Intra-articular Hematoma Block Compared to Procedural Sedation for Closed Reduction of Ankle Fractures

I must have missed this paper originally published in 2018 in Foot and Ankle International… perhaps my subscription has lapsed.

Either way, I’m intrigued.

These researchers sought to compare intra-articular hematoma blocks (IAHB) vs. procedural sedation to aid in the reduction of displaced ankle fractures (fracture subluxations or dislocations).

This was a retrospective chart review without great methods… but what the hell.

They identified 221 patients that underwent IAHB vs. 114 who got PS over 11 years in their single ED in Minnesota. The primary outcome was rate of successful reduction. But they also looked at reduction attempts, time to successful reduction, length of stay in the ED and some adverse events. However, they did not report on adequacy of pain reduction or patient satisfaction.

A hematoma block was performed using 10 to 12ml of 1% lignocaine without adrenalin that was injected into the tibiotalar joint. Ultrasound guidance was not used (but in my opinion can be helpful).

Results?

Patients were not randomised and as such, there were some substantial differences between the groups. As you can discern from the numbers, they liked their hematoma blocks twice as much as procedural sedation. However, more patients with complete dislocations got sedation.

The rate of successful reduction was about the same in both groups. About 70% were reduced with one attempt and 25% more by the second. Overall, there was a 90% success rate.

As for safety, one patient in the procedural sedation group got intubated… yikes!

This study has many limitations and is not high-quality evidence. Nevertheless, it is yet another paper demonstrating the utility and uptake of hematoma blocks for displaced ankle fractures. Even the New England Journal of Medicine has jumped on board with these blocks for ankles.

The beauty of a haematoma block is no need for a resuscitation room and lots of resources. It can quickly be performed by a single provider. In addition, a further reduction attempts can easily take place as the block will last for a while.

 

Covering:

MacCormick LM, Baynard T, Williams B, et al. Intra-articular Hematoma Block Compared to Procedural Sedation for Closed Reduction of Ankle Fractures. Foot & Ankle Int. 2018;39:1162-8. [Link to article]

Have you heard about the HEAR score?

We’ve all heart about the HEART score for risk stratification of patients with chest pain in the ED. Take away the troponin and you’ve got the HEAR score!

Yes, the HEAR score tries to identify patients at very low risk of ACS that don’t even need a troponin. The thought is this will decrease resource utilisation and improve patient flow.

The original “derivation” of the HEAR score was in 2020 by Smith LM, et al. These subsequent researchers from Calgary (go stampede!) sought to externally validate this strategy.

They conducted a secondary analysis of a prospective cohort study of patients with chest pain that got a troponin to exclude MI in their single ED.

They enrolled 1150 patients. Of those, 8% had index MI and 11% with MACE by 30 days. HEAR score <1 identified 202 (17.6%) of patients at very low risk of adverse events with a 99% sensitivity (95% CI 95.6-99.9%). Only one patient out of 202 was missed. 

As with most screening tools that are highly sensitive, it often means they are terribly non-specific. The HEAR score is no exception. As such, it should only be used as a one-way decision instrument. 

The authors of this study appropriately conclude that this very low risk cohort of HEAR <1 is unlikely to benefit from troponin testing and will lead to significant resource savings.

This is not exactly ground-breaking. A young patient with a low-risk story, a normal ECG, and no risk factors is very unlikely to have a problem.

Sure, it’s probably fine to skip the troponin. I think a lot of us have been doing this over the years via gestalt. But at least this study quantifies the risk and provides support for those clinicians who want to avoid troponin testing in very low risk patients.

Perhaps the greatest use of HEAR score is to allow you sleep at night… perhaps a bit of medico-legal defense when you document the score and send that low risk patient home without blood tests.

Covering:

O'Rielly CM, Andruchow JE, McRae AD. External validation of a low HEAR score to identify emergency department patients at very low risk of major adverse cardiac events without troponin testing. CJEM. 2022;24:68-74. [link to article]

Not so FAST? How a study on lung ultrasound got it wrong…

This study out of UC San Diego set out to determine the accuracy of lung ultrasound vs. supine portable chest x-ray for the detection of traumatic pneumothorax.

Yes, I also thought this research questions had been suitably answered.

