HINTS Exam for Vertigo: Caveat Emptor (Calgary EM Journal Club)

 

Hey all,

The March edition of Journal Club reviewed the HINTS exam for acute vestibular syndrome.  Much has been written/podcasted in the FOAM world about this controversial article, with the HINTS exam being touted as a godsend by some, while others recommend cautious use.  In addition to the usual critical appraisal of the article, journal club leaders Anthony Seto, Vanessa Potok and Andrew McRae also had us review the recommendations of 4 FOAM resources based on the HINTS article.  The FOAM recommendations were highly variable, to say the least. This post should be enlightening to many of us, and highlights the importance of actually reading articles yourself and critically appraising them, rather than implicitly taking advice based on the recommendations of a blog.

Article: HINTS to Diagnose Stroke in the Acute Vestibular Syndrome: Three-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging 

Jorge C. Kattah, Arun V. Talkad, David Z. Wang, Yu-Hsiang Hsieh, and David E. Newman-Toker. Stroke. 2009;40:3504-3510.

HINTSVertigo

Image courtesy emjclub.com

Before getting into the nitty gritty, these are a few major reasons we should be cautious with use of the HINTS exam.

1)The definition of the acute vestibular syndrome (AVS) is continuous vertigo for > 24 hours. Ie: Not intermittent vertigo.  There is a very small subset of patients who actually have AVS, and in general we would likely have a higher index of suspicion for ominous causes in patients with continuous vertigo.  At journal club we agreed that many of us were applying this to patients with intermittent vertigo.  These patients were not included in the study.

2)This was done by a single neuro-ophthamologist using specialized equipment (Frenzl goggles) on a small number of patients (n=101) who were referred to a tertiary care stroke center from 25 community centres.  Most of us are not likely using Frenzl goggles in the ED, nor have we had specific training in this exam.  The study needs to be validated by EPs performing the exam in a typical group of patients presenting primarily to the ED.

caveat-emptor

 

Image courtesy takenotenigeria.com

*May 20 Edit: Comments by Andrew McRae*

One novel aspect of this journal club was to examine the treatment of the HINTS exam by various FOAM resources. FOAM resources are rapidly becoming the most commonly used source of new medical information by both trainees and experienced providers. We examined the discussion of the HINTS exam on several emergency medicine blogs, chosen primarily because of their wide readership.

The FOAM resources all discussed key aspects of the inclusion criteria of the study, namely that patients all had acute vestibular syndrome with persistent vertigo, and emphasized that the HINTS exam should not be used in patients with intermittent vertigo.

However, JC participants noted wide variability in conclusions on the clinical utility of the HINTS exam for ED patients. FOAM resources varied from urging caution in using HINTS given the lack of data on inter-rater reliability of the exam and uncertain generalizability to emergency physicians without specialized equipment, to enthusiastic recommendation of incorporation of HINTS into practice with links to how-to videos and links to slow-motion camera apps that have not been rigorously evaluated.

FOAM resources included both thoughtful critical appraisal of the internal validity and generalizability of the HINTS exam studies (eg. EMNerd) as well as more practical “how-to” material. One challenge JC participants identified was that the how-to resources also referred to the supporting literature (some even describing HINTS as being supported by “VERY STRONG” evidence). This can lead to the impression that FOAM authors based their endorsement on rigorous critical appraisal (ie. producing a “how-to” could imply that the evidence supporting an intervention is solid), and participants had a difficult time differentiating “how-to” FOAM from rigorous critical appraisal.

The remainder of the JC discussion focused on how physicians can be savvy users of FOAM resources. Suggestions included examining several resources and comparing/contrasting their conclusions, as well referring back to and critically appraising the primary source literature. Participants agreed that FOAM resources can be excellent tools for identifying important new EM literature, but that it is ultimately the practitioner’s responsibility to appraise the evidence for him/herself prior to incorporating new evidence into practice. Participants agreed that it would be helpful for FOAM providers to be more explicit as to whether the material they were presenting is critical appraisal or a more practical “how-to”.

*End edit*

 

Criticalappraisal

Now let’s critically appraise the article.

