November 26, 2020

Background: We have covered tranexamic acid (TXA) on this blog in several posts. Its use has been studied for everything that bleeds from abnormal uterine bleeding to GI hemorrhage and from multisystem trauma to intracranial hemorrhage. While over the past few years it has been touted as the wonderdrug for bleeding, newer research is beginning to challenge that thought (CRASH-3 trial, HALT-IT trial, etc.). The CRASH-2 trial showed that early administration of TXA (within 3 hours) to trauma patients improved all-cause mortality. However, obtaining rapid IV access in low resource, rural, or combat settings can be challenging. Only recently has research been conducted about intramuscular administration of TXA. Actually…we should really say that there has been a resurgence of interest in IM TXA. There were a couple studies published about its pharmacokinetics and pharmacodynamics in the 1970s and 80s, followed by radio silence on the subject.1,2 Curiosity about the drug has picked back up over the past decade as its cost dropped and access to TXA increased exponentially. In fact, finding alternative routes of TXA administration in postpartum hemorrhage is a WHO priority.3 Today, we will review a recent article that explored the pharmacokinetics of intramuscular TXA in bleeding trauma patients.

October 26, 2020

Orbital compartment syndrome (OCS) is a rare, vision-threatening diagnosis that requires rapid identification and immediate treatment for preservation of vision.1-4 As with other compartment syndromes, rapidly increasing and sustained high intraocular pressures (IOP) can result in devastating consequences. OCS causes retinal and optic nerve ischemia due to increased pressure on those structures. Due to the time-sensitive nature of this condition, the emergency physician (EP) plays a critical role in the diagnosis and management of OCS.5 The definitive therapy for this condition is lateral canthotomy and inferior cantholysis (LCIC).

October 24, 2020

Background: It almost seems that when it comes to the use of the antifibrinolytic agent tranexamic acid (TXA) in trauma, one argument has just been completed and another one comes up right behind it. Let’s take a step back. Most agree that the evidence clearly supports the role of the early in-hospital administration of TXA in major trauma (in conjunction with balanced blood product transfusion practices). Given the benefit of in-hospital use, and the evidence supporting most benefit with earlier use, it seemed to make intuitive sense to bring this out into the prehospital setting closer to the point-of-injury – many agencies have done just that. However, this particular area of use did not have any associated high-quality evidence. Led by a team out of the University of Pittsburgh (the same group that brought us the PAMPer trial in 2018), Guyette et al just released the Study of Tranexamic Acid During Air Medical and Ground Prehospital Transport (STAAMP) trial, published in JAMA Surgery.

October 15, 2020

Background: A resuscitative thoracotomy is a time-critical high acuity, low occurrence (HALO) procedure – as an emergency physician you need to know how to do it, but depending on your practice environment, it may be a once-in-a-career maneuver. All the more reason that, if you have to do it, you want to make sure your effort counts. In a prior post, I advised that if you’re going to be doing a thoracotomy as an EM doc, you should do a clamshell approach. This was based both on some evidence from the surgical literature as well as personal experience – I feel the clamshell gives you the exposure you really need if you are doing this rarely and the time difference compared to an anterolateral approach is negligible. A recent paper from Newberry et al. (published ahead of print in Annals of Emergency Medicine) addresses this very issue – from an EM perspective.

October 10, 2020

From Oct 6th – 8th, 2020, Haney Mallemat (@CriticalCareNow) and his team put on an absolutely amazing online critical care conference called ResusX Rewired.  ResusX is a conference designed by resuscitationists to provide clinicians with the most up to date skills and knowledge to help make a difference in your patients' lives.  Haney and his crew made a combination of short-format, high-yield lectures, and completely customizable small group sessions with procedural demos seem easy.  There were so many high-quality speakers and pearls that I learned from this conference that I wanted to archive them here in one post for reference and to share with our readers/followers.