Date: February 19th, 2021

This is an SGEM Xtra episode. I had the honour of presenting at the Lehigh Valley Health Network Grand Rounds on February 4th, 2021. The title of the talk “Dogmalysis: Five Medical Myths in Emergency Medicine”. The presentation is available to listen to on iTunes and GooglePlay and all the slides can be downloaded using this LINK.

 

Five Medical Myths in Emergency Medicine

Myth #1: The use of non-selective NSAIDs will cause a nonunion in long bone fractures

Myth #2: Topical anesthetics will cause blindness if used in simple corneal abrasions for less than 48 hours

Myth #3: Mild paediatric gastroenteritis is best treated with expensive oral electrolyte solutions

Myth #4: Tranexamic acid (TXA) has been proven to saves lives and results in good neurologic function in patients with isolated traumatic brain injuries (TBI)

Myth #5: Epinephrine in adult out-of-hospital cardiac arrests (OHCA) results in better patient-oriented outcomes (POOs)

Each of the five myths is presented with some background information and the PICO (population, intervention/exposure, comparison and outcome). Key results are provided with a number of the study limitations (dog leash) identified. There is an SGEM bottom line and a link to the original SGEM episode to provide more results and critical appraisal. There is also a link to the original article for people to read the primary literature for themselves.

Myth #1: The use of non-selective NSAIDs will cause a nonunion in long bone fractures

When bones break, they usually heal with either surgical or non-surgical management. Sometimes the healing process can take longer than usual (delayed union), does not heal (non-union) or in poor alignment (malunion). Non-union is defined as “a failure of the fracture-healing process” and occurs in up to 1 in 10 fractures.

Several risk factors have been associated with increased risk of delayed or non-union: issues about the fracture (open/closed, displacement, location, etc) tobacco use, older age, severe anemia, alcohol intake, diabetes, low vitamin D levels, hypothyroidism, poor nutrition, infection, open fracture and certain medications (ex. steroids). 

One class of medication that has been implicated in negatively impacting bone healing is NSAIDs. Non-selective NSAIDs and COX-2 inhibitors. There have been multiple studies investigating this issue with mixed results.

The final cohort consisted of 339,864 patients identified in over 15 years. Less than 1% were diagnosed with a nonunion (2,996/339,864).

The mean age was in the 50’s and around 60% were female. The most common fractures were radius, neck of the femur and humerus.

Key Result: Patients who filled prescriptions for selective COX-2 inhibitors and opioids but not non-selective NSAIDs were associated with an increased risk of nonunion.

SGEM Bottom Line: There is no high-quality evidence to support the claim that non-selective NSAIDS cause an increased risk of nonunion.

SGEM#317: Dese bones gonna heal again, with or without a non-selective NSAID

Reference: George et al. Risk of Nonunion with Nonselective NSAIDs, COX-2 Inhibitors, and Opioids. J Bone Joint Surg Am. 2020