Thursday 2 September 2021

Utilization of Prophylactic Antibiotics After Nasal Packing for Epistaxis

When I trained, I was told I needed to prescribe prophylactic antibiotics after I placed nasal packing. It was thought this reduced the potential for toxic shock syndrome or sinusitis. Is this recommendation evidence based?


This single ED in Manhattan retrospectively reviewed 275 cases of anterior nasal packing and determined the rates of antibiotics given and evidence of benefit.

Most patients that got non-absorbable packs (Merocel, RapidRhino) got antibiotics. Those with absorbable packs (Surgicel, Gelfoam) did not.  Although this aspect of the study is robust, it is hardly important… I just don’t care.

I want to know how many patients got benefit from antibiotics.

Out of the 275 cases, there was one episode of sinusitis in each group. Looks like it doesn’t matter?

But there is a fatal flaw.

They didn’t really look for outcomes.

Only 40% of the patients had documented follow up! In addition, this would have been poor quality retrospective data.

If you don’t look for something, you will not find it. Interesting that this study got published.

Probably the best thing to come out of this “study” is their review of the literature.  In a nutshell, there is moderate evidence to show that antibiotics are not needed after nasal packing.

Good enough for me.



Hu L, Gordon SA, Swaminathan A, et al. Utilization of Prophylactic Antibiotics after Nasal Packing for Epistaxis. J Emerg Med. 2021;60:140-149. [link to article]


Elevated blood pressures are common in the ED, but are they important?


You can stop reading now if you want…

This was an electronic medical record review of 30,278 adults treated and released from the University of Alberta ED in 2016.

They identified those that had elevated BP’s at triage and cross-referenced them with multiple data bases to see if they developed cardiovascular events by 2 years(Databases included hospital EDIS, Pyxis, Pharmaceutical Information Network, administrative data holdings, National Ambulatory Care Reporting systems, outpatient billing claims etc.)

Of the 30,278 that were treated and released, about half had elevated BP’s at triage. 70% had no prior history of hypertension and eventually about a quarter of those subsequently received a diagnosis of chronic hypertension.

After adjusting for confounders, high BP at triage was not associated with adverse cardiovascular outcomes within 2 years of the ED visit.

I’m willing to believe this is true… but there are many methodologic limitations.

Don’t be mesmerized by the huge number of patients… this does not guarantee quality. Nor do large numbers reduce bias.

I’m concerned about a potential “garbage in & garbage out” phenomenon. The veracity of this study is predicated on the quality of the information in many large databases. (For example, a large database in the USA shows the rate of virgin births at 0.5%)

There were a lot of other issues; retrospective design, residual confounding, use of triage BP’s, lack of follow up, possible non-differential misclassification, etc.

So, are elevated BP’s in the ED important?

I still say no, but not necessarily due to this study. Heck, at least hypertension is better than hypotension. 



McAlister FA, Youngson E, Rowe B. Elevated Blood Pressures are Common in the Emergency Department but Are they Important? A Retrospective Cohrt Study of 30,278 Adults. Ann Emerg Med. 2021;77:425-432. [link to article]


Accuracy of OMI ECG findings vs traditional STEMI criteria for diagnosis of acute coronary occlusion MI... the OMI manifesto?

I’ve heard of many manifestos.

There’s the Communist Manifesto, the US Declaration of Independence, the Unabomber Manifesto and now we’ve got the OMI Manifesto.

(Ok… it’s not a freakin manifesto. But good to know about anyway.)

The charge is being led by the master sensei Dr Stephen Smith (of ECG blog fame) and his student Dr Pendell Meyers. They’ve published quite a few articles looking at additional ECG criteria to identify patients that may benefit from emergent reperfusion of an acute coronary occlusion.

They hypothesized that blinded interpretation of their new OMI criteria would be more accurate than the traditional STEMI criteria.

OMI criteria?

OMI (occlusion MI) is basically STEMI criteria plus some STEMI equivalents including:

Subtle STE not meeting criteria, hyperacute T waves, reciprocal ST depression and/or negative hyperacute T waves, STD worrisome for posterior MI, suspected new Q waves, terminal QRS distortion, positive Sgarbossa criteria, any inferior STE with SZTD or T wave inversion in aVL

Without going into any details of the study, they thought the OMI criteria were great. Sensitivity went up from about 40% to 85%. Specificity remained around 90%.

Unfortunately, the manuscript as published in the open access journal IJC Heart & Vasculature is quite difficult to follow. It is poorly presented and would have benefited from substantial revision. Either way, you don’t need to read it… the message is rather simple and has a degree of face validity (albeit with many limitations).

What are we to conclude?

If you are an expert at ECG interpretation, you can probably identify more patients with acute coronary occlusion MI by using OMI criteria (which most of us are already doing to some extent). Whether additional patients genuinely benefit from an aggressive intervention is officially not known.



Meyers P, Bracey A, Lee D, et al. Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. IJC Heart & Vasc. 2021:33; 100767 [link to full text article]