August 2020 Regions RAP

1) REBEL Cast Ep85: HALT-IT Trial for GI Bleeds, Reviewed by PGY3 Ryan Johnsen, MD

I scored the above BEEM rating because:

Given the significant amount of data and studies recently regarding TXA, this podcast discusses why this trial in particular is important and how it could change practice of some EPs and references other TXA studies. In a practice environment where TXA is being utilized and studied for hemorrhage of all kinds this study and review in particular could definitely affect how we practice EM in regards to GI bleeding.

The educational pearls include:

• No change in mortality from bleeding at 5 days with TXA administration.

• Increase in VTE risk (0.4 versus 0.8%) in placebo and treatment group respectively. 

• Good example and discussion of how study design can help with generalizability.

• In general, discussion about the benefits and harm of giving medications is important.

• Discussion of possible under-measure of adverse outcomes regarding DVT in asymptomatic clots is a good reminder to think about conclusions we draw from studies.

I chose the above EBM rating because:

The majority of the podcast is discussion of EBM, and very minimal personal bias. A bit of fanboy praise for the study. Though it is a pretty well designed study, this only slightly detracts from the very EBM geared discussion. Would have liked to see a bit more discussion of the secondary outcomes. 

2) REBEL Blog - RAFF2 Trial: Electrical vs Pharmacologic Cardioversion for AFib, Reviewed by PGY2 Joe Malicki, MD

I scored the above BEEM rating because:

First prospective trial about chemical vs. electrical cardioversion. Might make some EPs more likely to try chemical cardioversion.  Might lead to greater discussions between providers and patients regarding different approaches available for cardioversion in the ED.  May shape preference based on risk factors.  Overall, it gives providers an increased number of options for ED management of a common problem.

The educational pearls include: 

Good overview of atrial fibrillation management in the ED and the available evidence for guidelines regarding management.  Good breakdown and discussion of evaluating journal articles, particularly inclusion/exclusion criteria, methodology, and determining power of a study.  

I chose the above EBM rating because: 

It's a breakdown of available evidence from a prospective randomized controlled trial and makes recommendations based on the data presented with no expert opinion or anecdotal stories.  Unbiased in its presentation of the pros and cons of each. Clearly presents all the primary results from the study.

3) ALIEM Trick of the Trade: Sodium Bicarb for Hyponatremia, Reviewed by PGY1 River Cook , MD

I scored the above BEEM rating because:

The information presented is relatively new. The 2014 European Society of Endocrinology Guidelines for Treatment of Hyponatremia gives vague recommendations for treatment of hyponatremia with moderately severe symptoms with 150 ml of 3% hypertonic saline OR equivalent. In addition, EmCrit published a similar but more thorough post in 2016 on the use of sodium bicarbonate for the treatment of acute symptomatic hyponatremia. Recommendations for this substitution have not yet made it into the most recent addition of Tintinalli’s. However, despite little primary research on this topic, the substitution of sodium bicarb for hypertonic saline for the treatment of critically ill hyponatremic patients has been considered by the EM community on the basis of expert consensus. We know that it is effective in raising a patient’s serum sodium levels. So despite the need for larger studies, the information presented in this post is logical and important for treatment of acute symptomatic hyponatremia in the ED and will likely change the practice of some EPs. 

The educational pearls include: 

• For acute symptomatic hyponatremia, slowly administer 1 ampule (50ml) of sodium bicarbonate 8.4% over 5-10 minutes.

• 1 ampule of sodium bicarbonate has 50 mEq of sodium, roughly equal to the 51.3 mEq of sodium in 100 mL of 3% hypertonic saline. 

• If the serum sodium has increased less than 4mEq/L, repeat another bolus of either 100 mL 3% hypertonic saline or 50 mL sodium bicarbonate.

• Closely follow sodium levels, a 4-6 mEq/L increase should alleviate symptoms without causing herniation.

• Don’t correct sodium more than 6 mEq/L in 6 hours or 8 mEq/L in 24 hours.

I chose the above EBM rating because: 

In general, there is poor consensus regarding an algorithmic approach to treatment of acute symptomatic hyponatremia. Many of the current recommendations are based largely on expert recommendations. Neither of the articles cited by this post address the substitution of sodium bicarb for hypertonic saline, and in general there seems to be little primary research to support this. The first two references from the post are from Lexidrug. The author of the post uses these to support the equivalency between 50 mL of sodium bicarbonate and 100 mL of 3% hypertonic saline. However, neither of the articles cited by the author of the post mention the use of sodium bicarb as an alternative for hypertonic normal saline or give evidence based support for how it should be used. Therefore the recommendation for this should be regarded as level C evidence: consensus of expert opinion.

4) St. Emlyn’s Blog, Haldol for HA in ED, Reviewed by PGY2 Zander Coomes, MD

I scored the above BEEM rating because:

This study suggests that Haldol is an effective treatment for benign headache and it would be useful to have another proven tool in the treatment arsenal for this. Study population and convenience sampling method does seem to indicate that the results could be widely applicable across EDs in the US. I didn't give it a 5 because the results would be more convincing and more likely to change practice if there were follow up studies replicating the findings as well as further studies comparing Haldol versus other accepted headache treatments.

The educational pearls include: 

• Haldol is more effective than placebo for treatment of acute benign headache. 

• 2.5mg IV Haldol did not appear to cause significant QT prolongation. 

I chose the above EBM rating because: 

It was double-blinded and placebo controlled. Exclusion criteria were reasonable and there didn't appear to be significant disparity between baseline characteristics in the two groups. 

*Ethics: The blog post author did make a valid criticism that the ethics underlying a comparison of an analgesic versus a placebo are shaky. Although all participants without adequate pain control at 60 minutes received Toradol, that does mean that there was a portion of patients in the control arm of the study who were allowed to suffer for an extra 60 minutes before receiving treatment. 

5) JAMA, Reopening Primary Schools During COVID-19, Reviewed by staff Jackie Hegarty, MD

I scored the above BEEM rating because:

This is a great discussion on the risks of keeping primary school-aged children out of school as well as the benefits, it highlights the many gaps we could have for these children if school is not opened in person, which is a really important topic that is relevant/current/important/interesting. As we have little power over school district decisions (outside of lobbying, participation, etc.), this is not practice changing for EM.

The educational pearls include: 

- risk of infection as well as risk of a wider achievement gap will disproportionately hit schools with lower SES attendees, which also could disproportionately affect students/families of color

- data suggest that COVID-19 infection rates are lowest in the primary school age group; this is also the group that will benefit most from socialization in schools as well as teacher supervision (especially if parents work outside the home or if students have unique needs)

I chose the above EBM rating because: 

It aggregated data on education, policy, and Covid-19 infection rates and made some suggestions on education policy for this school year in the US but as this is just one collection of ideas from the authors, it may not represent the BEST evidence, despite the research being fairly grounded in the (limited) current data.