Quick Hits

Here are quick summaries of interesting papers to inform your practice

Jan 2025

Early Restrictive vs Liberal Oxygen for Trauma Patients (TRAUMOX2)

JAMA. 2025. https://jamanetwork.com/journals/jama/article-abstract/2827980

• This randomised controlled trial compared a restrictive oxygen strategy (target SpO₂ 94%) with a liberal strategy (12-15 L/min or FiO₂ 0.6-1.0) in trauma patients for the first 8 hours of care. The primary outcome—death and/or major respiratory complications within 30 days—occurred at similar rates in both groups (16.1% vs. 16.7%), with no statistically significant difference.

• While the overall findings do not support a restrictive oxygen strategy to reduce mortality or respiratory complications, atelectasis was less common in the restrictive group (27.6% vs. 34.7%).
• This suggests that while liberal oxygen therapy does not increase major adverse outcomes, avoiding excessive oxygen exposure may still offer some benefits. The study highlights the importance of individualized oxygen management in trauma patients rather than a one-size-fits-all approach.

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Oct 2024

Nebulised tranexamic acid for post-tonsillectomy haemorrhage 

Int J Pediatr Otorhinolaryngol. 2023. https://pubmed.ncbi.nlm.nih.gov/37423163

• Post-tonsillectomy haemorrhage is an uncommon but potentially life-threatening condition, and management frequently requires return to OT for definitive haemostasis 
• Tranexamic acid may be an option for these patients, though the evidence basis is poor and no prospective data exists 
• This is a retrospective analysis from a single hospital network in the USA which identified 83 cases of post-tonsillectomy haemorrhage who received nebulised TXA, and compared them with 249 cases in an age- and gender-matched control group  
• Both adult and paediatric cases were included, with a mean age of 20yrs 
• Those who received TXA had lower rates of operative intervention (36.1% vs 60.2%, p<0.0001) and lower rates of repeat bleeding (4.9% vs 14.2%, p=0.02) 
• No adverse effects were reported, though the study was not powered to detect this 
• Limitations include the retrospective study design; the data comes from a single hospital network limiting generalisability; and we don’t know why some patients received nebulised and some did not 

Take away: Nebulised TXA was associated with reduced rates of operative intervention in this single-institution retrospective study 

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Oct 2024

Relationship of b-hCG level to ectopic pregnancy and size 

West J Emerg Med. 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC11112661

• Ectopic pregnancy occurs in approximately 2% of pregnancies and is a leading cause of morbidity and mortality in early pregnancy 
• Risk factors include prior ectopic pregnancy, history of PID or pelvic surgery, assisted reproductive technology for conception, age > 35 years, and IUDs 
• The Discriminatory Zone is the b-hCG level at which an intrauterine pregnancy should be visible on ultrasound and is typically 1,500 mIU/mL for transvaginal ultrasound and 4000 mIU/mL for transabdominal ultrasound. The absence of a visualised intrauterine pregnancy when b-hCG is above these levels should be assumed to be an ectopic pregnancy.   
• This was a single-centre, retrospective study of patients with confirmed ectopic pregnancy looking to determine whether b-hCG levels correlate with the size of an ectopic pregnancy 
• Among 519 cases, while the mean b-hCG level at presentation was 7609 mIU/mL, the median was only 1209 mIU/mL; this means that 50.4% of ectopic pregnancies presented with b-hCG levels below the TVUS discriminatory zone 
• Additionally, 44% of those with ruptured ectopic pregnancy presented with b-hCG levels less than 1,500 mIU/mL 

Take away: In this study, more than half of patients with ectopic pregnancy had b-hCG levels below the transvaginal ultrasound discriminatory zone of 1,500mIU/mL. It is an important reminder that all patients with a positive pregnancy test and abdominal pain or vaginal bleeding should have an ultrasound to assess for ectopic pregnancy regardless of b-hCG level.  

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Sept 2024

Topical Diclofenac vs Oral Ibuprofen vs Combination Topical Diclofenac plus Ibuprofen for Back Pain 

Ann Emerg Med. 2024. https://pubmed.ncbi.nlm.nih.gov/38441515/

• 80% of adults will develop low back pain during their lifetime 
• Studies comparing NSAIDs vs placebo support the use of NSAIDs as first-line treatment of low back pain without sciatica, while the addition of other pharmacologic therapies, including opiates, have not been shown to improve outcomes  
• This was a 3-arm randomised, double-blind, placebo-controlled trial of adult patients presenting with low back pain comparing (1) oral ibuprofen and diclofenac gel, (2) oral ibuprofen and placebo gel, and (3) oral placebo and diclofenac gel 
• Outcomes were assessed by a questionnaire (Roland Morris Disability Questionnaire score) at 2 and 7 days after the ED visit 
• Ibuprofen-alone performed best (mean 10.1 point reduction in RMDQ), compared with ibuprofen-diclofenac gel (8.7 point reduction) and diclofenac-alone (6.4 point reduction); results were similar at both 2 and 7 days 
• There was no difference in adverse effects across groups 
• This study is limited in its single-centre design and that only patients with atraumatic, non-radicular were enrolled 