METHODS/SETTING/DESIGN/NUMBER OF PATIENTS INCLUDED

  • Prospective, cross-sectional study performed at single urban, academic hospital serving as regional stroke referral centre for 25 community hospitals

Patients were recruited from the emergency department (n=59), other institutions (n=37), admitted patients with cerebellar infarctions (n=4), and one outpatient (n=1). A total of 101 patients studied, collected over 9 years. 65% were men with mean age 62 (range 26 – 92 years old).

  • Single neuroophthalmologist did HINTS exam on patients
  • HINTS exam was performed between 1 hour to 9 days from symptom onset (mean 26 hours). 75% were examined within 24h of symptom onset.
  • All patients underwent neuroimaging generally after bedside HINTS. If they had imaging prior to HINTS, examiner was blinded to these results at time of assessment. 70% were imaged within 6h of symptom onset. 97% were imaged within 72h of symptom onset.
  • All patients (including those with suspected acute peripheral vestibulopathy) were admitted for observation and serial daily examinations
  • Stroke diagnosis: MRI with DWI (97%) or CT
  • Acute peripheral vestibulopathy diagnosis: absence of stroke in brainstem/cerebellum on MRI with DWI, lack of neurological signs on serial exam, and characteristic clinical course, +/- caloric testing
  • Eight patients with initial negative MRI later underwent repeat MRI for unexplained neurological signs suggesting brainstem localization

INTERVENTION/CONTROL

  • One neuroophthalmologist conducted HINTS exam
    • HI = Head Impulse
    • N = Nystagmus
    • TS = Test of Skew
  • “Benign” HINTS = abnormal “HI”, direction-fixed “N”, and absent “TS”
  • “Dangerous” HINTS = normal/untestable “HI” or direction-changing “N”, or present/untestable “TS”


INCLUSION CRITERIA

  • Core features of acute vestibular syndrome (rapid onset of vertigo, N/V, and unsteady gait +/- nystagmus). Note that duration of symptoms was not important to be included in the study, some patients had ~ 1 hr of symptoms prior to HINTS exam.
  • At least 1 stroke risk factor
    • Smoking
    • Hypertension
    • Diabetes
    • Hyperlipidemia
    • Atrial fibrillation
    • Eclampsia
    • Hypercoagulable state
    • Recent cervical trauma
    • Prior stroke
    • Prior MI

 

EXCLUSION CRITERIA

  • History of recurrent vertigo +/- auditory symptoms

OUTCOMES

  1. Determine diagnostic accuracy of skew deviation for identifying stroke in acute vestibular syndrome: compare proportions with skew deviation in peripheral versus central cases
  2. Determine added value of skew deviation beyond h-HIT: stratify results by horizontal head impulse test findings
  3. Compare HINTS exam’s sensitivity and specificity for presence of stroke

RESULTS

  1. Skew present in 17% of the 101 studied subjects and was associated mainly with brainstem lesions
    1. Skew in 4% (n=1 of 25) with acute peripheral vestibulopathy, 4% (n=1 of 24) with pure cerebellar lesions and 30% (n=15 of 50) with brainstem lesion (chi-squared, P=0.003)
  2. Skew correctly predicted lateral pontine stroke in 2 out of the only 3 cases in which an abnormal horizontal head impulse test erroneously suggested peripheral localization (Table 3, below)
  3. Dangerous HINTS = 100% sensitive and 96% specific for central lesion (Table 4, below)

STUDY CONCLUSIONS

  1. Skew deviation is insensitive for central pathology but fairly specific for brainstem involvement for patients with acute vestibular syndrome
  2. Skew may help identify stroke when a positive head impulse test falsely suggests a peripheral lesion
  3. HINTS appears more sensitive (100% for HINTS) and specific (96% for HINTS) than MRI with DWI in detecting stroke in first 24-48 hours after symptom onset

