The Skeptics Guide to Emergency Medicine

Date: April 2, 2026 Reference: Lee et al. GRADE-Based Clinical Practice Guidelines for Emergency Department Delirium Risk Stratification, Screening, and Brain Imaging in Older Patients With Suspected Delirium. AEM Feb 2026 Guest Skeptic: Dr. Christina Shenvi is a board-certified emergency physician, educator, keynote speaker, coach, and academic leader. She is widely recognized for her work in geriatric emergency medicine, faculty development, and professional identity formation in EM. She brings deep clinical expertise along with thoughtful perspectives on systems-level change and guideline development. Case: An 82-year-old woman with hearing impairment and mild baseline dementia is brought to the emergency department (ED) by her daughter because she became “not herself” over 24 hours. She is more sleepy, intermittently agitated, keeps losing the thread of conversation, and cannot say the months backward. She arrived by ambulance from home after nearly falling twice. Vitals show fever and mild tachycardia. The daughter reports foul-smelling urine and poor oral intake for two days. On examination, there is no head trauma and no focal neurologic deficit. The question in the ED is not simply “Is she confused?” but “Does she have delirium, how do we confirm it efficiently, and does she need a head CT as part of the workup?” Background: Delirium is an acute brain dysfunction: a disturbance in attention and awareness that develops over hours to days, fluctuates, and is accompanied by additional cognitive disturbances such as memory, language, orientation, or perceptual changes. In older adults, it is common, dangerous, and often goes unnoticed. The latest GED Delirium Guidelines indicate that delirium occurs in about 6% to 38% of older ED patients, increases mortality, contributes to functional decline, and imposes a significant burden on health systems. ED-based geriatric screening tools also highlight that delirium is frequently under-recognized by emergency clinicians and that hypoactive delirium is most common, making bedside detection even more challenging. For emergency physicians, delirium matters because it is rarely the final diagnosis. Delirium is usually a clue that something else serious is also wrong. The practical ED task is to identify the syndrome, search for precipitants, and avoid worsening the situation. But one reason the new guideline is so useful is that it is honest about the evidence gap. Prior reviews found no consistent ED-based strategy to prevent incident delirium or to treat prevalent delirium, so this guideline appropriately focuses on the parts of care for which there is sufficient evidence to guide bedside decisions now. It addresses risk stratification, diagnosis, and brain imaging. This delirium guideline is also notable because it was built using the newer GED 2.0 model for subspecialty guideline development [1]. The Geriatric Emergency Department initiative moved beyond the older consensus-based 2014 framework and adopted a transparent GRADE process: multidisciplinary working groups, explicit PICO questions, systematic reviews and meta-analyses, Evidence-to-Decision frameworks, attention to feasibility, equity, and stakeholder values, plus external stakeholder review. This SGEM episode highlights the first EM subspecialty guideline effort to fully adopt GRADE, and this delirium guideline shows that process in action. Clinical Questions: Which older ED adults are at the highest risk on walking in, and who should then be further assessed for delirium? (or CLS addition, should have special prevention measures or expedited treatment or bed placement). Which tools should be used to identify ED delirium? Should acutely confused older ED patients undergo head CT as part of the delirium evaluation? Reference: Lee et al. GRADE-Based Clinical Practice Guidelines for Emergency Department Delirium Risk Stratification, Screening, and Brain Imaging in Older Patients With Suspected Delirium. AEM Feb 2026 Authors’ Conclusions: “Rigorous ED-based research is needed to strengthen evidence and guide delirium care for older adults in geriatric emergency medicine.” Quality Checklist for a Guideline: The study population included or focused on those in the emergency department? Yes An explicit and sensible process was used to identify, select and combine evidence? Yes The quality of the evidence was explicitly assessed using a validated instrument? Yes An explicit and sensible process was used to value the relative importance of different outcomes? Yes The guideline thoughtfully balances desirable and undesirable effects? Yes The guideline accounts for important recent developments? Yes Has the guideline been peer-reviewed and tested? Yes/No Practical, actionable and clinically important recommendations are made? Yes The guideline authors’ conflicts of interest are fully reported, transparent and unlikely to sway the recommendations? Unsure Key Recommendations: They came up with six recommendations

