The Skeptics Guide to Emergency Medicine

Reference: Gibbs et al. Noninvasive Ventilation for Preoxygenation during Emergency Intubation (The PREOXI trial). NEJM June 2024. Date: July 17, 2024 Guest Skeptic: Dr. Aine Yore is an Emergency Physician, practicing in the Seattle, Washington area for over twenty years. She is the former president of the Washington chapter of ACEP and her career focus outside of clinical practice has been largely devoted to health care policy. Case: A 70-year-old man presents to the emergency department (ED) with an exacerbation of COPD. He is hypoxic on arrival with an oxygen saturation of 80% on room air. Although his oxygenation improves to 92% with supplemental oxygen by nasal cannula, he desaturates with minimal exertion and shows increasing fatigue indicating a need for greater respiratory support. He refuses non-invasive mechanical ventilation, as he has not tolerated it in the past, but is agreeable to intubation. His wife, who has been watching the monitors intently, says she is worried. “His oxygen levels keep dropping. How will you intubate him without them going too low?” Background: Preoxygenation is a critical step in the management of airway interventions, especially in critically ill patients undergoing tracheal intubation. This process involves the administration of supplemental oxygen before the induction of anesthesia to increase the oxygen reserves in the lungs, thereby reducing the risk of hypoxemia. Hypoxemia during intubation can lead to severe complications, including dysrhythmia, cardiovascular collapse, hypoxic brain injury, and death. Therefore, effective preoxygenation is essential to enhance patient safety during this high-risk procedure. Traditionally, preoxygenation has been achieved using an oxygen mask, which can deliver a high fraction of inspired oxygen (FiO2) under ideal conditions. However, oxygen masks have limitations. They do not provide positive pressure or ventilatory support, and the actual FiO2 delivered can be significantly lower than expected if the mask does not fit well. This can be particularly problematic in critically ill patients, who often present with compromised respiratory function and may not tolerate the procedure well. An alternative method of preoxygenation is the use of non-invasive ventilation (NIV), which includes devices like continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). NIV offers several advantages over traditional oxygen masks. It delivers a high FiO2 and provides positive pressure support, which can help maintain airway patency and improve ventilation. This is particularly beneficial for patients who are critically ill, and the risk of desaturation is high. Despite its advantages, the use of NIV for preoxygenation is not without challenges. It requires more time to set up and may increase the risk of aspiration in certain patient populations. Recent studies have explored the efficacy of NIV compared to traditional oxygen masks in critically ill patients. The findings suggest that NIV significantly reduces the incidence of hypoxemia during intubation. These results are promising and may influence future guidelines and clinical practices, emphasizing the importance of optimizing preoxygenation strategies to improve outcomes in critically ill patients. However, the optimal preoxygenation strategy to reduce the risk of hypoxemia and potential harm from it has not yet been determined. Clinical Question: Among critically ill adults undergoing tracheal intubation, will preoxygenation with non-invasive positive pressure ventilation reduce the incidence of hypoxemia between induction to two minutes after tracheal intubation, compared to preoxygenation with facemask oxygen? Reference: Gibbs et al. Noninvasive Ventilation for Preoxygenation during Emergency Intubation (The PREOXI trial). NEJM June 2024. Population: Critically ill adults (18 years and older) undergoing tracheal intubation with a laryngoscope and sedation Exclusions: Pregnant women, prisoners, those already receiving positive-pressure ventilation, and those with conditions precluding NIV (e.g., vomiting, severe agitation, facial fractures). Intervention: Preoxygenation with noninvasive ventilation using a tight-fitting mask connected to either a conventional or dedicated noninvasive ventilator (NIV) for three to five minutes before induction. Comparison: Preoxygenation using an oxygen mask (nonrebreather mask or bag-mask device). Outcome: Primary Outcome: Hypoxemia during intubation, defined as oxygen saturation less than 85% during the interval between induction of anesthesia and 2 minutes after tracheal intubation. Secondary Outcomes: Lowest oxygen saturation during the interval between induction and 2 minutes after tracheal intubation. There were also several exploratory outcomes including outcomes related to procedural complications and clinical outcomes including mortality. There were also outcomes related to patient safety. These are listed in the suppl

Reference: Florin TA, et al. Radiographic pneumonia in young febrile infants presenting to the emergency department: secondary analysis of a prospective cohort study. Emerg Med J. 2023 Date: May 29, 2024 Guest Skeptic: Dr. Christina Lindgren is a Pediatric Emergency Medicine Attending at Children’s National Hospital and Assistant Professor of Pediatrics and Emergency Medicine at the The George Washington University School of Medicine and Health Sciences in Washington, DC. She also serves as the Associate Program Director for the Pediatric Emergency Medicine Fellowship. Dr. Christina Lindgren Guest Author: Dr. Todd Florin is a Pediatric Emergency Medicine Attending at Lurie Children’s Hospital of Chicago where he is also the Director of Research and Associate Professor of Pediatrics and Emergency Medicine at Northwestern University Feinberg School of Medicine. Case: A 6-week-old boy is brought by his family to the emergency department for fever. He was found to have a temperature of 38.4C at home this evening. His parents tell you that he has been congested for the past few days and his cough seems to have worsened. They have been using a bulb suction device at home to help him breathe better, and he is still tolerating breastmilk and formula. There is a school-age sibling at home with cough and congestion as well which she has successfully passed on to the rest of the family. On your physical exam, you note that he has clear nasal secretions, normal oxygen saturation, and appears well. His parents ask you, “He’s so little. Do you think he has pneumonia? His sister had pneumonia in the past and got a chest x-ray. Does he need a chest x-ray as well?” Background: We’ve covered the topics of febrile infants and pediatric pneumonia multiple times on the SGEM: SGEM #171: Step-by-Step Approach SGEM #296: PECARN Clinical Prediction Rule for Low-Risk Febrile Infants SGEM #241: American Academy of Pediatrics (AAP) Guidelines for the Management of Febrile Infants 8-60 days old SGEM #338: SAFER Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia SGEM #359: SCOUT-CAP Short vs Standard-Course Antibiotics for Community-Acquired Pneumonia in Children SGEM #387: Lumbar Punctures in Febrile Infants with Positive Urinalysis Dr. Todd Florin It only makes sense that today, we get to combine both topics in one episode and talk about pneumonia in febrile infants <60 days. Pneumonia is tough to diagnose in this very young population based on just clinical examination alone. This can be particularly challenging because there is a lot of crossovers with bronchiolitis. There is no evidence-based guidance as to who gets a chest X-ray (CXR) and who does not. This leads to a lot of practice variation. Clinical Question: What factors (demographic, clinical, laboratory) are associated with radiographic pneumonia in febrile infants? Reference: Florin TA, et al. Radiographic pneumonia in young febrile infants presenting to the emergency department: secondary analysis of a prospective cohort study. Emerg Med J. 2023 Population: Febrile infants ≤ 60 days with rectal temperature ≥38॰C with CXR performed Excluded: Infants who appeared critically ill, already receiving antibiotics, premature <37 weeks gestation), significant comorbidities, indwelling devices, focal bacterial infections (cellulitis) Intervention: Evaluation of radiographic pneumonia, classified into definite pneumonia, possible pneumonia, and no pneumonia. Comparison: None Outcome: Demographic, clinical, and laboratory factors associated with radiographic pneumonia. Trial: Secondary analysis of data from previous PECARN study conducted from June 2016 to April 2019 Authors’ Conclusions: Radiographic pneumonias were uncommon in febrile infants. Viral detection was common. Pneumonia was associated with respiratory distress, but few other factors. Although ANC and PCT levels were elevated in infants with definite pneumonia, further work is necessary to evaluate the role of blood biomarkers in infant pneumonias. Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Unsure Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Were there any conflicts of Interest declared and who funded the study? Dr. Ramilo reported personal fees from Sanofi-Pasteur, Merck, and Pfizer, and grants from Janssen and the Bill & Melinda Gates Foundation, unrelated to this study. No other conflicts were reported. The study was funded by the Euni

Reference: Tjan et al. Conflict in emergency medicine: A systematic review. AEM June 2024 Date: July 5, 2024 Guest Skeptic: Dr. Lauren Westafer an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She co-founded FOAMcast and is a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and a research methodology editor for the Annals of Emergency Medicine. Case: A 71-year-old patient with a history of hypertension and well-controlled diabetes mellitus without organ involvement presents with left lower abdominal pain, afebrile, blood pressure 138/70 mm Hg, heart rate 82 beats per minute, and oxygen saturation on room air 99%. They are afebrile and tolerate oral intake. The emergency department (ED) evaluation reveals an unremarkable chemistry panel with normal renal function and a white blood cell count of 10,000. An abdominal pelvic CT scan demonstrates uncomplicated left-sided diverticulitis. The patient is feeling well enough to go home and you discharge the patient to home without antibiotics and ask them to follow up with their primary care provider or return if they get worse. In follow-up, the patient’s primary care provider is upset that the patient was not started on antibiotics. Background: We have discussed agitation in the ED on the SGEM several times. This has included the use of haloperidol for agitation due to psychosis (SGEM#45), droperidol for acute agitation (SGEM#328) and the problem with the term “excited delirium” (SGEM#218 and SGEM Xtra). We have also done an episode on rudeness and its impact on medical team performance (SGEM#227) and the prevalence of inter-physician professional weight bias (SGEM#343). One thing we have not specifically discussed is the conflict between clinicians. Conflict in the workplace is defined as a process beginning when individuals or groups perceive differences and opposition regarding interests, beliefs, or values. Workplace conflicts typically involve task issues (disparities in procedures, priorities, or resource allocation) and relationship (socioemotional) issues (breakdowns in interpersonal interactions). In healthcare, conflicts are attributed to factors like incompatible personal motivations, high workload, stress, role ambiguity, and poor leadership. Such conflicts hinder cohesive teamwork and decision-making, potentially compromising patient safety. These conflicts can ultimately lead to moral injury [1,2,3]. Conflicts in the ED often stem from clinical decision-making and actions, leading to potential adverse patient events and exacerbating access block issues. While individual studies have identified various factors contributing to conflict, there has been a lack of comprehensive reviews specific to the ED setting. Understanding the individual, team-level and systemic factors that contribute to conflict among clinicians in the ED may provide insights on ways to help efforts to reduce conflict. Clinical Question: What drives conflict in emergency medicine and are there strategies to reduce conflict? Reference: Tjan et al. Conflict in emergency medicine: A systematic review. AEM June 2024 Population: Empirical, peer-reviewed journal articles written in English about conflict in the ED context that answered one of the identified research questions. Participants included ED physicians, ED nurses, internal medicine (IM) physicians, surgeons, health care technicians, managers, and primary care providers. Excluded: Studies that didn’t focus on the ED context, did not address any specified research questions, nonempirical articles such as commentaries, opinion pieces, letters to the editor, non-English papers Intervention: Strategies and approaches to managing and resolving conflicts in the ED. These included communication training, handover standardization protocols, improving admission guidelines, changes in communication systems, and efforts to improve interpersonal and interdepartmental relationships. Comparison: The strategies for managing conflicts were compared to the usual practices and environments where such strategies were not implemented or where traditional methods were used. Outcomes: What constitutes conflict in the ED? What factors contribute to conflict in the ED? What strategies can be employed to address and resolve conflict in the ED? Type of Study – Systematic review Dr. Lee Wong This is an SGEMHOP episode, and it is my pleasure to introduce Dr. Lee Wong. He is an emergency physician at the Austin Hospital in Melbourne, Australia. He also just got a PhD from Swinburne University, Melbourne, researching Leader Identity Threat in emergency medicine. We also have the lead author, Mr. Timmothy Tjan. He is a final-year medical student at Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia. Authors’ Conclusions: “In emergency medicine, conflict is common and occurs at multiple levels, re