CRITICAL APPRAISAL

  • Internal validity
  • Pros
    • An appropriate reference standard was used initially: neuroimaging
    • Cons:
    • Partially unmasked examiner: although masked to results of imaging, was not masked to patient’s clinical history, general neurological exam, or obvious oculomotor findings
    • Selective MRI follow-up scans: MRI follow-up was only obtained for selected cases based on evolution of new neurological signs or atypical subtle oculomotor signs, potentially leading to the misclassification of strokes and acute peripheral vestibulopathy, increasing apparent sensitivity
    • Observer bias in interpretation of eye findings may inflate HINTS sensitivity
    • Unclear whether radiologist was blinded to HINTS exam results
    • Unclear whether there may have been other eye exam components that would be useful for predicting stroke and a validation study would be required if the current study functions as just derivation data
    • Relatively small sample size (N=101)
  • External validity
    • Pros:
    • HINTS is not very time consuming to do, and it is free
    • HINTS may be useful for the right patient population, i.e. active symptoms to avoid labeling a normal head impulse test as “central” in normal patients
    • Acute vestibular syndrome in the literature is defined as >24 hours. The study enrolled patients between 1 hour to 9 days. It seems to suggest that HINTS can be used for patients presenting as early as 1 hour after symptom onset.
    • Cons:
    • Generalizability of exam technique: HINTS was performed by a neuroophthalmologist and not by emergency physicians
    • Single examiner: unsure if testing style can be replicated by others
    • Restricted enrollment to high-risk patients: unclear whether results can be extrapolated to lower-risk population. However, there were some younger patients in the mix (15 were less than 50 y.o. and 6 were less than 40 y.o.). It was not clear which patients of what age had which risk factors, and if those combinations would make one at “lower” or “higher” risk.

It may have been useful to stratify patients into ataxic versus non-ataxic, since we are more concerned about what to do about patients who have less obvious neurological findings.

UCalgary Journal Club Group

These points were discussed during Journal Club on March 19, 2015:

  • In a patient with acute vestibular syndrome, who had a normal CTA and reassuring HINTS, would you send them home? 43% would consult neurology first. 57% would send the patient home.
  • Would you incorporate HINTS as an additional part of your physical examination? Most people agreed they would consider incorporating the HINTS components as part of their examination and, in particular, examining for high-risk nystagmus and skew deviation. There appeared to be agreement that the head impulse test may be challenging to perform, and we may not have adequate inter-rater reliability with a single, experienced neuro-ophthalmologist.
  • If you do use HINTS, ensure you use it on the right patient population: i.e. someone who has active persistent vertigo (acute vestibular syndrome patient) and not an intermittent vertigo like BPPV.
  • You may consider downloading a slow-motion camera application on your mobile device in order to detect the subtle ocular symptoms. However, the safety and accuracy of this practice has not been rigorously evaluated. Evidence in support of slow-motion applications is anecdotal at best, and its use is not recommended without evidence of its utility.
  • It may be challenging to differentiate between a normal versus abnormal head-impulse test. Moreover, an abnormal head-impulse test, although should imply a peripheral cause, can still mean a central cause. Therefore, direction-changing nystagmus and present skew deviation may be elements of HINTS less challenging to interpret.
  • Although there are many limits to the generalizability of the HINTS exam, if it can be conducted on the right patient population using appropriate technique, it may add to your overall diagnostic evaluation for patients with acute vestibular syndrome. Consider reviewing the HINTS exam: http://empablogsite.com/2014/08/hints-exam/

Thanks again to Anthony Seto and Vanessa Potok for compiling this excellent summary.

 

Cheers,

Chris

 

Novel Management of PEA Arrest (Calgary EM Journal Club)

ACLS management of PEA arrest is traditionally done using CPR, epinephrine and running through the H’s and T’s. Unfortunately, the H’s and T’s can be difficult to recall in a stressful situation, and furthermore, they do not approach cardiac arrest in a physiologic manner.

We recently reviewed the following paper that uses a novel approach to the management of PEA arrest.

Littmann et al. (2013) A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity. Medical Principles and Practice 2014.

Hypothesis

The authors suggest a revision of the current approach to PEA arrest in order to streamline diagnosis and thus guide resuscitation.

Methods:

The authors reviewed the current evidence around the ACLS guidelines.