Date: March 23, 2026 Dr. Christina Shenvi Guest Skeptic: Dr. Christina Shenvi is a board-certified emergency physician, educator, keynote speaker, coach, and academic leader. She is widely recognized for her work in geriatric emergency medicine, faculty development, and professional identity formation in emergency medicine (EM). She brings deep clinical expertise along with thoughtful perspectives on systems-level change and guideline development. This is another SGEM Xtra episode. Today’s show focuses on how to build high-quality subspecialty clinical practice guidelines, using the Geriatric Emergency Department Guidelines 2.0 (GED 2.0) as a model. We’ve talked about Geriatric EM a lot on the SGEM over the years. And if we’re serious about evidence-based emergency medicine, we must be serious about geriatric EM. Here are some previous SGEM episodes: SGEM#89: Preventing Falling to Pieces SGEM Xtra: Don’t Bring Me Down – Preventing Older Adult Falls from the ED SGEM#261: Cristal Ball to Assess Older Patients in the ED SGEM#280: This Old Heart of Mine and Troponin Testing SGEM#424: Ooh Ooh I Can’t Wait to Be Admitted to Hospital The original 2014 GED Guidelines were consensus-based and helped establish standards for geriatric emergency departments, including staffing, education, transitions of care, quality improvement, equipment, and protocols. Since then: The evidence base in geriatric EM has expanded. Expectations for clinical practice guideline development have evolved. The GRADE framework has become the international standard for rating the quality of evidence and the strength of recommendations. GED Guidelines 2.0 represent the first EM subspecialty effort to fully adopt the GRADE methodology and provide a transparent, reproducible model for future EM guideline development. This work involved a multidisciplinary collaboration, including experts affiliated with organizations such as the American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM), as well as geriatricians, methodologists, and patient representatives. Started with an open call to the Geriatric Emergency Medicine community via SAEM, ACEP, AGS, EUSEM, and ENA. With funding via JAHF. The GED Guideline 2.0 group is planning 14 Systematic Reviews/Meta-analyses, with 6 or 7 Clinical Practice Guidelines. They will all be available on the GEAR 2.0 website Five Questions for Dr. Shenvi I have five key questions to frame our discussion about the GED 2.0 Model for Subspecialty Clinical Practice Guidelines. As a reminder, they are called GUIDElines, not GODlines. This means they are meant to guide our care, not dictate care. 1) Why Update the Original GED Guidelines? The original 2014 GED Guidelines were enormously important because they gave the field its first shared framework for what high-quality emergency care for older adults should look like. But they were developed as consensus-based guidelines at a time when the evidence base in geriatric emergency medicine was much less mature than it is now. Since then, there has been major growth in research, especially through work from GEAR and GEAR 2.0, in areas like delirium, dementia, falls, medication safety, transitions of care, and elder abuse. The update was needed to ensure the guidelines reflected the newer evidence and remained clinically relevant. A second reason is that expectations for guideline development have changed. The paper makes clear that the original guidelines did not include a formal assessment of the quality, quantity, reproducibility, or applicability of the evidence. In today’s environment, clinicians and health systems expect more transparency about how recommendations are made, how strong the evidence is, and how benefits, harms, feasibility, and equity are weighed. GED Guidelines 2.0 was designed to meet those newer standards. A third issue was implementation. The original guidelines had a clear impact, especially through ACEP accreditation, but the paper notes that accredited GEDs still represent a minority of EDs, and many sites have struggled with barriers such as limited resources, competing priorities, and a lack of local champions. So, this update was not just about refreshing content. It was also about making the guidance more usable, transparent, and implementable in both accredited and non-accredited settings. Bottom line, hospitals won’t do things unless there are clear clinical reasons, or financial reasons, or mandates, like CMS measures, which are financial. 2) Why Adopt the GRADE Framework? GRADE stands for: Grades of Recommendation, Assessment, Development, and Evaluation. They provide a systematic, transparent framework for rating the quality of evidence and grading the strength of recommendations in healthcare. The group adopted GRADE because they wanted the updated guidelines to be more rigorous, more transparent, and more trustworthy. According to the paper, GED Guidelines 2.0 is the first emergency medicine subs