Date: June 29, 2024 Reference: Herbert L. Fred M.D. (1998) Old-Fashioned Doctors, Hospital Practice. This is an SGEM Xtra episode. I was honoured to be invited by Dr. Fernada Bellolio to the Mayo Clinic and present to the Department of Emergency Medicine. They were kind enough to allow me to speak about any topic. I decided to talk about an article Dr. Herbert L Fred published in 1998. You can get a copy of the slides by clicking on this LINK. When I say the term “Old fashioned” what comes to mind? Every generation of adults has been critical of the younger generation. This goes back a very long time. There is a wonderful comedy sketch by Monty Python called Four Yorkshiremen. These successful old men talk about how hard it was when they were growing up. One man complained he “lived for three months in a paper bag in a septic tank. We used to have to get up at six in the morning, clean the paper bag, eat a crust of stale bread, go to work down t' mill, fourteen hours a day, week-in week-out, for sixpence a week, and when we got home our Dad would thrash us to sleep wi' his belt.” This prompts another man to say… “luxury”. If you have never seen the Monty Python skit you check it out on YouTube. There is also a 90-second video that illustrates older generations crapping on the younger generation for thousands of years (The History of Adults Blaming the Younger Generation). Now that we have discussed the concept of being old-fashioned in general, let’s talk about old-fashioned doctors specifically. Isaac and Fitzgerald in the BMJ 1999 described seven alternatives to evidence-based medicine (EBM). One of the alternatives they were suggesting with their tongue firmly in their cheek was an old-fashioned doctor practicing Eminence-Based Medicine (EmBM). “The more senior the colleague. The eminent physician with the white hair and balding patch are called the “halo” effect. They place less importance on the need for anything as mundane as evidence. Experience, it seems, is worth any amount of evidence. These colleagues have a touching faith in clinical experience, which has been defined as ‘‘making the same mistakes with increasing confidence over an impressive number of years.” Dr. Herbert Fred This brings us to the article that this lecture is based on. Dr. Herbert L Fred wrote an opinion piece in the journal Hospital Practice in 1998. Dr. Fred was born in Waco Texas, went to medical school at Johns Hopkins, did his internal medicine at the University of Utah, served in the US Air Force and then went on to teach for nearly 6 decades at Baylor College of Medicine and The University of Texas Health Science Center at Houston. In his article, Dr. Fred commiserated by saying “In the 40 years that I have been a full-time medical educator, much has changed regarding what we teach and how we teach our students and house officers. As a consequence, I now confine myself to teaching basic medical principles-principles that should never change. But even so, today’s trainees tell me that what I say and do is old-fashioned.” It sounds like a little bit of ageism from his students. His article responded with what could be interpreted as some ageism about the students. Reading the article it can come across as condescending and paternalistic giving off a strong "OK Boomer" vibe. After Dr. Fred makes a dozen complaints, he concludes the article with “If so, then I am proud to be old-fashioned. And I believe that if more doctors today practiced medicine the old-fashioned way, our profession might regain some of the nobility and respect it once enjoyed.” I posted this article to social media asking if others considered themselves “old-fashioned”. The vast majority of people responded with positive comments and emojis. However, some pointed out another valid perspective about the condescending tone and ageism expressed in the article by Dr. Fred. I wanted to go through ten of his comments and show how these things are not necessarily old-fashioned or new-fashioned but rather timeless axioms of good medical practice. 1. Time With Patients "Is it because old-fashioned doctors spend whatever time it takes to obtain a good medical history and physical examination?" Seriously, we all would probably like to spend more time with our patients. Back in the 1960’s the emergency room was literally a ROOM. There was no specialty of emergency medicine (EM). The physician could take time and sit at the bedside longer and focus on the one patient in the only room. Things have changed significantly and it is now an emergency DEPARTMENT (ED). There is also the current reality of metrics forcing doctors to move faster, be more “efficient” and “meet ‘em, greet ‘em and street ‘em”. Then there is the dumpster fire of COVID-19 leading to the entire healthcare system seemingly signing out to the ED. We are expected to do primary care, manage post-op complications, be mental health experts, substance use disorder specialists,

Reference: Peters MJ, et al. Conservative versus liberal oxygenation targets in critically ill children (Oxy-picu): a UK multicentre, open, parallel-group, randomised clinical trial. Lancet. December 2023 Guest Skeptic: Dr. Anireddy Reddy is a pediatric intensive care attending physician in the Department of Anesthesiology and Critical Care Medicine at Children’s Hospital of Philadelphia. Dr. Anireddy Reddy Case: A 3-year-old girl presents to the emergency department (ED) with fever and respiratory distress. Her parents tell you that she has been sick for almost a week and her symptoms seem to be getting worse. In the past few days, her appetite has decreased, and she is breathing harder. On your exam, you note that she is very tired and can barely keep her eyes open. Her oxygen saturation is 78% on room air. She is breathing at a rate of 70 breaths per minute with diffuse retractions and nasal flaring. Your ED team quickly intubates her and places her on a ventilator. There is some improvement in her oxygen saturation to 92% and she is drawing adequate tidal volumes. The respiratory therapist asks you whether you want to increase the FiO2 to improve her oxygen saturation while awaiting transport to the pediatric intensive care unit. Background: Oxygen is one of the most prescribed therapies. Sometimes it almost feels like a knee-jerk reaction. We see that pulse ox saturation is low and the first thing we do is apply some form of oxygen. But like many interventions, there are potential harms and benefits. Yes, we purposely use the language of potential harms and benefits rather than risk and benefits. Using the term “risk” implies that a negative outcome may or may not happen. While the term “benefits” implies a positive outcome. It’s unbalanced. Too much oxygen has not been shown to improve outcomes in some conditions and has been associated with harm in others. Our guidelines for the treatment of pediatric acute respiratory distress syndrome also recommend a target saturation of 88-92%. Clinical Question: What is the optimal target for systematic oxygen in critically ill children receiving invasive ventilation? Reference: Peters MJ, et al. Conservative versus liberal oxygenation targets in critically ill children (Oxy-picu): a UK multicentre, open, parallel-group, randomised clinical trial. Lancet. December 2023 Population: Children >38 weeks corrected gestational age and younger than 16 years enrolled within 6 hours of being admitted to the Pediatric Intensive Care Unit (PICU) and receiving invasive mechanical ventilation with supplemental oxygen Excluded: known or suspected congenital cardiac disease or sickle cell disease, known pulmonary hypertension, when brain pathology/injury was the primary reason for admission, not expected to survive ICU admission, receiving long-term invasive mechanical ventilation prior, or have end-of-life care plans with limitations in resuscitation Intervention: Conservative oxygenation, defined as a target peripheral oxygen saturation (SpO2) of 88% to 92%. Comparison: Liberal oxygenation, defined as target SpO2 >94% Outcome: Primary Outcome: Duration of organ support at 30 days. This was a rank-based endpoint scored 1 to 30, and 31 if the patient died. Major components of organ support included respiratory (invasive and non-invasive), cardiovascular (vasoactives and fluid boluses), renal support, analgesia/sedation, transfusion, neurological, and metabolic support. Details can be found in the supplemental material. Secondary Outcomes: Mortality at PICU discharge, time to liberation from invasive mechanical ventilation, duration of organ support, length of PICU and acute hospital stay, functional status at PICU discharge, incremental costs at 30 days Trial: Pragmatic, multicentre, open-label, randomized controlled trial Authors’ Conclusions: “Among invasively ventilated children who were admitted as an emergency to a PICU receiving supplemental oxygen, a conservative oxygenation target resulted in a small, but significant, greater probability of a better outcome in terms of duration of organ support at 30 days or death when compared with a liberal oxygenation target. Widespread adoption of a conservative oxygenation saturation target (SpO2 88–92%) could help improve outcomes and reduce costs for the sickest children admitted to PICUs.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No. The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Unsure The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Unsure Follow-up was compl

Reference: Jansen et al. Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial. JAMA. 2023 Date: June 10, 2024 Guest Skeptic: Dr. Rob Leeper is an intensivist, trauma surgeon, and general surgeon at Western University where he also serves as the director of the Royal College Surgical Foundations program. He is particularly enthusiastic about medical education and the use of high-fidelity simulation to identify latent threats to patient safety and improve team-based crisis resource management. Case: A 24-year-old patient is involved in a high-speed motor vehicle collision. The patient was the intoxicated driver of a sport utility vehicle that left the road and collided head-on with a traffic light. The driver was ejected from the vehicle. On scene, he has a Glasgow Coma Scale (GCS) score of 14, is tachycardic at 130 beats per minute and hypotensive at 85/50 mmHg. He complains of severe pain in his abdomen and left upper extremity. He has an obvious angulated deformity of his left wrist. Pre-hospital personnel placed the patient in a cervical spine collar, obtained peripheral intravenous (IV) access, administered 250cc of 0.9% saline and provided rapid transport to the local trauma center which is less than 15 minutes away. On arrival at the trauma center, the patient’s vital signs and symptoms remain essentially unchanged from those on scene. You initiate standard, simultaneous assessment and resuscitation following the Advanced Trauma Life Support (ATLS) principles. You are debating the addition of resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct to your standard care. You wonder what the evidence is for this additional approach. Background: We covered REBOA on the SGEM 5 years ago with Dr. Robert Edmonds (SGEM#258). That was a review of a retrospective observational study of 593,818 trauma patients of which 140 received REBOA compared to 240 matched controls who did not receive this treatment. The overall mortality was worse with REBOA (35.7% vs. 18.9%, p=0.01). The SGEM bottom line in 2019 was that REBOA is currently an intervention of uncertain benefit. Although it has shown promise in some studies, this investigation leaves its therapeutic potential in question and arguably demonstrates harm. There may be substantial benefits in select groups of trauma patients, but these groups are not yet known. Trauma surgeons are hemorrhage control surgeons. Bleeding is the enemy and patient survival turns tenuously on our ability to identify and staunch hemorrhage in as expedient a fashion as possible. Time is our currency and, for patients with massive hemorrhage, minutes matter. Every strategy that enhances time to hemorrhage control is deserving of examination: Trauma Systems - Enhancing the training and tools for our pre-hospital teams, faster helicopters, more trauma centers, etc. Hemostatic Resuscitation - Permissive hypotension, whole blood and factor ratio resuscitation, warmed products, dynamic coagulation monitoring, etc. Enhanced Operative Strategies - Damage control surgery with truncated interventions, energy devices, hemostatic foams/gels/packs, etc. These approaches hold the possibility of enhancing our ability to save patient’s lives. One approach, which has seen a revival in its interest and utilization, is proximal balloon occlusion of the aorta. The rationale is simple, occluding the aorta above the level of bleeding will de facto reduce blood loss at the site of injury and lead to immediately increased blood pressure and, presumably, perfusion to the zone above the occlusion, typically the upper body, the heart, and the brain. A great variety of medical devices designed for this purpose have come to market over the last 15 years and a relatively heterogeneous collection of retrospective clinical data has been published with conflicting results. There are signals of improvement but also signals of harm with this technique. Given this equipoise, a robust prospective clinical trial was undertaken by a group of international trauma providers and researchers. The UK-REBOA was designed and conducted across 16 English trauma centers from 2017 to 2022 to provide the most evidence-based answer to the question of whether the addition of REBOA to standard care improves survival in massively bleeding trauma patients. Clinical Question: Does the addition of REBOA to standard trauma resuscitation practice improve survival for injured patients presenting to lead trauma centres with massive hemorrhage? Reference: Jansen et al. Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial. JAMA. 2023 Population: Adults aged 16 years or older presenting to 16 major trauma centers in the UK (2017-2022) with confirmed or suspected life-threatening torso hemorrhage am

