EM Quick Hits 21 TXA in GI Bleed, Pediatric DKA, POCUS for Shoulder Dislocations, Lisfranc Injuries, Dexamethasone for COVID Pneumonia, Consultation Tips

Topics in this EM Quick Hits podcast Salim Rezaie on HALT-IT trial for TXA in unstable GI bleed (0:30) Sarah Reid on pediatric DKA update in fluid management and cerebral edema (8:32) Hans Rosenberg on POCUS in shoulder dislocations via CJEM (15:30) Arun Sayal on Lisfranc injury pearls and pitfalls (23:57) Justin Morgenstern on RECOVERY Trial for Dexamethasone in COVID pneumonia (32:48) Walter Himmel on getting what you need from consultants (38:41) 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 Expand to view reference list * 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. * Chauncey JM, Wieters JS. Tranexamic Acid. [Updated 2019 Dec 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532909/ 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