Take away: Oral ibuprofen is more efficacious than combination therapy with diclofenac gel or diclofenac gel alone for acute low back pain 

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Sept 2024

As loud as a construction site: Noise levels in the ED

Australas Emerg Care. 2024. https://pubmed.ncbi.nlm.nih.gov/37532590/ 

• The WHO recommends that noise levels in hospitals should not exceed 35dB during the day
• For every 10-decibel increase in noise levels, sound is perceived as twice as loud; this impacts on stress levels, patient and provider satisfaction, communication, performance and well-being 
• For reference, at 35 dB light rain can be heard, 70dB is a television on loud volume and 100dB is using an electric drill
• This was a single site study conducted in St Vincent’s ED in Sydney where noise levels were measured at six locations in the ED (ambulance bay, 2 acute bed spaces, 2 short stay bed spaces, and the waiting room) over a 24 hour period 
• Results: the average noise level was 56.5dB, and was highest in the acute treatment areas and waiting room (both ~60dB). Peak noise levels were highest in the ambulance bay (102dB) and waiting room (99.68dB)
• Noise levels were highest in the afternoon and early evening (between 2-7pm in most locations)
• The limitations of this study include it was conducted at a single site on a single day, though the results on face value are unsurprising

Take away:  The ED is a loud place, and taking time to escape that noise during your shift is important for your wellbeing

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July 2024

End-tidal capnometry during emergency department procedural sedation and analgesia: a randomized, controlled study

World J Emerg Med https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4786492/

• A prospective, randomised, non-blinded trial of End-Tidal CO2 monitoring among patients undergoing procedural sedation in a single ED in Canada
• Patients were randomised either to standard care—including continuous oxygen therapy, cardiac and O2 monitoring, and blood pressure monitoring every 5 minutes—or to standard care plus ETC monitoring
• Almost all were ASA I or II; propofol was used in 95% of cases; and the most common reasons for sedation were orthopaedic procedures (71%)
• The primary outcome was the need for airway intervention, including a variety of events such as airway repositioning or intubation
• A difference in the primary outcome was observed but was driven solely by the rate of airway repositioning, which occurred in 18.4% of the control group and 26.2% of the ETC group. The rate of hypoxia was rare and comparable between groups (1.4% in the control group vs 1.9% in the intervention group)
• There were higher rates of hypotension in the ETC group (3.3% vs 1.4%)
• Otherwise, there was no strong evidence of harm associated with ETC monitoring

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July 2024

Serious Bleeding in Patients With Atrial Fibrillation Using Diltiazem With Apixaban or Rivaroxaban

JAMA https://jamanetwork.com/journals/jama/article-abstract/2817546

• Large retrospective cohort study of 204,155 patients who received a Factor Xa inhibitor (apixaban or rivaroxaban) with either metoprolol (150,880) or diltazem for AF management
• The theoretical basis is that both Factor Xa inhibitors are metabolised primarily by the CYP450 system, and diltiazem is a strong inhibitor of that system. Therefore coadministration may raise the levels or delay the elimination of Factor Xa inhibitors and result in more bleeding events
• Diltiazem was associated with a significantly higher rate of bleeding-related hospitalization and death with recent evidence of bleeding (60 per 1,000 PYs vs 50 per 1,000 PYs)
• Risk of bleeding was highest with diltiazem doses > 120mg/day

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June 2024

A Patient-Level Meta-Analysis of Intensive Glucose Control in Critically Ill Adults

NEJM https://evidence.nejm.org/doi/10.1056/EVIDoa2400082

• 20 trials with 14171 patients analysed with data available on in-hospital mortality
• Of these 1930 (27.3%) and 1891 (26.8%) individuals assigned to intensive and conventional control, respectively, died (risk ratio, 1.02; 95% confidence interval [CI], 0.96 to 1.07; P=0.52; moderate certainty)
• No subgroups where intensive glucose control was beneficial were identified
• Intensive glucose control did significantly increase the risk of severe hypoglycaemia (risk ratio, 3.38; 95% CI, 2.99 to 3.83; P<0.0001)

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June 2024

Anticoagulation Versus Antiplatelets in Spontaneous Cervical Artery Dissection: A Systematic Review and Meta-Analysis

Stroke https://www.ahajournals.org/doi/abs/10.1161/STROKEAHA.124.047310

• 11 studies (including 2 RCTs, 9 observational) with 5039 patients
• 30% treated with anticoagulation and 70% antiplatelets
• Anticoagulation was associated with lower risk of ischaemic stroke 0.63 [95% CI, 0.43 to 0.94]; P=0.02 but higher major bleeding risk RR 2.25 [95% CI, 1.07 to 4.72]; P=0.03
• Suggests that an individualised patient approach is needed along

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