Date: March 26, 2026 Dr. Rob Leeper Guest Skeptic: Dr. Robert Leeper is a trauma surgeon at the London Health Sciences Centre and an ATLS instructor who has helped train generations of physicians in trauma care. He has previously joined SGEM for: SGEM #200 – Bloodletting and Alexander Hamilton SGEM #256 – RLQ Pain and Appendectomy SGEM #345 – Non-operative Management of Appendicitis It’s SGEM Xtra time, where we go beyond a single paper and dive into broader topics that impact our daily practice. Now, some of you may remember that back in 2018, we did a Top 10 list for ATLS 10th Edition. Yes, we cranked it up to 10. ATLS 10th Edition: Top 10 Changes But today… We’re not stopping at 10. Because this SGEM episode goes to 11. If you don’t get that reference, go watch This Is Spinal Tap. It’s a mockumentary about a fictional rock band whose amplifiers go to 11 instead of 10. And when asked why they didn’t just make 10 louder, the guitarist replies: “These go to 11.” And that brings us to ATLS, now officially in its 11th edition. For those who don’t know the history of ATLS, here is the brief back story. ATLS was born out of tragedy. In 1976, orthopedic surgeon Dr. James Styner crashed his small plane in rural Nebraska. His wife died at the scene. He and his children survived but were severely injured. When they arrived at a small hospital, the trauma care they received was, by his account, disorganized and inadequate. Styner later said: “When I can provide better care in the field with limited resources than my children and I received at the primary care facility, there is something wrong with the system.” That moment led to the development of a structured approach to trauma, one that could be taught, replicated, and standardized. The first ATLS course was introduced by the American College of Surgeons (ACS) in 1980. It emphasized something radical at the time: a systematic, prioritized assessment of trauma patients, beginning with Airway, Breathing, Circulation, Disability, Exposure (ABCDE). In EM, our alphabet is A-B-CT, send them to the donut of truth. But back to the 1980s, the systematic ABCDE approach wasn’t about memorizing injuries. It was about preventing death from the first thing that kills. Over the decades, ATLS became one of the most widely adopted trauma education programs in the world. It has trained hundreds of thousands of clinicians in over 80 countries. And like any long-running franchise (Star Wars, Mission Impossible, Star Trek and Batman), each new edition tries to improve on the original. So today, instead of a Top 10 list as we did for ATLS 10, we’re going with: The 5 important changes in ATLS 11. Because sometimes less is more. Even if the amplifier goes to 11. Five Changes to the ATLS 11th Edition 1. xABCDE – Hemorrhage Now Comes Before Airway: The most noticeable clinical change in ATLS 11 is the addition of the “x” to ABCDE, making it xABCDE, with the “x” standing for exsanguinating hemorrhage. Massive external bleeding is now formally prioritized before airway management in select patients. While many trauma teams have already internalized the “bleeding kills first” principle, especially after a decade of military-to-civilian trauma translation, ATLS has now codified it. In practical terms, this reinforces early tourniquet use, direct pressure, and hemostatic adjuncts as first-line priorities when appropriate. It’s less of a revolution and more of an official acknowledgment that the trauma world has already turned the volume up on hemorrhage control. But formalizing it in the primary survey does matter, because what gets taught gets practiced. 2. Hemodynamic Optimization Before Intubation: Another subtle but important evolution in the 11th edition is the greater emphasis on resuscitating shock before proceeding with rapid sequence intubation (RSI). ATLS 11 highlights the risk of peri-intubation hypotension and arrest in unstable trauma patients, encouraging clinicians to correct hemodynamics before pushing paralytics. This aligns with growing emergency medicine literature around the dangers of precipitous airway management in the shocked patient. It’s a welcome shift toward physiologic thinking rather than purely procedural thinking. In other words, it reminds us that the airway isn’t just anatomy, it’s physiology. 3. Major Structural Reorganization and Systems Focus: The changes to ATLS 11 aren’t just clinical. This edition reorganizes the manual into three major sections: resuscitation, trauma systems/context, and specific injury patterns. More notably, it introduces full chapters on Trauma Systems, Injury Prevention, Trauma-Informed Care, and Communicating Serious News. This reflects a broader view of trauma care that extends beyond the primary survey. ATLS is no longer just about what happens in the first 15 minutes. It is also about the system in which those 15 minutes occur. For instructors, this may feel like an expansion into public health. Whether that’s evolution or missi