Reference: Kruse et al. Systematic Review, Quality Assessment, and Synthesis of Guidelines for Emergency Department Care of Transgender and Gender-diverse People Recommendations for Immediate Action to Improve Care. WJEM December 2023 Date: May 30, 2024 Guest Skeptic: Dr. Kay Dingwell is a rural emergency physician working in Prince County, PEI with a special interest in gender-affirming care and improving the care of trans and gender-diverse patients. Case: A 16-year-old nonbinary youth on testosterone blockers and oestrogen has come into your emergency department (ED) having twisted their ankle while playing soccer. You learn they are ordering hormones online as they do not have any gender-affirming primary care. You don’t see a large number of trans patients in your ED and you wonder if there might be specific recommendations that can guide your care of this adolescent. Background: In North America, trans and gender diverse (TGD) people make up 0.3% to 0.6% of the overall population, and up to 4.1% of the adolescent population according to Statistics Canada [1] and The Williams Institute in the US [2]. It has been shown in previous research that TGD individuals have both high ED avoidance due to discrimination, as well as a high need for emergency services due to the impacts of minority stress on this population [3,4]. Trans individuals are at higher risk of experiencing violence, adverse substance use, homelessness, and mental health challenges, among other challenges which may impact their health. These patients often report negative experiences when accessing emergency care, and there is an established lack of research to guide their care in the emergency department. A group of researchers, including members of the queer community, set out to perform a systematic review, quality assessment, and synthesis of clinical practice guidelines and best practice statements on the care of transgender and gender-diverse individuals at any stage of accessing emergency department care. Clinical Question: What clinical practice guidelines (CPGs) exist to inform the care of transgender and gender diverse (TGD) patients in the emergency department? Reference: Kruse et al. Systematic Review, Quality Assessment, and Synthesis of Guidelines for Emergency Department Care of Transgender and Gender-diverse People Recommendations for Immediate Action to Improve Care. WJEM December 2023 Population: Transgender and gender-diverse populations of any age, in any setting, region, or nation. It included both medical and paramedical care within these groups. Exclusions: Not a guideline or best practice statement, or guidelines/BPS not relating to TGD patients or ED care, full text not available, or not in English Intervention: There was no intervention. The study looked at implementing clinical practice guidelines (CPG) and best practice statements (BPS) for the care of TGD individuals in ED. Comparison: The guidelines and statements were assessed against quality standards using the AGREE-II and AGREE-REX criteria, rather than comparing different types of care or interventions against each other. Primary Outcome: The identification and assessment of the quality and applicability of guideline recommendations relevant to ED care of TGD people. Authors’ Conclusions: “This is the most comprehensive review of clinical practice guidelines and best practice statements for ED care of transgender-diverse populations to date and reveals several important actionable recommendations for the care of TGD people in the emergency department.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes The search for studies was detailed and exhaustive. No The primary studies were of high methodological quality. Unsure The assessment of studies were reproducible. Yes The outcomes were clinically relevant. Yes There was low statistical heterogeneity for the primary outcomes. No The treatment effect was large enough and precise enough to be clinically significant. No Conflicts of Interest: There were no financial conflicts of interest or sources of funding to declare. Key Results: The initial search identified 1997 articles, with 291 moving on to full-text review after the application of inclusion criteria, resulting in a further 190 being excluded. Of the remaining studies, seven articles had a total of ten recommendations that were relevant to any stage of emergency care. They analyzed these using the AGREE-II tool to assess the methodological quality, and then the AGREE-REX tool to assess the quality and strength of the ten guideline recommendations, eight of which ended up being recommended for use by the assessors as two had no consensus. The eight recommendations include four on sexual health, one on primary care access, one on training ED staff in culturally competent care of TGD patients, one on substance use, and one on mental health. Primary Outcome: Eight Recommendations Transgender people i

Reference: Tavender E, et al. Triage tools for detecting cervical spine injury in paediatric trauma patients. Cochrane Database Syst Rev. 2024 Date: May 29, 2024 Guest Skeptic: Dr. Caleb Ward is a pediatric emergency medicine attending and Associate Professor of Pediatrics and Emergency Medicine at Children’s National Hospital and The George Washington School of Medicine and Health Sciences in Washington, DC. His research focuses on the pre-hospital care of children by EMS. He is the principal investigator for EMSC State Partnership in Washington, DC and is also involved in various multi-center EMS studies with the Pediatric Emergency Care Applied Research Network (PECARN). Dr. Caleb Ward Case: A 4-year-old boy is brought to the emergency department (ED) by Emergency Medical Services (EMS) after falling from a tall tree. The fall was witnessed by his family. They tell you that he is going through a Spiderman phase and tries to climb everything. They saw him slip off the tree and landed in the grass below. He did not have any loss of consciousness. EMS placed him in a C-collar and brought him to you. On examination, you only notice a few scrapes, but he is cradling his left arm and complaining that it hurts. There looks to be an obvious deformity of his forearm. The family members ask you, “he seems uncomfortable in the neck collar, can we remove it? Do you think he injured his neck?” Background: Pediatric cervical spine injuries (CSI), though rare, can have devastating consequences if missed. Imaging studies include X-rays, CT scans, and MRIs. Typically, we see the use of X-ray or CT more often in the acute setting. The downside of these methods is exposing children to radiation. Clinical Decision Rules (CDRs) have been developed to help guide decision-making and minimize unnecessary tests and imaging while detecting significant injuries. Because there is no standardized process for identifying children with CSI after blunt trauma, practice varies based on clinician, institution, location, and available resources. We have covered some of these CDRs in pediatrics on the SGEM before: Ankle and Knee Injuries (SGEM#3, SGEM#5) Trauma (SGEM#127) Appendicitis (SGEM#155) Head Trauma (SGEM #412, SGEM #225) Febrile Infants (SGEM#171, SGEM #296) While there are CDRs for cervical spine injury in adults like the Canadian C-spine Rule and NEXUS criteria for C-spine imaging, we do not have a dedicated, accurate CDR for pediatric patients. Clinical Question: Which triage tools or Clinical Decision Rules (CDRs) are most effective for detecting cervical spine injuries in pediatric trauma patients? Reference: Tavender E, et al. Triage tools for detecting cervical spine injury in paediatric trauma patients. Cochrane Database Syst Rev. 2024. Population: Children (aged 0 to <18 years) who underwent blunt trauma evaluation in emergency departments. (ED) Excluded: Patients with previous cervical spine surgery or congenital cervical spine anomalies Intervention: Application of various CDRs or sets of clinical criteria to evaluate the presence of cervical spine injuries following blunt trauma. Comparison: The CDRs were compared with each other and with reference standards like X-ray, CT, MRI, or clinical clearance/follow-up in low-risk children. Outcome: The primary outcome of interest was the diagnostic accuracy of the CDRs, specifically their sensitivity and specificity in detecting cervical spine injuries. Trial: Systematic review Authors’ Conclusions: “There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.” Quality Checklist for Systematic Review Diagnostic Studies: The diagnostic question is clinically relevant with an established criterion standard. Yes The search for studies was detailed and exhaustive. Yes The methodological quality of primary studies were assessed for common forms of diagnostic research bias. Yes The assessment of studies was reproducible. Yes There was low heterogeneity for estimates of sensitivity or specificity. Unsure The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision-making models. No Were there any declared financial conflicts of interest? No financial conflicts of interest Results: The five included studies reported a total of 21,379 children, with age ranges from less than 3 years to under 18 years. Studies were conducted in various countries including the USA, UK, Australia, Canada, and Brazil. The median prevalence of CSI was 0.98% with IQR of 0.5% to

Reference: Borgundvaag et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department. AEM May 2024 Date: May 22, 2024 Dr. Bjug Borgundvaag Guest Skeptic: Dr. Bjug Borgundvaag is the Founding Director of the Schwartz/Reisman Emergency Medicine Institute (SREMI), at Sinai Health System. He is a Professor of Emergency Medicine and a Clinician Scientist in the Department of Family and Community Medicine at U of T. Prior to his medical training, he completed a PhD in Pharmacology at U of T. He has been involved in ED-based clinical research examining ways to improve care for patients with alcohol use disorder in the ED for over two decades. This is an SGEM HOP but with a twist. We are not going to do a structured critical appraisal of GRACE4 but rather turn it into an SGEM Xtra. When we combine SGEMHOP with an SGEM Xtra I hope we get some…AMAZING knowledge translation for GRACE4. "The SAEM GRACE program addresses the best practices for the care of the most common chief complaints that can be seen on the tracking board of any emergency department in the country, based upon research and expert consensus. These guidelines are designed with de-implementation as a guiding principle to reasonably reduce wasteful testing, provide explicit criteria to reduce foreseeable risk, and define sensible and prudent medical care." GRACE1: Recurrent, Low-Risk Chest Pain GRACE2: Recurrent, Low-Risk Abdominal Pain GRACE3: Acute Dizziness & Vertigo For this SGEMHOP Xtra combo episode on GRACE4, we are going to give a case scenario, a little background information, ask a clinical question, provide authors’ conclusions, go through the recommendations and a case resolution. Case 1: A patient presents to the ED with nausea, vomiting and some abdominal pain complaining of alcohol withdrawal. He reports that his last drink was 9 hours ago, and he typically consumes 60 oz of spirits/day. He has had prior hospital admissions for the management of alcohol withdrawal, including seizures and one prior episode of delirium tremens. Management: The patient is initiated on a Clinical Institute Withdrawal Assessment (CIWA) protocol and administered intravenous (IV) doses of diazepam hourly for the next 18 hours. There was a 6-hour delay until the first dose of diazepam was administered. Over those 18 hours, his CIWA stubbornly stays at around 18, and by the 15-hour mark, has increased to 21 despite receiving 20mg of diazepam hourly. By the 18-hour mark, he has had a total of 240 mg of diazepam and is getting worse. Clinical Question 1: Is IV phenobarbital, in addition to diazepam, helpful in managing this case of severe alcohol withdrawal? Authors’ Conclusions: There is limited direct high-quality evidence from clinical trials supporting the use of phenobarbital as an adjunct to benzodiazepines for managing moderate to severe AWS in the ED setting. Although the direct prospective evidence comparing these interventions in ED patient populations is limited, the balance between desirable and undesirable effects favours adjunctive phenobarbital over benzodiazepine alone. This is based, in large part, on indirect evidence illustrating the benefits of adjunctive phenobarbital including, but not limited to, reduction on the need for intubation, decreased hospital length of stay, decreased ICU admission and length of stay. Recommendation 1: In adult ED patients (over the age of 18) with moderate to severe alcohol withdrawal, who are being admitted to the hospital we suggest using phenobarbital in addition to benzodiazepines as compared to using benzodiazepines alone. (Conditional recommendation, FOR) [Low to Very Low certainty of evidence] Good practice statement: All patients treated for alcohol withdrawal should be offered follow-up treatment where such treatment is available. Case 1 Resolution: After receiving 240 mg of diazepam over 18 hours with no improvement, the patient was given phenobarbital 5 mg/kg as an infusion. The patient’s symptoms showed significant improvement, and 1 hour later the patient was given an additional 5 mg/kg dose resulting in complete symptom resolution. Case 2: A female patient presents to the ED with moderate alcohol withdrawal. She has consumed 26 oz of vodka a day, for the last four years. She has no history of being admitted to the hospital for the management of alcohol withdrawal syndrome (AWS). Background 2: The patient is treated with diazepam using a symptom-driven approach including hourly CIWA assessments including long-acting benzodiazepines to manage symptoms according to severity. Her AWS resolves over the next 8 hours, and she is ready to be discharged home by the end of your shift. You make a referral to a local addiction medicine service for her to be seen a few days later. Clinical Question 2: Should this patient be offered anti-craving medication upon discharge? Autho