Results/Proposed recommendations

Based on the literature review the authors felt cause-specific treatment of PEA arrest is more user friendly than the current ACLS teaching for a number of reasons.

  • The current ACLS teaching H’s and T’s of ACLS are cumbersome.
  • The current ACLS teaching is difficult to remember in code situation.
  • The proposed changes focus on more likely causes of PEA arrest.
  • The proposed changes provides a framework to work from.

As a result, the authors proposed the following algorithm to diagnose and manage the most common underlying etiologies of PEA arrest.

littman_pea_algorithm

 

Photo courtesy Adelaide Emergency Physicians

Conclusion

The authors felt that their simplified and structured approach offered additional advantages over the current ACLS teachings in three main ways:

  1. Organized approach using EKG telemetry to differentiate between narrow complex (mechanical cause) vs. wide complex (Metabolic cause) PEA.
  1. The structured approach reduces the number of possible diagnosis for either wide or narrow QRS morphology.

 

Wide complex

A wide complex morphology in PEA arrest is likely to be hyperkalemia or sodium channel blocker toxicity.

 

Narrow complex

Whereas a narrow complex EKG are more likely to be due to PE, cardiac tamponade, tension pneumothorax or hyperinflation. In addition, with narrow complex morphology in PEA arrest, the use of ED ultrasound is likely to further identify the underlying cause.

 

  1. The algorithm provides specific treatment recommendations depending on the initial QRS morphology.
  1. Wide complex
    1. In the case of a wide complex (metabolic cause) PEA arrest the recommendations suggest IV calcium chloride and sodium bicarbonate depending if the clinical picture is hyperkalemia or sodium channel blockers overdose.
  1. Narrow complex
    1. In the case of narrow complex (mechanical cause) PEA arrest the recommendation suggest fluids wide open and using additional ultrasound to help determine if pericardiocentesis, needle decompression, thrombolysis or ventilator management is needed.

Critical Appraisal:

Pro:

  • A comprehensive review of current ACLS PEA arrest guidelines
  • Common sense approach to PEA arrest

Cons:

  • Recommendation only – not a study
  • No data to suggest improved outcomes etc.
  • Difficult to conduct future RCT to determine effect.

 

Journal Club Discussion:

There were a number of strengths and weaknesses that came out of the group discussion:

Strengths:

  • The recommendations were based on solid review of the current literature/guidelines and most liked the idea of a structured approach to PEA arrest.
  • The recommendations focused on the most likely causes of PEA arrest and removed ancillary causes that would appear obvious during assessment (eg. Hypothermia, hypoxia). The group agreed that this provided for a more manageable list to remember as well as a framework for treatment.
  • The addition of mechanical hyperinflation as a cause was uniformly agreed as a strong point of the recommendations.
  • The additional use of ultrasound was seen as a good step forward in helping to better identify underlying etiology of the PEA arrest.

Weaknesses:

  • The absence of trauma, hypokalemia, hypoglycemia, hypothermia, hypoxia and acidosis was a concern for some who felt that there can be subtle presentations that would go un-noticed.
  • Generalizable/Staff dependent – Requires ED physicians to be trained in use of ultrasound. (eg. rural areas etc.)

 

Overall, most journal club participants agreed that the framework was a good idea and helped with recall of important etiology; however, most did say that it would not substantially change their practice as they already use the current model without difficulty or use a modified version of the proposed recommendations.

For more reading on PEA, and whether it actually exists, check out the EDECMO podcast episode #13, here.

Cheers,

Chris

 

 

The Negative or Inconclusive Ultrasound in Appendicitis – Can a CDR help?

abdominal_pain-pic

The September edition of journal club featured two articles focused on the diagnosis of appendicitis.  These articles each highlight some critical EBM points, which is why I’m breaking them apart into separate posts. This post will only focus on the first article, which examined a potential clinical decision rule for the management of patients with inconclusive or negative ultrasonography in the setting of suspected appendicitis.

 

 

Acad Emerg Med. 2014 May;21(5):488-96. doi: 10.1111/acem.12374.

A simple clinical decision rule to rule out appendicitis in patients with nondiagnostic ultrasound results.

