Journal Feed Weekly Wrap-Up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.

#1: Managing Hyperkalemia with Insulin/Glucose

Spoon Feed
Use of insulin/glucose to treat hyperkalemia works, but hypoglycemia is a common side effect. Here are some pearls to give this treatment more safely.

Why does this matter?
Hyperkalemia is a life-threatening condition that requires prompt management in the ED. One of the most common treatment options is the administration of insulin and glucose to help shift potassium into the cell temporarily. Usually this is ordered as 10 units of regular insulin IV and 1 ampule of D50. This article explores some common myths and debunks them.

“Pour some sugar on me!”

  1. Consider decreasing insulin dose (5 units or 0.1 U/kg) or increasing dextrose load (50 g) in patients with one or more of the following risk factors:

    • Pretreatment blood glucose (BG) < 150 mg/dL

    • Acute kidney injury/chronic kidney disease

    • No history of diabetes mellitus

    • Weight < 60 kg

    • Female sex.

  2. An insulin dose of 5 units (or 0.1 U/kg) has similar efficacy as 10 units and may be safer. The exception to this was seen in a subset of patients with initial potassium levels > 6 mmol/L, where the 10 U group was superior to the 5 U group (K decreased by 1.08 mmol/L vs 0.83 mmol/L, respectively, p=0.018).

  3. A dose of 25 g of dextrose (1 amp of D50) may be inadequate for hypoglycemia prevention, especially in patients with kidney disease and decreased clearance of insulin. Consider a higher dose of dextrose (2 amps, 50 g) or giving it with the insulin as a 4h infusion to decrease the incidence of hypoglycemia.

  4. You should monitor blood glucose levels hourly for 4-6h to match the 4-6h duration of regular insulin when given IV. D50 IV boluses only last around one hour.

Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician. J Emerg Med. 2019 May 11. pii: S0736-4679(19)30250-1. doi: 10.1016/j.jemermed.2019.03.043. [Epub ahead of print]

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For more, see this emDocs post.

#2: TXA vs Packing for Epistaxis

Spoon Feed
Intranasal tranexamic acid (TXA) with nasal compression was as effective as Merocel nasal packing for bleeding cessation in anterior epistaxis, had a lower rebleeding rate, and was better tolerated than nasal packing.

Why does this matter?
TXA is an antifibrinolytic agent used to improve hemostasis and decrease bleeding. Several studies have demonstrated the utility of TXA for management of anterior epistaxis, usually by soaking nasal packing materials in TXA before insertion. However, since nasal packing has several disadvantages, could topical intranasal TXA be used in lieu of nasal packing for anterior epistaxis management?

Can TXA help stop the bleeding? Only the nose knows…
This was a single center, 135-patient randomized controlled trial that compared the effectiveness of external nasal compression after application of topical intranasal TXA, external nasal compression after application of topical intranasal saline (placebo-controlled group), and Merocel anterior nasal packing for stopping spontaneous anterior epistaxis with a secondary outcome of rebleeding within 24 hours. TXA was administered as atomized 500 mg diluted in 5 mL normal saline solution sprayed into both nostrils.

The success rate for stopping anterior epistaxis within 15 minutes was 91.1% (41 of 45 patients) in the nasal compression with TXA group, 93.3% (42 of 45 patients) in the nasal packing group, and 71.1% (32 of 45 patients) in the nasal compression with normal saline group. There was no statistically significant difference between the tranexamic acid and nasal packing groups.

Rebleeding within 24 hours occurred in 13.3% of patients in the TXA group, 26.7% in the nasal packing group, and 40% in the compression with saline solution group. Furthermore, 7 out of 45 patients in the nasal packing group had severe pain during nasal packing and requested the procedure be terminated. None of the patients in the TXA group complained of severe pain.

This study had several limitations and importantly only one nasal packing material (Merocel) was used for comparison. However, this study suggests that TXA application with nasal compression was as good as standard nasal packing at stopping bleeding, better at preventing rebleeding within 24 hours, and may be more comfortable and cost-effective than ready-made commercial anterior nasal packing.

Evaluating Effectiveness of Nasal Compression With Tranexamic Acid Compared With Simple Nasal Compression and Merocel Packing: A Randomized Controlled Trial. Ann Emerg Med. 2019 May 9. pii: S0196-0644(19)30249-5. doi: 10.1016/j.annemergmed.2019.03.030. [Epub ahead of print]

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#3: Hypothermia in Infants and Serious Bacterial Infection

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Infants ≤60 days of life with hypothermia (< 36 °C) had serious bacterial infection (SBI) 2.8% of the time. There is a suggestion that those 15-28 days with high absolute neutrophil count (ANC) and thrombocytopenia had even greater odds of SBI.

Why does this matter?
We know fever is often bad news in young infants. We know hypothermia is as well. But sometimes infants are exposed too long after a bath and have a transient drop in temperature. Are there other clinical factors that would raise our suspicion for SBI in hypothermic infants ≤60 days?

Hypothermia isn’t cool
This was a retrospective review at a single center over 12 years that identified 360 hypothermic (< 36 °C) infants ≤60 days, of which 2.8% (10/360) had SBI. Using multiple logistic regression, they found three variables that were statistically significant (though a little iffy).

  • Infants 15-28 days had greater odds of SBI than 0-14 days. aOR 7.60 (95%CI, 1.81-31.86)

  • “Higher” ANC had greater odds of SBI. aOR 1.25 (95%CI, 1.04-1.50). It was not clear in the full text – “higher” ANC than what? The median ANC in the SBI patients was 2.96 vs. 2.90 in the non-SBI infants; average in the SBI group was 5.19. But there were 7/10 with ANCs 1.6-4.7, which is very reassuring. So, I don’t know how practical this is. We will learn more about ANC cutoffs tomorrow.

  • Finally, “lower” platelet count also increased odds of SBI. aOR 0.99 (95%CI, 0.99-1.00). Again, I’m not sure – “lower” platelet count than what? Median was 213 in those with SBI; 298 without SBI.

What’s the take home here? Infants ≤60 days with hypothermia had SBI nearly 3% of the time. Although this is a lower rate than in febrile infants, I think we probably need to treat them similarly. If they are over 2 weeks, ANC is really high, or platelet count really low, that’s even more concerning.

Another Spoonful
Although the podcast won’t drop until next Sunday July 7, Rob Orman has a pretty comprehensive ERcast episode on infant fever you won’t want to miss. This link gets you a discount and JF an Amazon gift card. Nice!

Factors associated with serious bacterial infections in infants ≤60 days with hypothermia in the emergency department. Am J Emerg Med. 2019 Jun;37(6):1139-1143. doi: 10.1016/j.ajem.2019.04.015. Epub 2019 Apr 11.

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