Date: May 13, 2024 Guest Skeptics: Dr. Rebecca Szabo is an obstetrician/gynecologist and medical educator specializing in simulation from Melbourne, Australia working at The Royal Women’s Hospital and The University of Melbourne. This is her first time as a guest skeptic on the SGEM, she has created FOAMed content through various media, including the MedEd Stuff N Nonsense Podcast. Dr. Dennis Ren is a pediatric emergency medicine physician at Children’s National Hospital in Washington, DC. He is the lead for SGEMPed and has created content for other FOAMed sites like First10EM, Don’t Forget the Bubbles, and PedsRAP. This is an SGEM Xtra episode discussing lessons we learned from watching the show Ted Lasso. We have done other SGEM Xtra episodes looking at how various pop cultures impacted us as physicians and influenced us as people. SGEM Xtra: Star Trek Made Me A Better Physician with kindness mentor Dr. Brian Goldman SGEM Xtra: Lead Me On – What I Learned from Top Gun with my BFF Dr. Chris Carpenter SGEM Xtra: Holding Out for a Hero – Lessons from The Dark Knight with PEM superhero Dr. Dennis Ren Five Questions for the Guest Skeptics Why did you like the show so much? Who is your favourite character? Who do you identify most within the show? What friend do you have that represents the ethos of the show? Who do you think needs to watch the show? Listen to the SGEM podcast on iTunes or Spotify to hear Dennis and Rebecca's answers. Ten Lessons Learned from Watching Ted Lasso Be Curious, Not Judgemental Optimism and Positivity Be a Goldfish Empathy and Compassion Vulnerability Open-mindedness The Importance of Family Learning from Failure Leadership Inclusivity and Respect Listen to the SGEM Xtra podcast on iTunes or Spotify to hear Rebecca and Dennis discuss these lessons. The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. So, patients get the best care, based on the best evidence. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

Reference: Jain A, et al. Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial. Br J Surg. March 2023 Date: May 7, 2024 Guest Skeptic: Dr. Brian Lee is a pediatric emergency medicine attending at the Children’s Hospital of Philadelphia and Assistant Professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania. Dr. Brian Lee Case: A 5-year-old girl comes to the emergency department (ED) after smashing her finger with a hammer. Her mother, who possesses a strong “do-it-yourself” attitude, was busy constructing a bookshelf for her daughter when the girl grabbed a hammer to help and promptly dropped it on her finger. On your exam, the girl is tearful and has a bloody index finger, and the fingernail is almost nearly avulsed. She is otherwise uninjured. Her mother tells you, “I remember this happening to me when I was younger, and they had to remove my fingernail. Is there any way to save the fingernail?” Background: Fingertip and nail bed injuries are some of the most common hand injuries in children. These can range from subungual hematomas to lacerations to partial amputations. Fingers and hands are important for performing daily activities, and we want to ensure that these injuries heal appropriately. That includes considerations for function and cosmesis. Some myths have been perpetuated throughout the years regarding finger injuries. For example, the teaching that if a subungual hematoma is >50% of the nail bed, then the nail should be removed because there is likely an underlying nailbed laceration that needs to be repaired. This is not true because we have learned that if the nail is otherwise intact, we can just trephinate it and be done.[1] Another practice that we’ve encountered in fingertip injuries where the nail is avulsed is replacing the nail during the repair. Reasons for that practice include protecting the repair, splitting the nail fold, and reducing infection. But there is not really high-level evidence to back up those claims, and some centers have even advocated for not replacing the nail given the challenges of adequately cleaning the native nail. [2] Suturing nailbeds and suturing avulsed fingernails back on tend to be a bloody mess. This might be the time for the “don’t just do something, stand there” approach [3]. Clinical Question: Is discarding the fingernail during nail bed repair superior to retaining it? Reference: Jain A, et al. Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial. Br J Surg. March 2023 Population: Children less than 16 years of age with nail bed injury to a single finger occurring within 48 hours of presentation believed to require surgical repair Exclusion: Infected injury, underlying nail disease, deformity to the injured finger, amputation, loss of nail bed requiring reconstruction, multiple nail bed injuries Intervention: Fingernail replacement after debridement and suturing of the nail bed or fingernail substitute like foil. Comparison: No fingernail replacement. Outcome: Primary Outcome: Co-primary outcomes of surgical site infection at 7-10 days and cosmetic appearance of the nail using the Oxford Fingernail Appearance Score (OFNAS) Secondary Outcomes: Quality of life based on the EuroQol Five Dimensions (EQ-5D-Y), pain at first dressing change, surgical site infection by 4 months, parent assessment of nail appearance at 4 months, cost difference Trial: Multicentre, pragmatic two-arm parallel-group superiority randomized controlled trial Authors’ Conclusions: “After nail bed repair, discarding the fingernail was associated with similar rates of infection and cosmesis ratings as replacement of the fingernail, but was cost saving.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No The patients were adequately randomized. Yes The randomization process was concealed. No The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). No The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Unsure Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. Yes Financial conflicts of interest. None. Results: They recruited 451 children presenting to 20 secondary-care hospitals with 224 allocated to the nail-discarded group and 227 in the nail-replaced group. The average age was approximately 5.9 years, about 54% of participants were male and most injuries were due to crush and avulsion of

Reference: Tanner et al, A retrospective comparison of upper and lower extremity intraosseous access during out-of-hospital cardiac arrest resuscitation. Prehospital Emergency Care. February 2024. Date: April 25, 2024 Guest Skeptic: Missy Carter is a PA working in an ICU in the Tacoma area and an adjunct faculty member with the Tacoma Community College paramedic program. She is also the local director of the difficult airway EMS course at Washington State. Case: EMS arrives with a 58-year-old woman who suffered an out-of-hospital cardiac arrest (OOHCA). When emergency department (ED) staff roll her to remove her clothing her humeral intraosseous (IO) is dislodged. Later the medic asks you if she should bother placing an upper extremity IO or just stick with the tried-and-true tibial plateau. Background: We have looked at getting access in the pre-hospital setting on SGEM#231. That episode was a study comparing intravenous (IV) vs IO access for OOHCAs. It was a secondary analysis of an observational study which showed an association between decreased favourable neurologic outcomes in the IO group compared to the IV group. Despite that weak evidence, placement of IO in OOHCA has become a routine procedure for many EMS providers. The classic location for IO placement is the tibial plateau. This is because of the ease of finding anatomic landmarks and their location away from other procedures like defibrillation, CPR, and airway management. Some studies have suggested quicker delivery of medications and fluids through the upper extremity IO route compared to the lower extremity route. Clinical Question: Does upper extremity placement of intraosseous access versus lower extremity placement matter in out-of-hospital cardiac arrest? Reference: Tanner et al, A retrospective comparison of upper and lower extremity intraosseous access during out-of-hospital cardiac arrest resuscitation. Prehospital Emergency Care. February 2024. Population: Adults 18 or greater with an OOHCA Excluded: IV access before IO, DNR, interfacility transfers, and EMS-witnessed arrests Intervention: Upper extremity IO placement (100% humeral) Comparison: Lower extremity IO placement (97.8% tibial & 2.3% femoral) Outcome: Primary Outcome: Return of spontaneous circulation (ROSC) Secondary Outcomes: Survival to hospital discharge and survival to discharge home. Authors’ Conclusions: “In this large prehospital dataset, upper extremity IO access was associated with a small increase in the odds of ROSC in comparison to lower extremity IO access. These data support the need for prospective investigation of the ideal IO access site during OHCA resuscitation.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Yes Was the follow-up of subjects complete enough? Unsure How precise are the results? Very Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes and No Results: The study population consisted of 155,884 patients, with 76% receiving lower extremity access and 24% upper extremity access. The median age was 65 years, 61% being male, 81% presumed a cardiac etiology and 54% were witnessed arrests. Key Results: Upper extremity IO access was associated with slightly greater odds of achieving ROSC compared to lower extremity IO access. Primary Outcome: Odds Ratio (OR) for ROSC was 1.11 [95% CI: 1.08 to 1.15] Secondary Outcomes: Survival to discharge OR 1.18 [95% CI; 1.00 to 1.39] Survival to discharge to home OR 1.23 [95% CI; 1.02 to 1.48] 1. Retrospective Observational Study: The study's retrospective observational design could lead to potential biases from unmeasured confounder factors. 2, Upper or Lower: 76% of the IOs which were placed were performed in the lower extremity (98% tibial and 2% femoral). The remaining 24% were all upper (humeral). It would be interesting to know what factors determined the insertion site chosen and if this might affect the outcomes. 3. Loss to Follow-up: There was 17% of patients lost to follow-up. Given the small effect sizes observed in the study, this could have been biased by the results if those patients were systematically different. 4. Subgroup Analysis: Intubated patients with upper extremity IO did worse than intubated patients with lower extremity IO. Is this an outlier or is it possible that doing multiple complex procedures distracts the team from providing meaningful procedures (high-quality CPR and defibrillation) in a timely manner? Another subgroup difference observed was patients with shorter ischemic time (witnessed arrest and/or bystander CPR) and

