Observe in the ED 3-6 hours

-Repeat x-ray. If no progression and patient is asymptomatic, discharge with follow up in 12 hrs- 2 days.     Otherwise admit.

  1. Stable patient, large pneumothorax

                -Small-bore catheter (<14F/pigtail)    OR    16-22F chest tube and admit

Note: Some physicians have discharged patients with a chest tube in place and a Heimlich valve with follow up in 1-2 days if the patients refuse hospitalization but are reliable. This makes me nervous.


                -Needle aspiration

-There is pretty good data (multiple recent articles) behind needle aspiration of pneumothoraces instead of placing a chest tube. This is the recommended treatment in England but this is not in the American College of Chest Physicians guidelines.  A 2008 Annals review shows no difference in rate of failure/recurrence but lower rates of hospitalization, length of stay, comfort.  HRD has a prior blog post about this.

-You can watch a video of this procedure on the NEJM site under the article: Pasquier et al. “Needle Aspiration of Primary Spontaneous Pneumothoraces” NEJM 2013; 368:e24

  1. Unstable patient

                -Large chest tube.  Could use 16F-22F chest tube but will likely use 24F-28F chest tube as PPV is likely required.


Submitted by Heather Groth.


Baumann et al. “Management of Spontaneous Pneumothorax: An American College of Chest Physicians Delphi           Consensus Statement” Chest. 2001;119(2):590-602.

Bintcliffe et al. “Spontaneous Pneumothorax” BMJ 2014; 348:g2928

Pasquier et al. “Needle Aspiration of Primary Spontaneous Pneumothoraces” NEJM 2013; 368:e24


Up to Date

Zehtabchi S, Rios C L. Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy? Annals of Emergency Medicine 2008; 51(1): 91-100.