Leeuwenburgh MM1Stockmann HBBouma WHHoudijk APVerhagen MFVrouenraets BCobben LPBossuyt PMStoker JBoermeester MAOPTIMAP Study Group. 

 

Objective
  • Intent of the clinical decision rule (CDR) was to create a tool that could rule out appendicitis in patients with negative or inconclusive ultrasounds without additional imaging such as a CT or MRI and be safely discharged and seen the following day for reassessment.
  • Their aim was to identify low risk patients for appendicitis with negative or inconclusive ultrasound that they defined as <10%.
Setting
  • Carried out in the Netherlands at University and Teaching hospitals
Population and Inclusion Criteria
  • Development and Validation data were retrospectively extracted from 2 different imaging studies occurring at different times.
  • There were 199 patients in the development set and 120 patients in the validation set.
  • In both the development and validation set, subjects were selected from a diagnostic accuracy study and were patients with clinically suspected appendicitis that presented to the Emergency department who had negative or inconclusive ultrasound results.
  • All patients in both groups received additional imaging such as a CT scan. An expert panel that based its decision on all data attained including pathology and clinical course determined a final diagnosis of appendicitis.

appendicitisultrasoundpic

Methods
  • 14 clinical variables associated with appendicitis were identified from the two diagnostic accuracy studies.
  • Development population: Univariate logistic regression methods were used to estimate odds of appendicitis based on each variable. Those with positive association were included in a multivariable logistic regression model; ultimately they came up with the most promising variables to build the CDR. CRP was added on to see if it would increase sensitivity.
  • 4 variables were identified to make a CDR (male, migration of pain to RLQ, vomiting and WBC >12), they applied this to the development and validation population retrospectively.
Results/Conclusion
  • The 4 variables identified as most promising were male, migration of pain to RLQ, vomiting and WBC >12.
  • The addition of CRP>10 did not significantly improve the sensitivity of the rule.
  • The authors applied their 4 variable CDR to both the development and validation population set. In the development set they claim that use of the rule would reduce the probability of appendicitis from 26% (51/199 – these are the number that had +ve appy) to 12% (15/126 that were discharged ultimately had appendicitis)
  • In the validation set, applying the CDR reduced the probability of appendicitis from 20% (24/120 – total in group that had +ve appy) to 6% (4/72 – these were discharged home that ultimately had +ve appy).
  • They compare the NPV of the CDR as 94% (CI 87-98%), which was comparable to the NPV of CT and MRI (there was no statistical difference).
  • The authors conclude that their CDR significantly reduces the probability of appendicitis in negative and inconclusive u/s and those patients could be safely discharged home with next day evaluation.

Screen shot 2014-12-04 at 3.28.13 PM

Critical Appraisal/Group Discussion

There are multiple methodologic standards for interpreting a CDR.  The Annals of Emerg Med has a nice 2014 update on this here.  This would be a good paper to read or bookmark for residents.

The clinical scenario in which an emergency physician is presented with a young patient with clinically suspected appendicitis and an inconclusive ultrasound is common and one that could benefit from a well designed CDR to rule out disease in a moderate to high risk patient. Unfortunately, other than asking a relevant question, there are several limitations of this CDR that prevents it from being clinically useful.

First, the rule would have been more helpful if it resulted in a definitive course of action such as CT vs No CT or discharge only, rather than next day re-evaluation for all. Its design and methodological standards were also not ideal. Data for both the development and validation were retrospectively taken from two separate diagnostic accuracy studies that a priori were not designed to create a CDR. Patients were selected as a convenience sample introducing sampling and spectrum bias and there was no mention of blinding. Resident and staff radiologists performed ultrasounds, which is not the standard here in Canada. This may also explain the high rate of positive appendicitis in negative ultrasounds as the skill level of the ultrasonographers varied immensely.

It was also puzzling that the authors included negative ultrasounds in their study, as most physicians with a negative ultrasound would typically send the patient home with clear discharge instructions. In addition, the radiologists were aware of the fact that they were involved in a diagnostic accuracy study that likely introduced a performance bias and may have influenced the high inconclusive ultrasound rate (22 and 47%). In addition to the aforementioned, external validity was also limited by the CDR performance difference in the development and validation set (12% vs 6% miss rate) and by a high prevalence of appendicitis (52-60%). There were a few experts in pediatric appendicitis in attendance and our local data was quite different – we had a much lower prevalence of incompletely visualized appendices.