In 2020, a CochraneReview included 13 prospective paired comparative accuracy studies and concluded that ultrasound was about 90% sensitive vs. 50% for a chest x-ray. Both are highly specific.

Regardless of the consistent evidence, let’s consider face validity. Anyone who is competent in lung ultrasound knows that ultrasound is much better at finding pneumothorax. There is no planet in the solar system where a supine portable chest x-ray is going to be more sensitive than ultrasound.

But this study concludes the opposite… chest x-ray was better!

Huh? How could this be?

This was a retrospective registry review. Retrospective data is often poor quality. Registry data is even worse. Garbage in... garbage out. Ironically, this study would never have been included in the Cochrane review.

What is the probability that this single study with worse quality evidence is correct and all the consistent higher quality studies are wrong?

Yes, the probability is close to zero.

But where did this study really go wrong?

I think the authors answered the question themselves, “… in a non-study environment, such as ours, the pleural views were not universally performed with the same rigor as in a prospective study designed specifically to detect pneumothorax.”

I think this is probably the answer.

There are many other problems with this study, but I’m limited by word count. So briefly, the  methods for assessment of diagnostic accuracy of a test were performed backwards. They used the wrong probes for lung ultrasound. They used the wrong clinicians to perform and interpret the ultrasound. That was only to name a few...

As expected, there were many concerned letters to the editor. Even one from Dr Giovanni Volpicelli who is the world leader and pioneer of lung ultrasound. But the authors stuck with the strategy of “never admit you are wrong” and doubled-down in their conclusions.

A bit sad really...

Covering:

Santorelli JE, Chau H, Godat L, et al. Not so FAST- Chest ultrasound underdiagnoses traumatic pneumothorax. J Trauma Acute Care Surg.2022;92:44-8.[link to article]

 

 

Nonoperative or Surgical Treatment of Acute Achilles’ Tendon Rupture

Why do emergency clinicians need to know about this paper? Afterall, we will not be making treatment decisions about to operate or not…

Two reasons.

First, we need to know the “next step” and be able to inform our patients of what the treatment options are likely to be.

Second, this was an RCT published in the New England Journal of Medicine. This is the highest impact medical journal on the planet. Papers published here set the guidelines about how we practice medicine.

These authors from Norway randomized 554 patients with acute Achilles tendon rupture to one of three treatment arms: conservative, open repair, or minimally invasive surgery.

The primary outcome was the change in the Achilles tendon Total Rupture Score at 12 months. They also looked at incidence of tendon re-rupture.

They standardized the aftercare & rehabilitation in all groups. They required casts and weight bearing as tolerated using an ankle-food orthosis with heel wedges for 6-8 weeks. They did not report on earlier return to functional status between groups.

Results?

At 12 months, there was no difference in the rupture score. As expected, there were more re-ruptures in the conservative vs. surgical arms (6.2% vs. 0.6%). And there were more nerve injuries in the surgical groups.

All studies have limitations and this one is no exception. An RCT is only as good as the measuring tool of its primary outcome. I’m not sure what to make of the rupture score and self-reporting may have led to bias.

What are we to make of this?

In the long term, there probably is no big difference between conservative vs. surgical management.  

Nevertheless, there is probably enough wiggle room with the interpretation of this study for orthopedists to continue doing whatever they like. Conservative seems fine in the long run, but there are higher rates of re-rupture. Surgical treatment is about the same but comes with the potential for nerve injury and infection.

Seems like we are right back where we started!

 

Covering:

Myhrvold S, Brouwer E, Andresen T, et al. Nonoperative or Surgical Treatment of Acute Achilles’ Tendon Rupture. N Engl J Med 2022;386:1409-20. [link to article]

Risk of delayed intracranial hemorrhage after an initial negative CT in patients on DOACs with mild traumatic brain injury

To identify delayed hemorrhage, some clinicians will repeat a head CT in patients on NOAC’s with mild traumatic brian injury (TBI) after the initial head CT is negative.

How common is delayed hemorrhage with DOAC’s?

Hmmm….

These authors from Italy performed a retrospective multicentre observational study. They found 1426 patients taking NOAC’s who were evaluated in the ED for mild TBI (GCS 14-15). Of these 916 (68%) underwent 24 hours of observation and a repeat CT after the initial one was negative.

In the end, only 14 (1.5%) patients had delayed hemorrhage found on repeat CT. None of these patients had neurosurgery or died (but I presume they had their DOAC’s withheld).