Reference: Ramesh S, Ayyan SM, Rath DP, Sadanandan DM. Efficacy and safety of ultrasound-guided erector spinae plane block compared to sham procedure in adult patients with rib fractures presenting to the emergency department: A randomized controlled trial. AEM April 2024 Date: April 19, 2024 Guest Skeptic: Dr. Suchismita Datta. She is an Assistant Professor and Director of Research in the Department of Emergency Medicine at the NYU Grossman Long Island Hospital Campus. Case: You are doing great things and helping many patients during your shift in the emergency department (ED) when you hear a trauma alert being called overheard. You walk over to the trauma room, and you see a healthy-looking 52-year-old male complaining of chest trauma after being involved in a motor vehicle collision before arrival. His imaging shows mildly displaced rib fractures of ribs four through seven. He is stable but complaining of pain despite initial IV acetaminophen and ketorolac. You offer him some opioids which he says makes him throw up. He’s been texting with his daughter who is an emergency medicine ultrasound fellow, and she mentioned something about using the ultrasound to inject something to decrease his pain. Background: We have covered rib fractures once before on the Skeptics' Guide to Emergency Medicine. This was on SGEM#324 looking at using spirometry to guide discharging older patients with rib fractures. The evidence was not robust enough back in 2021 to confidently use this potential tool. We know that rib fractures are associated with an increased risk of morbidity and mortality – specifically related to hypoventilation-related complications [1]. These risks are particularly higher in the elderly [2]. A clinical decision tool called the STUMBL score was derived and validated by Battle et al in 2014 [3]. It risks stratified older patients with blunt trauma. An attempt was made to externally validate this tool in New Zealand by Murkerji et al 2021 [4]. It did not perform as well which is not unusual for a clinical decision instrument [5]. Rib fractures can cause lung splinting and therefore, pain management is a very important part of the management of rib fractures. In addition to coming with a litany of undesired systemic side effects such as a depressed level of consciousness and decreased respiratory drive, opioid pain medications are also short-acting and require frequent redosing. With the 2014 CDC declaration that prescription drug overdose is one of the five top health threats, there has been a movement away from opioids as the mainstay of pain management for rib fractures [6]. There have been some studies that looked at the efficacy of alternative pain management strategies, but very few have looked at the efficacy or safety of ultrasound-guided erector spinae plane block. Clinical Question: How effective and safe is an ultrasound-guided erector spinae plane block in patients with rib fractures? Reference: Ramesh S, Ayyan SM, Rath DP, Sadanandan DM. Efficacy and safety of ultrasound-guided erector spinae plane block compared to sham procedure in adult patients with rib fractures presenting to the emergency department: A randomized controlled trial. AEM April 2024 Population: Adult patients with confirmed rib fractures and a numeric rating score (NRS) greater than 4, despite routine analgesia. Exclusions: Allergies to specific medications, penetrating thoracic trauma, pregnancy, infection or laceration at the injection site, specific health conditions (e.g., systolic BP < 100 mm Hg, subcutaneous emphysema at the block site), chronic pain, chronic analgesic use, substance abuse, immediate surgical need, or inability to give consent. Intervention: Ultrasound-guided erector spinae plane block (ESPB) using a high-frequency linear array transducer. The procedure targeted the transverse process corresponding to the fractured rib, where 0.5% bupivacaine was injected after confirming needle placement with saline. Comparison: A sham procedure involved similar preparations without actual needle insertion or injection. Outcome: Primary Outcome: The reduction in pain intensity, was measured using the 11-point NRS at six time points over 12 hours. Secondary Outcomes: The amount of rescue analgesia in morphine equivalents and the occurrence of adverse events. Type of Study: Randomized control trial, prospective, interventional Dr. Manu Ayyan This is an SGEM Hot Off the Press episode, and it is our pleasure to introduce Dr. Manu Ayyan. He is an Associate Professor at Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), Puducherry, India. Dr. Ayyan is a nationally recognized educator and recipient of the 2017 INDUS-EM Emergency Medicine Leadership Award. Authors’ Conclusions: “Ultrasound-guided ESPB resulted in significantly reduced pain intensity over the study period, reduced amount of rescue analgesia, and had no discernible difference in adverse events when compared with a sham.” Qua

Reference: Albers GW et al. TIMELESS Investigators. Tenecteplase for Stroke at 4.5 to 24 Hours with Perfusion-Imaging Selection. NEJM Feb 2024 Date: April 12, 2024 Guest Skeptic: Dr. Vasisht Srinivasan is an Emergency Medicine physician and neurointensivist at the University of Washington and Harborview Medical Center in Seattle, WA. He is an assistant professor in Emergency Medicine, Neurology, and Neurosurgery at the School of Medicine at the University of Washington. Case: A 70-year-old woman was brought into the emergency department by EMS after her family reported she was having trouble talking. They noticed this earlier in the day and let her rest, but when she had trouble moving her right arm, they called 911. Initial evaluation by medics revealed right hemiplegia, a right facial droop, left gaze deviation, and aphasia. When she arrives in your ED, her family tells you she was last seen normal about 12 hours ago. A code stroke is activated, and the initial CT head shows no signs of hemorrhage or early ischemic changes. A CT angiogram shows a proximal middle cerebral artery occlusion. CT perfusion showed a 10 mL core and 189 mL penumbra. As you speak to your stroke team, the question of thrombolysis comes up, as her core is quite small, and the stroke may still be very early in its time course. Background: The question of thrombolysis for acute ischemic stroke dates back nearly 30 years to the initial NINDS trial published in 1995 [1]. Since that time, numerous studies and analyses have been undertaken to categorize the potential benefits and potential harms associated with thrombolysis in stroke [2-8]. We have discussed this issue multiple times on the SGEM including: SGEM#29: Stroke Me, Stroke Me SGEM#70: The Secret of NINDS SGEM Xtra:Thrombolysis for Acute Stroke SGEM Xtra: Walk of Life SGEM#297: tPA Advocates Be Like – Never Gonna Give You Up With the pentad of thrombectomy trials published in 2015 [9-13] and the extension of the thrombectomy window in 2018 following the publication of DAWN [13] and DEFUSE-3 [15], the standard of care has now shifted to mechanical thrombectomy for large vessel occlusion, though thrombolysis is still used up to 4.5 hours from onset of symptoms. We have looked at the issue of EVT with or without thrombolytics on the SGEM a few times. SGEM#137: A Foggy Day – Endovascular Treatment for Acute Ischemic Stroke SGEM#292: With or Without You – Endovascular Treatment with or without tPA for Large Vessel Occlusions SGEM#297: tPA Advocates Be Like – Never Gonna Give You Up SGEM#333: Do you Gotta Be Starting Something – Like tPA before EVT? SGEM#349: Can tPA Be A Bridge Over Trouble Waters to Mechanical Thrombectomy? There have also been several SRMA on this issue [16-21] a few guidelines published on the topic [22-24] and ACEP is currently working on a clinical policy to address this question of EVT +/- thrombolytics. Following nearly a decade of research into Tenecteplase (TNK), beginning as early as 2012 [25], this agent has supplanted alteplase (tPA)as the preferred thrombolytic agent at both some large stroke centers as well as many community sites designated as primary stroke centers. SGEM#377 covered one of those trials comparing tPA to TNK. The AcT trial was a pragmatic, multicentre, open-label, registry-linked, randomized, controlled, non-inferiority trial [26]. This trial reported that TNK was non-inferior to tPA in stroke patients treated within 4.5 hours of symptom onset. Studies from the UK [27], Australia and New Zealand [28, 29], and several studies from Norway [30, 31] have similarly shown that it is neither superior to alteplase nor is it inferior. Perfusion imaging allows more careful patient selection for therapies as it identifies those patients with salvageable ischemic tissue (penumbra) that can be “rescued” if reperfused versus those who have a large burden of infarct (core) that cannot be recovered with reperfusion. However, this requires advanced software not readily available at most EDs and is generally only found at large, referral centers with comprehensive stroke center designation. The standard criteria for intervention come from the DEFUSE-3 trial [15] and are reflected in the inclusion criteria for this study. Clinical Question: Does giving TNK between 4.5 – 24 hours, using perfusion imaging to select patients, improve outcomes after stroke? Reference: Albers GW et al. TIMELESS Investigators. Tenecteplase for Stroke at 4.5 to 24 Hours with Perfusion-Imaging Selection. NEJM Feb 2024 Population: Adults 18 years of age with independent function (mRS 0 – 2) pre-stroke, with an ischemic stroke and could receive the drug/placebo within 4.5 – 24 hours from last known to be well, with NIHSS at least 5, with ICA and/or MCA occlusion on CTA/MRA. Also, needed core < 70 mL, penumbra ≥ 15 mL, and core:penumbra ratio at least 1.8 (DEFUSE-3 criteria) Fig 1 from the DEFUSE-3 trial Exclusions: There were several exclusions published in a separate document [3

Reference: Drysdale SB et al. Nirsevimab for Prevention of Hospitalizations due to RSV in Infants. N Engl J Med. 2023 Date: March 29, 2024 Guest Skeptic: Dr. Michael Cosimini is a pediatrician in Portland Oregon. He is the designer of Empiric Game, a medical editor and contributor to Pediatrics Reviews and Perspectives (PedsRAP) and the digital media editor at Academic Pediatrics. He is passionate about podcasting and serious games for medical education. Dr. Michael Cosimini Case: A 4-month-old twin girl is brought by her parents to the emergency department (ED) for respiratory distress. She has had congestion, a runny nose, and a cough for the past three days. Her parents think her breathing has been getting worse, and she is breathing faster. On your examination, you see that she is tachypneic with a respiratory rate of 66 breaths per minute. You also note subcostal retractions. Her oxygen saturation on room air is 86%. After nasal suctioning, she remains tachypneic, but her oxygen saturation remains under 90%. A viral swab comes back positive for respiratory syncytial virus (RSV). The decision is made to put her on supplemental oxygen via nasal cannula and admit her to the hospital for close observation. Her parents tell you, “She has a twin brother at home. We heard about this new vaccine for RSV. Does it work?” Background: RSV is a major cause of respiratory illness in young children. It is common in bronchiolitis which leads to symptoms like coughing, wheezing, and difficulty breathing. RSV is a major reason why infants are hospitalized for respiratory issues, especially during the fall and winter months when RSV infections are more prevalent. It's hard to think about RSV without recalling the quote “Don’t just do something, stand there!” Because there have been so many things that we’ve tried for bronchiolitis that really don’t seem to have had much effect including hypertonic saline (SGEM#157), high-flow nasal oxygen (SGEM#228), corticosteroids, bronchodilators, etc (SGEM#167). One thing that has also been tried but not covered on the SGEM is a "vaccine" for RSV. Attempts at developing a vaccine against RSV go back decades. The first significant effort to develop an RSV vaccine occurred in the 1960s. A formalin-inactivated RSV vaccine (FI-RSV) was developed and tested in infants and young children. However, instead of protecting against RSV, the vaccine led to worsened infection in many children resulting in some being hospitalized and two deaths. This tragic outcome slowed the development of an RSV vaccine for years. Over the next three decades, researchers sought to understand the immune response to RSV infections and explore potential vaccine targets other than the inactivated virus. During the 2000s, advances in molecular biology, immunology, and vaccine technology rekindled scientists’ efforts in RSV vaccine development. Researchers began exploring various approaches, including protein subunit vaccines, vectored vaccines, live-attenuated vaccines, and mRNA vaccines. Over the last decade, several RSV vaccine candidates have entered clinical trials. These trials have included vaccines for infants, older children, and at-risk adults, such as the elderly and pregnant women (intending to provide passive immunity to newborns). While some RSV vaccine candidates have shown promise, the challenge has been to find a vaccine that is safe, effective, and can provide long-lasting immunity. In 2022 in the European Union and UK and 2023 in the US and Canada approved Nirsevimab to prevent RSV. This is a monoclonal antibody that is supposed to neutralize RSV. Nirsevimab specifically targets a protein that is critical for the virus’s ability to enter and infect human cells, thereby stopping the disease process in its tracks. This action does not rely on the recipient's immune system to activate or produce antibodies, providing immediate protection. This new vaccine technology represents a shift towards monoclonal antibody (mAb) therapy for RSV prevention. Some have been offering nirsevimab to healthy term kids primarily discussing it with families using data from MELODY [1]. This RCT enrolled 1,490 kids and showed good safety compared to placebo, reduced medically attended lower respiratory tract infections, but was not powered to show reduced hospitalization. Clinical Question: What effect does nirsevimab have on hospitalizations for RSV-associated lower respiratory tract infections in healthy infants? Reference: Drysdale SB et al. Nirsevimab for Prevention of Hospitalizations due to RSV in Infants. N Engl J Med. 2023 Population: Infants <12 months with a gestational age of at least 29 weeks entering first RSV season Exclusions: History of immunocompromise, active RSV or lower respiratory tract infection at the time of enrollment, mother received RSV vaccine, eligible for palivizumab. There was a long list of exclusion criteria. Intervention: Single IM injection of nirsevimab (50 mg or 10