Ultimately there was consensus that a ‘miss rate’ of 12% was too high for both pediatric and adult populations. A miss rate of 3-5% would be more reasonable. In general when most staff are presented with a negative ultrasound, if there is a re-assuring re-examination of the patient they will discharge them with very clear instructions of when to return to medical attention. With respect to an inconclusive ultrasound, where there is a lot more diagnostic uncertainty, most staff will proceed to a CT scan if clinically concerned in the adult population. Our pediatric emergency colleagues typically get their patients admitted for serial examinations from general surgery.

An inconclusive ultrasound in the context of clinically suspected appendicitis remains a clinical presentation that would benefit from a CDR that is both methodologically rigorous in derivation and leads to a defined clinical action.

Look for more on appendicitis in the coming weeks.  We review a meta-analysis of the Alvarado Score and Pediatric Appendicitis Score, and focus on measures of heterogeneity within a meta-analysis.

Thanks to Natasha Wright (PGY-2) for contributing and Shawn Dowling (FRCPC) for reviewing this summary.

Cheers,

Chris

 

SOCMOB joins REBELEM

Hi all,

Screen shot 2014-08-11 at 2.28.43 PM

I’m excited to report that I’ve joined the group over at REBELEM.com (Rezaie’s Evidence Based Evaluation of Literature in Emergency Medicine) and my first post on the use of Colchicine for treatment of pericarditis is now up.

For those of you who don’t follow REBEL:EM, what are you waiting for?  With Salim Rezaie (@srrezaie), Anand Swaminathan (@EMSwami), Matt Astin (@mastinmd) and multiple other guest contributors, this site is cranking out practical, evidence based content every few days.

I’ll still be posting/cross-posting here, but also have a few other projects that I’m working on.

Cheers,

Chris (@socmobem)

Novel therapies for Anterior Epistaxis (Calgary EM Journal Club)

Nosebleedpulpfiction

Epistaxis can be managed in many ways, from a simple squeeze of the nose to stuffing it with a tampon, and everything in between.  Today we’ll look at two novel methods of managing anterior epistaxis, one of which has become my go to for the moderate, non-anticoagulated bleeder.  Both of these techniques obviate the need for packing and are thus very popular among both patients and physicians.  These articles were reviewed at the University of Calgary EM Journal Club, May 2014.

For a review of epistaxis and a solid general approach, here are a few options:

1)The Skeptics Guide to Emergency Medicine (TheSGEM.com) Episode #53 “Sunday, Bloody Sunday” – Ken reviews the basics and one of the articles we’ll discuss here today.

2)For a very thorough approach, check out Schlosser’s NEJM review of epistaxis from 2009. (Subscription required)

TXAampouleimage
Option #1 – Tranexamic Acid

The first new option for epistaxis is topical application of the IV form of tranexamic acid.  Incredibly easy to do, just take an ampoule of TXA (1 gram/10 mL) and soak 15 cm of cotton pledget/gauze with 500 mg (5 mL) of the TXA solution.  Stuff it up the nostril, get them to pinch the nose for 15 minutes and come back.  The bonus is that you have 500 mg for the other nostril in the same vial, so feel free to do both.

This technique was far superior to traditional packing in terms of ED length of stay, patient/physician satisfaction, and had no increased rate of re-bleed at 7 days.  I have personally found this technique tremendously successful in my limited use thus far.  1 of 4 patients failed, but their INR would have precluded them from the study anyway.

NB. Patients with an INR > 1.5 were excluded from this study. See BEEM Commentary section.

Full journal article critical appraisal is below.