Reference: Wong KH, et al. Improving Use of Oral Antihistamines in a Children’s Hospital. Pediatrics. Feb 2026; Date: March 15, 2026 Dr. Stephanie Kubala Guest Skeptic: Dr. Stephanie Kubala is an attending physician in the Division of Allergy and Immunology at Children’s Hospital of Philadelphia. She is double board-certified in both pediatrics and allergy and immunology. Case: A 5-year-old girl is brought in by her parents for an itchy rash. Her symptoms started last night. The parent reports an itchy, raised red rash on her trunk and extremities. She has not had any fever. She does not have any difficulty breathing, wheezing, vomiting, or diarrhea. On your exam, you note hives on her body but no lip or tongue swelling. Her lungs are clear to auscultation. She intermittently scratches at the rash. Her parents tell you, “We gave her a dose of diphenhydramine last night, and it may have helped a little, but it seems to have worn off. Can you help?” Background: In a lot of emergency departments, “hives = diphenhydramine” is practically muscle memory. It’s familiar, it’s been around forever, and families often expect it because it’s what they already have at home. As with many medical interventions, we must weigh potential harms against potential benefits. The problem is that diphenhydramine and other first-generation antihistamines like hydroxyzine come with a bunch of potential side effects, such as sedation, anticholinergic side effects, and unpredictable behavior changes in some kids. It doesn’t always last very long, which can lead to repeat dosing and frustrated families when symptoms come back a few hours later. On the other hand, second-generation antihistamines like cetirizine target the same H1 receptor for itch and urticaria but tend to be longer-acting and better tolerated, which is why many guidelines and expert groups prefer them for routine allergic symptoms. And there’s a bigger safety angle here, too: first-generation agents show up in dosing errors and misuse/overdose cases. The real issue isn’t whether second-generation antihistamines like cetirizine work. They do. We need to start asking why our systems still nudge clinicians toward the older first-generation antihistamines as a default. The issue is well-suited to a quality improvement (QI) study. Before we dive into the details of the study itself, let’s talk about some basics around QI. QI helps close the gap between best practice and day-to-day care. It starts with a clear, measurable aim (what you want to improve, by how much, by when). This is followed by a simple measurement plan: an outcome measure (the main result you’re trying to change), process measures (the steps that should drive that result), and balancing measures (what might worsen unintentionally). Teams then map the current workflow, identify barriers, and build a key driver diagram that links the aim to the handful of system levers most likely to move the needle. The work is tested and refined using Plan–Do–Study–Act (PDSA) cycles. [2] These are iterative rather than a single big rollout. Data is tracked over time with run/control charts to show whether changes are real and sustained. Clinical Question: Can a bundled QI approach meaningfully reduce first generation antihistamine use and increase cetirizine use among pediatric patients receiving oral antihistamines in the ED and inpatient settings? Reference: Wong KH, et al. Improving Use of Oral Antihistamines in a Children’s Hospital. Pediatrics. Feb 2026; Population: Patients 6 months to 21 years in the pediatric ED and inpatient units at a tertiary academic children’s hospital Excluded: Patients in NICU, PICU, or hematology-oncology units Intervention: There were 3 main drivers: education/awareness, cetirizine availability, and standardization through clinical pathways. Comparison: Pre-intervention baseline prescribing practices Outcome: Primary Outcomes: There are two primary outcomes: The proportion receiving oral FGA and the proportion receiving cetirizine Secondary Outcomes: PED revisits within 48 hours, median LOS, clinicians’ knowledge, frequency of clinical pathway use and monthly antihistamine cost. Type of Study: Quality improvement initiative Authors’ Conclusions: “Using the Model for Improvement, we reduced FGA use and increased cetirizine use in the PED and inpatient setting.” Quality Checklist for Ql Study (adapted from QI-MQCS): Do they clearly state the problem and why it mattered? Yes Do they explain why the intervention should improve the outcome? Yes Are the specific changes described in enough detail that another site could reproduce them? Unsure Do they describe the setting the intervention took place (type of hospital/clinic, size, population)? Yes Do they describe the approach to designing and introducing the program? Yes Is the evaluation approach explicit? Yes Do they describe what they are comparing against? Yes Are data sources clear and is the primary outcome operationally defined? Yes Is th