Reference: Harrison et al. Mortality in adolescents and young adults following a first presentation to the emergency department for alcohol. AEM March 2024. Date: March 27, 2024 Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals. Case: It’s a Friday evening at the end of the academic year in the Paediatric Emergency Department (ED) and you are with the parents of a 15-year-old girl who has been brought in acutely intoxicated from an unofficial “School’s Out” party. Although your patient has recovered and is now fit for discharge, her parents are very worried that this may mean she is at more risk in the future. Background: We know that alcohol is a major cause of mortality and morbidity across the world [1] and that ED attendance due to it is rising [2,3]. We also know that adults who attend ED with alcohol-related problems are at an increased risk of death in the following year [4]– in fact, we discussed exactly that in SGEM#313 where we agreed that increasing frequency of alcohol-associated ED visits was associated with increasing mortality. However, we haven’t previously looked at the effect of alcohol in this specific vulnerable age group. CLINICAL QUESTION: IS A FIRST ED PRESENTATION RELATED TO ALCOHOL ASSOCIATED WITH INCREASED MORTALITY IN ADOLESCENTS AND YOUNG ADULTS? Reference: Harrison et al. Mortality in adolescents and young adults following a first presentation to the emergency department for alcohol. AEM March 2024. Population: Patients aged 12-29 with ≥1 ED visit in Ontario 2009-15. Excluded: Patients not resident in Ontario, those who were not eligible for OHIP 2 years before and 3 years after, and those with an alcohol-related ED visit in the 2 years before study commencement. Intervention: Any visit related to alcohol Comparison: No visits related to alcohol Outcomes: Primary Outcome(s): Mortality at 1 year Secondary Outcomes: Mortality at 3 years, cause of death, predictors of death. Type of Study: Retrospective cohort study. Dr. Daniel Myran This is an SGEM HOP and we are pleased to have the lead author Dr. Daniel Myran on the show. Dr. Myran is the Canada Research Chair, Social Accountability, University of Ottawa Investigator, Assistant Professor, Department of Family Medicine, University of Ottawa, Associate Scientist, Ottawa Hospital Research Institute with a Cross Appointed School of Epidemiology and Public Health, University of Ottawa Authors’ Conclusions: "Incident ED visits due to alcohol in adolescents and young adults are associated with a high risk of 1-year mortality, especially in young adults, those with concurrent mental health or substance use disorders, and those with a more severe initial presentation." Quality Checklist for Observational Cohort Studies: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? No Was the follow-up of subjects complete enough? Yes How precise are the results? The confidence intervals are well away from zero, so precise enough. Do you believe the results? Yes Can the results be applied to the local population? Yes and unsure Do the results of this study fit with other available evidence? Yes Funding? Canadian Institutes of Health Research, Ontario Ministry of Health, Ontario Ministry of Long-Term Care. One author received speaker fees from pharma for unrelated subjects. Results: There were 71,778 alcohol-related attendances out of 2,340,097 total attendances in the study period. Of the alcohol-related attendances, 56% were male, 25% in the lowest income quintile, and 68% related to acute intoxication. KEY RESULT: ED ATTENDANCE WITH AN ALCOHOL-RELATED ISSUE WAS ASSOCIATED WITH AN ODDS RATIO OF 3.07 FOR MORTALITY AT 1 YEAR. Primary Outcome: 1-year mortality was 0.35% in the alcohol group versus 0.1% in the non-alcohol group for an adjusted odds ratio of 3.07 (95% confidence intervals 2.69-3.51). The odds ratio varied across demographics (see Table 2). Secondary Outcomes: Mortality at 3 years, cause of death, predictors of death. Listen to the SGEM podcast to hear Daniel’s response to our five nerdy questions. 1. Retrospective Study: As a retrospective study, you could only explore covariates that were routinely recorded, so there is a risk of missing unknown confounders like chaotic lifestyle or neurodivergence. Do you have any insights into these based on your experience in the field? 2. Inclusion Criteria: You relied on ICD-10 coding to identify alcohol-related attendances. Although this is likely to be accurate for diagnoses like acute intoxication and alcoholic cirrhosis, do you think it risks under-identifying the involvement of alcohol in other situations like intimate partner v

Reference: Marx et al. Simple Aspiration versus Drainage for Complete Pneumothorax: A Randomized Noninferiority Trial. Am J Respir Crit Care Med. 2023 Date: March 22, 2024 Guest Skeptic: Dr. Richard Malthaner holds the prestigious position of Chair/Head of the Division of Thoracic Surgery and serves as the Director of the Thoracic Robotic Program at Western University's Schulich School of Medicine and Dentistry. Dr. Malthaner currently serves as the Vice President of the Canadian Association of Thoracic Surgeons and is the founder of the Skeptik Thoracik Journal Club. Case: A 25-year-old female medical student presents with right chest pain and dyspnea. Chest x-ray (CXR) shows a “complete pneumothorax.” Background: The first time we got together to discuss chest tubes was on SGEM#129. That episode had two questions. The first question was in a trauma patient, how clinically useful is a CXR after putting in the chest tube? The answer we came up with was to put the tube on the correct side, within the triangle of safety, and within the pleural space. Continue to obtain a CXR post chest tube knowing it will probably not change management. Be more concerned if the patient is doing poorly or the tube is not draining. The second question we tried to answer was does chest tube location matter? The answer is that the part of the location that matters in these situations is that the chest tube is safely placed on the correct side and in the pleural space. The next time were talking chest tubes was not in trauma patients but rather in patients with their first large spontaneous pneumothorax in SGEM#300. We only had one question asking if they all needed a chest tube. The bottom line for that episode was it's reasonable to provide conservative management in a patient with large first-time spontaneous pneumothoraxes if you can ensure close follow-up. We have looked at other chest-related issues with other guest skeptics. SGEM#339 looked at the optimal anatomical location for needle decompression for tension pneumothorax with Dr. Rob Edmonds. That study did not support the claim that the second intercostal space-midclavicular line is thicker than the fourth/fifth intercostal space-anterior axial line. The most recent time we have explored something involving chest tubes was with guest skeptic Dr. Chris Root (SGEM#355). We wanted to know if the size of the chest tube matters in hemodynamically stable patients with traumatic hemothorax. That was a multicenter, non-inferior, unblinded, randomized, parallel assignment comparison trial that reported small percutaneous catheters were non-inferior to large open chest tubes for traumatic hemothorax. Patients can present with a spontaneous pneumothorax. This is defined as air in the pleural space between the lung and the chest wall with no obvious precipitating factor. It can occur in existing lung disease (secondary spontaneous pneumothorax) or with no known underlying lung pathology (primary spontaneous pneumothorax). Chest tube drainage remains the reference first-line treatment of primary spontaneous pneumothorax, however, complications occur in 9–26% of such cases. A less invasive alternative approach is simple aspiration, which could be an option. The best way to manage a first primary spontaneous pneumothorax episode remains unclear. Clinical Question: Is simple aspiration non-inferior to chest tube drainage for first-line lung expansion in patients with complete primary spontaneous pneumothorax? Reference: Marx et al. Simple Aspiration versus Drainage for Complete Pneumothorax: A Randomized Noninferiority Trial. Am J Respir Crit Care Med. 2023 Population: Adults aged 18–50 years with a first episode of a symptomatic completed spontaneous pneumothorax for <48 hours. Complete was defined as total separation of the lung from the chest wall. Exclusions: Tension pneumothorax, traumatic and recurrent pneumothorax, and primary pneumothorax associated with pleural effusion or secondary pneumothorax with underlying lung disease. Pregnant or lactating women; patients not available for follow-up; and those with major incapacitation, unable to give consent, or under trusteeship, guardianship, or judiciary protection were also excluded. Intervention: Simple aspiration using a polyurethane safety catheter mounted on a blunt needle (Turkel Thoracentesis Kit, Cardinal Health) placed in the second intercostal space midclavicular line. Free drainage for 15 minutes then -25 cm suction for 30 minutes. Clamp the tube and then obtain a CXR. If the lung is up the tube is removed. Monitor for 24 hours in the ED and then send the patient home. If the lung is not up, more suction for 30 minutes. If not up, chest tube drainage and the patient admitted. If the lung is up then the tube is removed. Comparison: Chest tube drainage (Vygon Thoracic trocar drain 16 or 20 Fr) with the tube placed in the fourth or fifth intercostal space mid-axillary line. Pleur evac drains of BPDS700 type. CX

Date: March 16, 2024 This is an SGEM Xtra episode. Yes, that is two back-to-back SGEM Xtra episodes. The critical appraisal that was lined up for this week's episode got delayed due to some scheduling problems with clinical responsibilities. You can access all the slides for this episode from this LINK and see the presentation on YouTube. This episode is from a talk I gave a few years ago on social media for knowledge translation. How this technology could make the world a better place. I’ve come to recognize that many SGEMers are not very familiar with the best movie decade of all time, the 1980’s. Therefore, I created this talk using the Matrix as a more contemporary theme from the late 1990’s early 2000’s. The Matrix was a groundbreaking movie created by Lana and Lily Wachowski and released in 1999. It started a movie franchise blending science fiction and action in a visual masterpiece. The first movie introduces us to a dystopian future in which humanity is unknowingly trapped inside the Matrix, a simulated reality created by intelligent machines to distract humans while using their bodies as an energy source or batteries. Thomas Anderson (Mr. Anderson), a computer programmer by day and a hacker named Neo by night, discovers the truth about the Matrix. He is drawn into a rebellion against the machines, led by Morpheus and Trinity. Neo is believed to be "The One," a prophesized hero destined to end the war between humans and machines. The film explores themes of reality, freedom, and control. Like Morpheus in The Matrix, “all I’m offering is the truth, nothing more”. "What if I told you"…Morpheus never says that in The Matrix. Yet “what if I told you” is one of the most well-known Memes. There are many quotes from movies that are wrong/misquoted. Here are three examples of movie misquotes. For a list of the top ten movie misquotes click on the LINK: Play it again Sam (Casablanca 1942): That line is never said in the movie Casablanca. Humphrey Bogart actually says ”You played it for her, you can play it for me. If she can stand it, I can. Play it!". Luke, I am your father (Star Wars V The Empire Strikes Back 1980): The actual line by Darth Vader is “No, I am your father.” If you build it, they will come (Field of Dreams 1989): James Earl Jones says"People will come, Ray." Back to the lecture, Morpheus sitting in the chair wearing cool sunglasses and offering Neo the red and blue pill never said “What if I told you”. In the actual dialogue in the scene, Morpheus says: "Do you want to know what 'it' is?". What it is for today’s lecture is the problem with knowledge translation and how it can be addressed with Social Media. Trinity tells Neo in The Matrix “It's the question that drives us, Neo. It's the question that brought you here. You know the question, just as I did. In the movie, the question was “What is the Matrix”? For this lecture, the question is “How long does it take for high-quality clinically relevant information to reach the patient? There are a few answers to the question of how long knowledge translation takes in medicine. One answer is from Dr. John Jackson who was a British Neurologist. He said, “It takes 50 years to get a wrong idea out of medicine, and 100 years a right one into medicine.” This means it takes decades for knowledge translation. In the age of social media that is way too long. Max Planck Another answer to the question about how long knowledge translation takes in science comes from Dr. Max Planck. He was a famous physicist who said “New scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a die generation grows up that is familiar with it.” In other words, it is not facts, evidence or logical arguments that convince people to change their position on a subject but rather the old advocates had to die first for the new information to take hold and become accepted. It takes a generation for knowledge translation. Morris et al published a paper in the Journal of the Royal Society of Medicine in 2011 trying to put an exact number on how long it takes for high-quality, clinically relevant information to reach patients. They came up with the number, 17 years. This is not for 100% of the clinical information but rather only 14%. Journal of the Royal Society of Medicine While I think that the specific number is not as important as the concept that it can take more than a decade for a minority of clinically relevant evidence to be widely adopted by clinicians. Why does it take so long in medicine? A model has been put together that identifies seven major issues that prevent patients from getting the best care, based on the best evidence. This has been called the Leaky Pipe Model of knowledge translation. The first five leaks are at the level of the clinician and the last two leaks are patient-level problems. So, there is

