Friday 3 June 2022

Nonoperative or Surgical Treatment of Acute Achilles’ Tendon Rupture

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.


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!



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?


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?



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.


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.



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]


Thursday 2 June 2022

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.



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]