Date: March 11, 2026 Reference: RENOVATE Investigators and the BRICNet Authors; High-Flow Nasal Oxygen vs Noninvasive Ventilation in Patients With Acute Respiratory Failure: The RENOVATE Randomized Clinical Trial. JAMA March 2025 Guest Skeptic: Dr. Rory Spiegel is an emergency medicine and critical care physician known for his work in evidence-based medicine and critical care. He is widely recognized for translating emerging research into practical bedside insights through lectures, writing, and digital medical education. His work focuses on resuscitation science, airway management, and the critical appraisal of medical literature. I’m in Maui at the Centre for Continuing Medical Education Year in Review Course. CCME has been doing courses for almost 40 years. The courses take place at amazing locations in the US, including Maui, Hilton Head, Key West, and NYC. CCME recruits four outstanding educators to review ~260 articles from the past year. It’s a unique course because there are no PowerPoint slides to get in the way of the attendees and the speakers. Two faculty members summarize a few articles on a topic in ½ hour with direct interaction with the speakers. You come to this course…you are up to date on the latest EM literature. Case: A 64-year-old woman with a history of COPD (GOLD stage III) and hypertension presents to the emergency department (ED) with worsening shortness of breath over the past 24 hours. She reports increased sputum production and wheezing. On arrival, she is tachypneic and speaking in short phrases. Her vital signs are heart rate 104 beats per minute, blood pressure 148/86 mm Hg, respiratory rate 30 breaths per minute, and SpO₂ 88% on 4 L nasal cannula. She is using accessory muscles and has diffuse expiratory wheezes on auscultation. An arterial blood gas reveals pH 7.29, PaCO₂ 58 mm Hg, and PaO₂ 62 mm Hg. Chest X-ray shows hyperinflation without focal consolidation. Background: Acute respiratory failure (ARF) is one of the most common serious respiratory problems managed in emergency medicine and critical care. For decades, noninvasive ventilation (NIV) has been a central part of therapy for selected patients. This is particularly true for those with COPD exacerbations and acute cardiogenic pulmonary edema. By delivering positive pressure, NIV reduces the work of breathing, improves oxygenation and ventilation. This intervention has been shown to reduce intubation rates and mortality in specific populations. However, NIV can be poorly tolerated, requires a tight mask seal and monitoring, and is resource-intensive [1-3]. These downsides can become more problematic in disease states that are not readily reversible over the first few hours. High-flow nasal oxygen (HFNO) has emerged over the past decade as an attractive potential alternative. By delivering heated, humidified oxygen at high flow rates, HFNO improves oxygenation, improves ventilator efficiency by reducing dead space, and is often better tolerated than mask-based ventilation. Its physiologic appeal and ease of use have led to widespread adoption, particularly during the COVID-19 pandemic. Yet enthusiasm has at times outpaced evidence, and important clinical questions remain: Is HFNO equivalent/non-inferior to NIV in preventing intubation or death? How does it perform across different types of respiratory failure? And when should clinicians choose one over the other? Clinical Question: Is HFNO noninferior to NIV regarding the rates of endotracheal intubation or death at 7 days across five distinct patient groups with ARF? Reference: RENOVATE Investigators and the BRICNet Authors; High-Flow Nasal Oxygen vs Noninvasive Ventilation in Patients With Acute Respiratory Failure: The RENOVATE Randomized Clinical Trial. JAMA March 2025 Population: Hospitalized adults with ARF (hypoxemia plus respiratory effort or tachypnea) classified into 5 groups: Nonimmunocompromised with hypoxemia Immunocompromised with hypoxemia COPD exacerbation with respiratory acidosis Acute cardiogenic pulmonary edema (ACPE) Hypoxemic COVID-19 Exclusions: The main exclusion criteria were if there was an urgent need for endotracheal intubation, hemodynamic instability or contraindications to NIV. Intervention: High-flow nasal oxygen (HFNO) delivered continuously, titrated toward 60 L/min. Comparison: Noninvasive ventilation (NIV) delivered through a face mask. Outcome: Primary Outcome: Endotracheal intubation or death within 7 days. Secondary Outcomes: 28-day and 90-day mortality, mechanical ventilation-free days, and ICU-free days. Type of Study: Multicenter, adaptive, noninferiority randomized clinical trial using a Bayesian hierarchical model with dynamic borrowing across patient groups. Authors’ Conclusions: “Compared with NIV, HFNO met prespecified criteria for noninferiority for the primary outcome of endotracheal intubation or death within 7 days in 4 of the 5 patient groups with ARF. However, the small sample sizes in some patient groups and the