Date: March 6, 2024 This is an SGEM Xtra created from a lecture I gave for the Rural Ontario Medical Program (ROMP) ICE Camp Retreat in Collingwood, Ontario last month. ROMP helps Ontario medical students & residents arrange core & elective rotations in rural Ontario. An old friend, Dr. Matt De Stefano invited me to give a lecture to the PGY-3 Emergency Medicine Residents. Matt said it could be a talk on anything so I decided to create a new presentation called “A Philosophy of Emergency Medicine” This lecture was inspired by the wonderful Professor Melanie Trecek-King. She is a science educator from the USA and has an amazing website called Thinking is Power. I bought a T-shirt from Melanie that says “Be curious, be skeptical and be humble”. Such great wisdom from an amazing science communicator. For the presentation at ROMP, I made a friendly amendment to Melanie’s three items substituting that last piece of advice “Be Humble” (which is very important) with “Be Teachable” for the audience of PGY3 Emergency Medicine Residents. If you are interested in seeing all the slides they can be downloaded from this LINK or you can watch the episode on YouTube. Be Curious: The lecture started not with a 1980s cultural reference but rather with a recent cultural reference from the TV show Ted Lasso. Be Curious, not judgmental. This was a great show for a variety of reasons and we are planning to do a special SGEM Xtra episode on how the lessons we learned from Ted Lasso made us better. Be Skeptical: This is the second important part of my EM philosophy. Carl Sagan is arguably one of the most famous skeptics ever. He in part inspired this knowledge translation project called the Skeptics’ Guide to Emergency Medicine. Probably one of his most famous quotes was that “extraordinary claims require extraordinary evidence” Be Teachable: The third philosophical point I wanted to make about Emergency Medicine was to encourage you to Be Teachable. This does not just apply to when you are a resident but also when you become an attending physician. You will not always be right. Be Kind: One more super important thing that you should consider as part of your EM philosophy is to be kind. It is something I learned from Dr. Brian Goldman. Brian is the host of the amazing CBC show White Coat Black Art and has authored several great books. One of the best books he wrote was called The Power of Kindness - Why Empathy is Essential in Everyday Life. The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. So, patients get the best care, based on the best evidence. If you would like a copy of all the slides used in this presentation simply click on the LINK and you can see all the slides on YouTube. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics' Guide to Emergency Medicine.

Reference: Gibbons et al. The sonographic protocol for the emergent evaluation of aortic dissections (SPEED protocol): A multicenter, prospective, observational study. AEM February 2024. Date: February 28, 2024 Guest Skeptic: Dr. Neil Dasgupta is an emergency medicine physician and ED intensivist from Long Island, NY. He is the Vice Chair of the Emergency Department at Nassau University Medical Center in East Meadow, NY, the safety net hospital for Nassau County. Case: A 59-year-old man walks into your community emergency department (ED) complaining of chest pain. It is described as a ripping sensation that radiates to his back. His vital signs are all normal and the ECG done at triage does not show an occlusive myocardial infarction. The chest x-ray is unremarkable, and his troponin is not elevated. You suspect an acute aortic dissection (AoD). However, your CT scanner is offline for two hours of scheduled maintenance. He will need to be transferred to the tertiary care center which is 35 minutes away by ground EMS if it is a dissection. Your Spidey senses are tingling, and you don't want to wait for the CT scanner to be back online to make the diagnosis. Arrangements are made for him to be transferred stat to the tertiary hospital while he is still stable. You wonder if a quick POCUS examination looking for three sonographic findings while waiting for the paramedics could help determine the likelihood of this being an AoD. Background: We recently covered acute aortic syndrome (AAS) on SGEM#430. AAS has been called the lethal triad and includes aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer [1]. It is a rare but deadly condition that can present in atypical ways leading to delays in diagnosis and an associated increase in mortality. This episode is going to focus on acute aortic dissection (AoD) which is classified into two major types according to the Stanford classification system: Type A and Type B. This system is based on the location of the tear and helps guide treatment strategies. Type A dissections Involves the ascending aorta and may extend into the descending aorta. It's more common and more dangerous than Type B, as it can lead to serious complications like rupture into the pericardial space leading to cardiac tamponade, aortic valve insufficiency, or myocardial infarction. Symptoms may include more severe chest pain radiating to the back, loss of consciousness, or symptoms of stroke if the blood supply to the brain is affected. Type A AoDs generally require an emergent trip to the operating room as soon as they are identified to reduce the likelihood of a terrible outcome. Type B dissections occur in the descending aorta only, after it has passed the arteries that supply blood to the arms and head. They are less common than Type A and usually less immediately life-threatening, but still serious and potentially fatal if not treated properly. Symptoms can include sudden onset of pain in the back or abdomen, depending on the exact location and extent of the dissection. The pain is often described as tearing or ripping. Speed is important in making the diagnosis of an AoD due to the associated increase in mortality with delays [2,3]. We know from last week that clinical decision tools (CDTs) are not ready for prime time. This is consistent with the American College of Emergency Physicians (ACEP) which does not recommend the routine use of clinical decision rules in suspected cases of AoD [4]. Clinical Question: What is the diagnostic accuracy of three sonographic findings for acute aortic dissection? Reference: Gibbons et al. The sonographic protocol for the emergent evaluation of aortic dissections (SPEED protocol): A multicenter, prospective, observational study. AEM February 2024. Population: A convenience sample of adult patients with clinically suspected Stanford type A or B AoDs before performing a POCUS or CTA from January 2010 to December 2019 Excluded: Those patients unable to consent, those with a preexisting or traumatic AoD, and individuals who did not receive a POCUS evaluation prior to advanced imaging (CTA, MRA, or TEE). Intervention: POCUS performed by PGY1 to 3 EM residents to identify three sonographic findings consistent with acute aortic dissection. This included (1) the presence of either a pericardial effusion or (2) an intimal flap, or (3) an aortic outflow track (AOFT) diameter greater than 35 mm measured from the inner wall to the inner wall within 20 mm of the aortic annulus during end-diastole. Comparison: CTA of chest-abdomen-pelvis, MRI/MRA, or cardiology-performed TEE Outcome: Primary Outcome: Diagnostic accuracy of identifying a Stanford Type A and B AoDs Secondary Outcomes: Test characteristics of each of the three individual sonographic findings for diagnosing Stanford type A and B AoDs Type of Study: Multicenter, prospective, observational, cohort study of a convenience sample of adult patients. Dr. Ryan Gibbons This is th

Reference: Li, T., & Gal, D. (2023). Consumers prefer natural medicines more when treating psychological than physical conditions. Journal of Consumer Psychology 2023, Date: February 23, 2024 Guest Skeptic: Ethan Milne is a Marketing PhD student at the Ivey Business School (Western University). He researches how moral outrage and status-seeking personalities motivate social media aggression, and how retribution can motivate consumer donations. Case: A 20-year-old male presents to the emergency department with palpitations. After a good history, directed physical examination and appropriate investigations you suspect he is suffering from a major depressive disorder (MDD) with a comorbidity of anxiety. He is not a threat to himself or others and wants assistance. You arrange for him to be followed up by his family physician to discuss possible treatment options which include medications. He expresses concern that taking a synthetic drug to treat his depression wouldn’t allow him to be his authentic self. Background: Major Depressive Disorder, commonly known as depression, is a significant mental health condition. Depression is a leading cause of disability worldwide and is a major contributor to the overall global burden of disease. It affects an estimated 5-10% of the population at any given time, with variations depending on demographic factors such as age and gender. It is generally more common in women than in men and can occur at any age, although it often first appears during late adolescence to mid-20s [1]. The National Institute of Health (NIH) estimates that around 8.3% (21.0 million) of US adults over 18 have experienced a major depressive episode in the last year. Various factors can increase the risk of developing MDD, including genetic predisposition, personal or family history of depression, major life changes, trauma, stress, and certain physical illnesses and medications. Depression has been reported to be most prevalent among young women aged 12-17 (29.2%) [2]. The current diagnostic criteria for MDD are outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR). These criteria serve as a guideline for clinicians to diagnose depression. To be diagnosed with MDD, a person must experience at least one of the two symptoms for at least two weeks: Depressed Mood: Most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). Loss of Interest or Pleasure: Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day. The person must also have five or more of the following symptoms during the same 2-week period, and these symptoms represent a change from previous functioning. Significant Weight Loss or Gain (or decrease or increase in appetite nearly every day) Insomnia or Hypersomnia: Trouble sleeping or sleeping too much nearly every day. Psychomotor Agitation or Retardation: Noticeable by others, not merely subjective feelings of restlessness or being slowed down. Fatigue or Loss of Energy: Nearly every day. Feelings of Worthlessness or Excessive or Inappropriate Guilt: Nearly every day, not merely self-reproach or guilt about being sick. Diminished Ability to Think or Concentrate (or indecisiveness, nearly every day) Recurrent Thoughts of Death: Recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. These symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. They must not be attributable to the physiological effects of a substance or another medical condition. Also, the occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. There are several treatment options for MDD and often patients will do a combination of things. It can be a challenge to treat depression effectively and the evidence to support different treatments varies. Lifestyle and Home Remedies: Regular exercise, maintaining a healthy diet, getting enough sleep, and avoiding alcohol and drugs can help manage symptoms of depression. Psychotherapy: Cognitive Behavioral Therapy (CBT): This is a highly effective form of therapy that focuses on identifying and changing negative thought patterns and behaviours that contribute to depression. Interpersonal Therapy (IPT): IPT focuses on improving interpersonal relationships and communication patterns. Psychodynamic Therapy: This explores how unconscious emotions and past experiences contribute to current feelings and behaviours. Medications: Antidepressants: These are the most commonly prescribed medications for depression, including selective serotonin reuptake inhibitors (SSRIs)