Flosealimage
Option #2 – Floseal Hemostatic Matrix

The second new option is actually not so new.  It comes from a 2005 paper in Laryngoscope and compares the use of Floseal gel matrix to traditional packing.  Floseal is a product similar to Gelfoam, Surgicel, etc. used for hemostasis, except it does not require platelet activation like the others.  This is theoretically fantastic as many of our epistaxis patients are on ASA/Clopidogrel or other anti-platelet agents.  Notably, this study included patients with INRs up to 4.5 and had fewer exclusion criteria than the TXA study.

This was a small, 70 patient study with industry sponsorship (BTW, I get paid nothing by anyone!) that showed improved patient/physician satisfaction, reduced head and neck surgery (HNS) consultation rates and decreased re-bleed rates in the Floseal group.

My main issue with the Floseal study is that I don’t have Floseal!! I’m not sure if anyone else has experience with this product, would love to hear your comments if you do.  It looks to be about $165/application, which although more than a nasal tampon, probably pays for itself with reduced re-visits and HNS consults.  However, I could just use TXA for many of these patients and it costs pennies.

Full article critical appraisal is below.

Article #1

A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial

Clinical Question:Is topical tranexamic acid (TXA) superior to traditional nasal packing for the treatment of anterior epistaxis?

Reference:American Journal of Emergency Medicine 31 (2013) 1389–1392

PubMed ID:23911102

Population:   Adult ED patients (n=216)

Intervention: 15 cm cotton pledget soaked in injectable TXA (500 mg in 5 mL) inserted into the bleeding nostril.

Comparison: Cotton pledget soaked in epiephrine (1:100000) + lidocaine (2%) for 10 minutes followed by packing with cotton pledgets coated in tetracycline.

Outcome:     Cessation of epistaxis within 10 minutes, rebleeding at 24 hours and 7 days, length of stay (LOS) and patient satisfaction.
Authors’ Conclusions: “Treating anterior epistaxis with the topical use of injectable form of tranexamic acid is better than usual nasal packing”.

Quality Checklist:

1. The study population included or focused on those in the ED.  Yes.

2. The patients were adequately randomized. Yes.

3. The randomization process was concealed.  Yes.

4. The patients were analyzed in the groups to which they were randomized. Yes.

5. The study patients were recruited consecutively (i.e. no selection bias).  Unsure.

6. The patients in both groups were similar with respect to prognostic factors.  No.

7. All participants (patients, clinicians, outcome assessors) were unaware of group allocation.  No.

8. All groups were treated equally except for the intervention. Yes.

9. Follow-up was complete (i.e. at least 80% for both groups). Yes.

10. All patient-important outcomes were considered. Yes.

11. The treatment effect was large enough and precise enough to be clinically significant.  Yes.  

Key Results:

Outcome TXA (%) Anterior nasal packing Odds Ratio (95% CI) p-value
Bleeding stopped < 10 min 71 31.2 2.28 (1.68-3.09) <0.001
Discharge <2 hours 95.3 6.4 14.8 (7.2-30.4) <0.001
Complications 4.7 11 0.42 (0.15-1.16) 0.128
Re-bleed at 24 hrs 4.7 12.8 0.36 (0.14-0.98) 0.034
Re-bleed at 1 week 2.8 11 0.26 (0.07-0.88) 0.018
Patient satisfaction 85 44 <0.001

 

BEEM Commentary:

The patients in the TXA group had a much higher rate of previous epistaxis (58.1% vs. 13.6%) compared with the packing group. This could alter the authors conclusions. Physicians were not blinded to treatment group which is a potential source of bias. Finally, many groups were excluded in this study, including, INR >1.5, visible bleeding vessel, major trauma, pre-existing coagulopathy and posterior bleeds.

Comments on author’s conclusion compared to BEEM conclusion:

This study did show positive outcomes with using tranexamic acid for anterior epistaxis, although many patient groups were excluded from the study.

The Bottom Line:

TXA seems to be a good alternative to nasal packing for earlier patient discharge and improved patient satisfaction.

Clinical Application:

Consider using a TXA soaked cotton pledget for your next anterior epistaxis patient.

What do I tell my patients?

We have several options for treating your nosebleed. One of them is to soak some cotton with a medication called tranexamic acid and leave it in your nose for 10-15 minutes. If it works, it will allow you to go home sooner and without nasal packing that has to be removed in a few days. 