Date: March 5, 2026 Today, we’re not in the studio. We’re not in Canada. We’re not even in North America. We are in Oxford. And not just Oxford, we are recording this SGEM Xtra in a pub. This will be the second-ever SGEM PUBcast. We need to travel back in time to 2012 for the first PUBcast. That happened when I came to Oxford for a mini-fellowship at the Centre for Evidence-Based Medicine (CEBM) on how to teach evidence-based medicine (SGEM#6). I had no idea that experience would change my professional career and open so many doors for me around the world. In that early SGEM episode, we did a structured critical appraisal of a 2011 BMJ article by Subramanian et al. called: Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study. That trial examined the dominant grip strength of male orthopedic surgeons compared with male anesthesiologists. No surprise, they found orthopedic surgeons had significantly greater grip strength. However, they also compared the two specialties using an intelligence score and found that orthopedists scored significantly higher than anesthetists. The SGEM bottom line was that the stereotypical image of male orthopedic surgeons as strong but stupid is unjustified in comparison with their male anesthetist counterparts. Well, the SGEM has grown over the last 14 years, with greater than 85,000 subscribers, has been translated into four other languages, and has more than 600 episodes. Tonight, we are back in Oxford at the historic St. Aldate’s Tavern. We are surrounded by centuries of scholarship, skepticism, and possibly a few pints of beer. Joining me to co-host this SGEM Xtra PUBcast is the wonderful Melanie Golob. She is a DPhil candidate in Evidence-Based Health Care here at Oxford. Melanie is also the HTA Program & FFS Operations Manager in the US. Melanie Golob has been a shining star of the DPhil Program for Evidence-Based Health Care and a real ambassador of Evidence-Based Medicine (EBM). Some of us who are older might say you are the Julie McKoy of the DPhil program. She makes everyone feel welcome and appreciated. Questions for Melanie Golob Listen to the SGEM Xtra podcast on iTunes or Spotify to hear Melanie's responses. Question#1: Why Oxford? What drew you here for your DPhil? Was it the Centre for Evidence-Based Medicine (CEBM) specifically? Is there something “statistically significant” about Oxford’s approach to EBM? Does being in a place with this much academic history change how you think? Responds Question#2: What is Your Research About? What problem are you trying to solve with a Living Evidence Synthesis (LES)? Why does “living” evidence matter? Are we ready for AI-assisted living evidence? Question#3: Advice for Future Oxford Students What advice would you give someone interested in doing a DPhil in Evidence-Based Health Care? What makes someone a good candidate? What’s the hardest and most rewarding part? Questions for DPhil Candidates Layal and Taylor Who are you (name and where are you from), and what brought you to Oxford? What is your area of research? What is the most challenging thing about being at Oxford, and the best thing? That concludes the second SGEM PUBcast. We will be back next episode, trying to cut the knowledge translation window from over 10 years to less than 1 year with the power of social media. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. Note: Other people mentioned on the PUBcast Ross Drain- 4th Year Medical Student at Keble College, University of Oxford Juliana Louw - 5th Year Medicine Student at University of Oxford and President of Oxford Lifestyle Medicine Society Carl Heneghen - Professor of Evidence-Based Medicine, University of Oxford Liam Barrett - Emergency Medicine Trainee pursuing a DPhil in Medical Sciences at the University of Oxford Nicholas De Vito - Postdoctoral researcher at the Bennett Institute for Applied Data Science Layal Bou Harfouch- Drug Policy Analyst at the Reason Foundation, DPhil Candidate at the University of Oxford and Founder of Omniwomyn Taylor Hirschberg - CEO Scientist, AI Healthcare Researcher, Pulitzer and GLAAD nominated, Documentary Film Maker and DPhil candidate at the University of Oxford.