Another interesting aspect… no delayed hemorrhages were found in patients who had the initial head CT greater than 8 hours after injury.

The findings of this study are similar with others looking at warfarin. Consistency in the literature is comforting.

So, we have a pretty simple message. Routine delayed head CT is not necessary. But 1.5% is not zero… so we still need to be a little careful.

And another question… is it DOAC’s or NOAC’s?

 

Covering

Turcato G, Cipriano A, Zaboli A, et al. Risk of delayed intracranial haemorrhage after an initial negative CT in patients on DOACs with mild traumatic brain injury. Am J Emerg Med. 2022;53:185-189. [link to article]

Single dose phenobarbital for the outpatient treatment of alcohol withdrawal... interesting

Phenobarbital has some ideal properties for the treatment of alcohol withdrawal. In particular, it has a long half life (about 100 hours) allowing for a single dose without the requirement for prescriptions.

However, there are some genuine safety concerns especially if they are mixed with other drugs or alcohol. And there is little high-quality evidence to support it’s use in patients being sent home from the ED.

This is a retrospective chart review of patients discharged from a single ED in California over a three-year period with a discharge diagnosis of alcohol withdrawal. Patients were stratified into three categories; those who got benzo’s, benzo’s plus phenobarbital or just phenobarbital alone.

The primary outcome was return ED encounter within 3 days of the index visit. (Yes, this is an odd primary outcome, but it was chosen for pragmatic purposes as below...)

470 patients were included. 235 got benzo’s, 133 got phenobarbital, and 102 got the combination special.

Results?

Treatment with phenobarbital (alone or in combination) was associated with a decreased odds ratio of a return ED visit within 3 days. (AOR 0.45 95% CI 0.23, 0.88  and AOR 0.33 95% CI 0.15,0.74 respectively).

The cynic in me wonders if this is because phenobarb patients died… (But this was probably not the case as the author were eventually able to account for most patients)

It is interesting to note that patients who received phenobarbital got much more GABA agonist medication than those that simply got benzodiazepines. Four times as much was given if you adjust for drug equivalence. Perhaps this is why they were less likely to return?

Unfortunately, this paper does not address the big question of safety. It would take a much larger study with more robust methodology (that avoids loss to follow-up) to answer this. And such a study would be very difficult to undertake as this cohort of patients are unreliable and not likely to be compliant with study protocols etc.

What’s the take home message?

Phenobarbital for the outpatient treatment of alcohol withdrawal is tempting, but there is arguably not enough evidence to support its routine use.

 

Covering:

Lebin A, Mudan A, Murphy CE, et al. Return Encounters in Emergency Department Patients Treated with Phenobarbital Versus Benzodiazepines for Alcohol Withdrawal. J Med Tox. 2022;18:4-10.  [link to full text of article]

 

Risk for recurrent VTE in patients with subsegmental PE managed without anticoagulation- A prospective study

Modern imaging technologies have put a virtual microscope into the human body and can find smaller and less significant disease. Our treatment of these conditions often falls under old recommendations meant for more substantial illness. Can treatment of mild disease result in more harm than benefit?

This question is particularly true when it comes to subsegmental PE. Does it require anticoagulation?

These researchers found 266 patients with low-risk subsegmental PE and referred them to a thrombosis clinic for management. The patients underwent lower extremity ultrasound to exclude DVT at the time of diagnosis and one week later. Patients without DVT had anticoagulation withheld and they were followed up for 90 days looking for evidence of recurrent VTE.

In the end, 8  (3% 95% CI, 1.6%-6.1%) out of the 266 patients developed VTE. The authors report higher rates in some subgroups but this analysis is not really justified given the low number of recurrences. 

There are some important limitations to remember. These patients were low risk. They did not have cancer nor prior VTE. They all had repeated leg ultrasound to exclude DVT. Long term rates beyond 90 days were not assessed. In addition, false positive CTPA's may have skewed the results towards lower rates of recurrent disease. 

What are we to conclude?

Recurrent VTE in low-risk patients with subsegmental PE is pretty low. This may be a good time for shared decision making.

 

Covering:

Le Gal G, Kovacs M, Bertoletti L, et al. Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation. Ann Intern Med. 2022;175:29-35 [link to article]