Reviewers: Chris Bond and Ken Milne

 

Article #2 

Prospective, Randomized, Controlled Clinical Trial of a Novel Matrix Hemostatic Sealant in Patients with Acute Anterior Epistaxis

Clinical Question:How does Floseal Matrix Hemostatic Sealant (Floseal) compare to nasal packing for the treatment of anterior epistaxis?

Reference:Laryngoscope. 2005 May;115(5):899-902.

PubMed ID:15867662

Population:   Adults (>18) with acute anterior epistaxis (n=70)

Intervention: Floseal Matrix Hemostatic Sealant

Comparison: Traditional nasal packing (eg. Merocel, Vaseline gauze, Rhinorocket, etc.)

Outcome:      Patient level of comfort and satisfaction, MD assessed effectiveness, ease of use and satisfaction, HNS (head and neck suregery) surgery consult rate, rebleed rate and crossover into other group.

Authors’ Conclusions: Floseal is more effective than nasal packing in treating patients with acute anterior epistaxis.

Quality Checklist:

1. The study population included or focused on those in the ED.  Yes.

2. The patients were adequately randomized.  Yes.

3. The randomization process was concealed. Yes.

4. The patients were analyzed in the groups to which they were randomized. Yes.

5. The study patients were recruited consecutively (i.e. no selection bias). Unsure.                                    

6. The patients in both groups were similar with respect to prognostic factors.  Yes. 

7. All participants (patients, clinicians, outcome assessors) were unaware of group allocation.  No.

8. All groups were treated equally except for the intervention.  No.

9. Follow-up was complete (i.e. at least 80% for both groups).  Unsure.

10. All patient-important outcomes were considered.   Yes.

11. The treatment effect was large enough and precise enough to be clinically significant.   Yes.

Key Results:

Reduced rate of HNS consult in Floseal group (8.6% vs. 31%, p<0.05), reduced rebleed rate within 7 days (14% vs 40%, p<0.05), reduced rebleed at follow-up visit (0% vs. 63%, p<0.001) and increased crossover in the packing group (23% vs. 3%, p<0.05).  Patient comfort and satisfaction was much better in the Floseal group, as was MD assessed effectiveness, ease of use and satisfaction (all p<0.001).

BEEM Commentary:

While the results are compelling, this study does have several limitations.  This was an industry funded,  non-blinded study and thus the MD and patient questionnaires are at significant risk for bias.   Furthermore, this was a small study (70 patients) and the primary outcome was not specified. We also do not know if patients were recruited consecutively, and are unsure of which group the crossover patients (23% in the packing arm) were analyzed in.  Other treatment (such as hypertension) was left to the discretion of the treating physician. Floseal is significantly more expensive than traditional packing methods ($165/application), however, this cost is likely offset by the decreased need for HNS consultation and lower rebleed rate.

Comments on author’s conclusion compared to BEEM conclusion:

Although the study does suffer from several limitations, it would be difficult to blind patients to gel matrix vs. packing, and Floseal for anterior epistaxis seems to be a reasonable option.

The Bottom Line:

Floseal is a potentially useful option for the management of anterior epistaxis.

Clinical Application:

Floseal offers another alternative in the management of anterior epistaxis.

What do I tell my patients?

We have several options for managing your nosebleed.  One of them is to insert a gel like substance into the nostril to stop the bleeding.  If it works, it will be more comfortable than inserting nasal packing and won’t increase your chance of rebleeding. 

Reviewers:Chris Bond

 

Questions? Experience with Floseal, Surgicel, etc. for epistaxis?  Please comment below.

Cheers,

Chris

@socmobem

 

References:

Schlosser RJ.  Clinical Practice: Epistaxis. N Engl J Med. 2009 Feb 19;360(8):784-9. doi: 10.1056/NEJMcp0807078.

Zahed RMoharamzadeh PAlizadeharasi SGhasemi ASaeedi MAmerican Journal of Emergency Medicine 31 (2013) 1389–1392

Mathiasen RA, Cruz RM. Laryngoscope. 2005 May;115(5):899-902.