Reference: McLatchie et al and DAShED investigators. Diagnosis of Acute Aortic Syndrome in the Emergency Department (DAShED) study: an observational cohort study of people attending the emergency department with symptoms consistent with acute aortic syndrome. EMJ Nov 2023. Date: February 11, 2024 Guest Skeptic: Nirdosh Ashok Kumar, Emergency Medicine Specialist – Aga Khan University Hospital, Karachi, Pakistan. Case: A 66-year-old female with a history of smoking, hypertension, and type-2 diabetes presents to the emergency department (ED) with syncope while walking her dog. She complains of retrosternal chest pain radiating to her jaw. She is bradycardic, hypotensive, and tachypneic. She is received in the resuscitation room. Monitors have been attached, and intravenous (IV) access has been achieved and IV analgesia has been given. The ECG shows sinus tachycardia with non-specific ST-T changes. The chest x-ray is unremarkable. However, she is still in severe pain. A post-graduate year 2 (PGY-2) resident asks you if it could be a ruptured abdominal aortic aneurysm, aortic dissection, or angina. Background: The diagnosis of acute aortic syndrome (AAS) is commonly delayed or missed in the ED. AAS has been referred to as the “lethal triad” that incorporates aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU) [1]. It is a rare condition with a high mortality rate and can present in atypical ways. It affects approximately 4,000 people per year in the United Kingdom [2] and 43,000 to 47,000 people per year in the USA [3]. The annual incidence rate of AD ranges between 2.9 and 7.2 per 100,000. [4-8] The misdiagnosis rate is estimated to be between 16% and 38%6,[9-19] with a diagnostic delay of up to 24 hours for 25% of cases, and mortality follows a linear increase of 0.5% per hour in the first 48 hours. [20] A retrospective observational study from Canadian researcher, Dr. Robert Ohle was published in CJEM in 2023. This study found that between 2003 and 2018, there were 1,299 cases of AAS in Ontario, the largest province in the country. It reported an overall annual incidence rate of 0.61 per 100,000 people which is much lower than previously reported rates. The study also highlighted the significant mortality rate associated with AAS, with a one-year mortality rate decreasing from 47.4% to 29.1%, and ED mortality at 14.9%​​. [21] When looking specifically at atraumatic chest pain presentations to the ED, it is estimated the incidence of AAS is one in 980. [22] It can be like looking for a needle in a haystack of chest pain patients. The gold standard for diagnosing AAS is to perform a CT aorta angiogram (CTA). However, scanning everyone chest pain patient would have a very low diagnostic yield [23,24], expose many patients to unnecessary ionizing radiation and end up being very costly. It would be great if there was a validated clinical decision tool (CDT) to help clinicians be more selective in using CTA to diagnose AAS. Some CDTs have been devised and tested for diagnosing AAS. [25,26] The Aortic Dissection Detection Risk Score (ADD-RS) is one CDT that has been derived and tested. Four studies with methodologic limitations were included in an SRMA of the ADD-RS and published in AEM 2020. [27] The authors concluded that patients with an ADD-RS score of ≤ 1 with d-dimer < 500 ng/mL have high sensitivity for ruling out AASs. However, it is unclear if it is good enough for clinicians to use, better than clinical gestalt [28,29], and an impact analysis has not been done to determine if it would lead to fewer CTAs and d-dimers being performed. Clinical Questions: What are the characteristics of ED attendances with possible AAS, how effective are existing clinical decision tools (ADD-RS, Canadian Guideline, Sheffield, AORTAs) and the use of CTA in an undifferentiated cohort of ED patients? Reference: McLatchie et al and DAShED investigators. Diagnosis of Acute Aortic Syndrome in the Emergency Department (DAShED) study: an observational cohort study of people attending the emergency department with symptoms consistent with acute aortic syndrome. EMJ Nov 2023. Population: Adult patients 16 years of age or older attending one of 27 EDs in England, Wales, or Scotland with onset of symptoms within the past seven days of possible AAS (chest pain, back pain, abdominal pain, syncope, or symptoms related to mal perfusion). Excluded: Absence of any potential AAS symptoms (chest pain, back pain, abdominal pain, syncope, or symptoms related to mal perfusion). Intervention: Clinical judgment, various clinical decision tools characteristics and performance of existing clinical decision tools (ADD-RS, AORTAs, Canadian and Sheffield AAS CDTs), the D-dimer (evaluated separately and in combination with other tools) and CTA. Comparison: None Outcome: Primary Outcome: Diagnostic accuracy of clinical gestalt, ADD-RS, AORTAs, Canadian and Sheffield AAS clinical decision tools and D-dimer (separately and

Reference: Curry SD, et al. Systematic Review of CT Angiography in Guiding Management in Pediatric Oropharyngeal Trauma. Laryngoscope. March 2023 Date: January 30, 2024 Guest Skeptic: Dr. Alexandra (Ali) Espinel is an Associate professor of pediatrics and otolaryngology at Children’s National Hospital and George Washington University. She is also the director of the Pediatric Otolaryngology Fellowship at Children’s National Hospital. Case: You’re working the morning shift in the emergency department (ED) when you encounter a 3-year-old boy and his family. His parents tell you that he was getting ready to go off to daycare and brushing his teeth while standing on a step stool by the sink. He slipped and the toothbrush poked him in the back of the mouth. Initially, his parents noticed that he was bleeding from his mouth and saw what looked like a wound towards the back of his throat. The boy cried immediately afterwards but has otherwise been acting like himself. On your exam, you notice a small penetrating intraoral injury just lateral to the soft palate without evidence of continued bleeding. His parents ask you, “Is he going to be, okay? We’re glad he’s not bleeding anymore. Do you think he needs any imaging to see if he hurt anything?” Background: Kids like to put things in their mouths. Kids like to run around. Sometimes, kids may fall while having something in their mouth which may cause damage to their oropharynx. The ensuing damage can vary. It could be blunt trauma or penetrating trauma. We get concerned about injuries to the soft palate because of possible deep space neck infection and the risk of injury to the carotid artery behind it which has been associated with thrombosis, dissection, and cerebral infarctions. These super scary complications have been reported in the literature but seem relatively rare. We have many clinical decision tools for imaging in pediatric head trauma [1] or abdominal trauma [2]. But we do not have any of the same tools for oropharyngeal injury which means that there is wide variation about which imaging studies are ordered. Clinical Question: What is the role of CT angiography (CTA) in the diagnosis and management of pediatric oropharyngeal trauma? Reference: Curry SD, et al. Systematic Review of CT Angiography in Guiding Management in Pediatric Oropharyngeal Trauma. Laryngoscope. March 2023 Population: Patients <18 years old with trauma to the oropharynx. They included meta-analyses, systematic reviews, randomized control trials (RCTs), case-control and cohort studies, case series and case reports. Excluded: Oropharyngeal trauma combined with other severe head injury or multisystem trauma, not primary research, non-English publication Intervention: CTA Comparison: No CTA Outcome: radiologic and clinical outcomes including infection, injury to vasculature, cerebrovascular injury, and neurologic abnormalities. Type of Study: Systematic Review and Meta-Analysis of diagnostic studies. Authors’ Conclusions: “Imaging with CTA yielded radiological abnormalities in a few instances. These results do not support the routine use of CTA in screening pediatric oropharyngeal trauma when balanced against the risk of radiation, as it rarely resulted in management changes and was not shown to improve outcomes.” Quality Checklist for Systematic Review Diagnostic Studies: The diagnostic question is clinically relevant with an established criterion standard. Yes The search for studies was detailed and exhaustive. No. The methodological quality of primary studies was assessed for common forms of diagnostic research bias. Yes. The assessment of studies was reproducible. Yes There was low heterogeneity for the primary outcome. Yes. The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision-making models. No. Results: The initial search identified 5,078 papers after duplicates were excluded. Only eight studies were included in the final analysis. All those studies were retrospective cohort studies. Only five of eight studies reported rates of CTA use. Key Results: Routine use of CTA in screening pediatric oropharyngeal trauma is not recommended. These eight studies encompassed a total of 662 patients. Among those patients, 293 underwent CT imaging of some kind, and 255 patients were specified as undergoing CTA. Some patients also underwent carotid angiography (3.4% of patients who underwent CT or CTA) for indications that included free air near the carotid, a bruit on neck exam, hematoma next to the carotid artery, carotid spasm, history of tonsil injury and profuse bleeding, and carotid artery exposure with arterial compression. There were two cases in which CTA showed disruption of the carotid intima without a thrombus. These two patients were treated with aspirin. Some patients were admitted to the hospital for observation. Only six out of the eight studies reported antibiotic treatment. Importantly, no patients were reported to have a cerebrovas

Reference: Wilkinson-Stokes M, Betson J, Sawyer S. Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis. Emerg Med J. February 2023 Date: January 24, 2024 Guest Skeptic: Dr. Rupinder Sahsi is a fellow EBM enthusiast with academic appointments at McMaster University and Wright State University who works as an emergency physician in Kitchener-Waterloo, Ontario, Canada. He is also an assistant medical director for EMS at the Centre for Paramedic Education and Research in Hamilton, Ontario, Canada. Case: You are an advanced care paramedic dispatched to the scene of a 53-year-old female with chest pain. She developed retrosternal chest discomfort shortly after she came in from using her snowblower. You provide her with two tablets of ASA to chew while your partner acquires an ECG, which ultimately shows clear ST elevation in the inferior leads and some ST changes in V1-V2 that make you wonder if your patient is having an acute myocardial infarction (MI) with right-sided ventricular involvement (RVI). Your patient rates their pain as an 8/10 and looks visibly uncomfortable. Do you give nitroglycerin? Background: You have likely heard the caution to avoid nitrates in acute myocardial infarctions that have right ventricular involvement. What is that based upon? As is often the case, when you go back to the primary literature, you discover we are standing on pillars of salt and sand. The evidence for this recommendation is a single observational study of 40 patients published in 1989 [1]. Yet, the findings in those 40 patients went on to be the evidence commonly cited by the American Heart Association (AHA) [2] and the European Society of Cardiology (ESC) [3] in their recommendation against the use of nitrates in acute MIs if there is right ventricular involvement. The pathophysiologic rationale was that nitrates would cause vasodilation and thus reduce RV preload, decreasing left end diastolic volume, and ultimately resulting in clinically important hypotension. Many times, pathophysiology has been used to explain something in medicine only to be discovered later that the body is much more complicated than we thought. That 40-patient study by Ferguson et al did show a statistically significant increased likelihood of hypotension in RVMI patients who received nitrates, but to me, the study design was just plain weird. This was a retrospective trial that looked at 40 patients with inferior MIs. Twenty of them had hypotension after nitrates and 20 of them were not hypotensive. They looked back and saw that a higher proportion of patients with inferior MI and hypotension had ECG evidence of RV involvement. Sounds okay, but by having equal numbers of hypotensive and non-hypotensive patients, they’ve exaggerated the incidence of hypotension. It’s not 50-50. In all comers with MI, the rate is probably closer to <3%. On top of that, there was no standardization of the nitrate dose or route of administration, so it’s hard to know how to extrapolate the findings to our standard nitrate admin protocols. I was not surprised by this information. Fanaroff et al looked at the ACC/AHA guidelines from 2008-2018 [4]. They found 26 guidelines with 2,930 recommendations. Only 9% were Level A while 50% were Level B and 41% were Level C. Compare that previously mentioned 40-patient study to the 2016 Canadian study by Robichaud et al which was 22 times larger (n=1,004) than the Ferguson study [5]. It looked at the administration of a standardized amount of nitroglycerin in MI patients with various vascular territories involved. It shows no statistical difference in adverse events between patients with and without RVMI – a relative risk of 1.02 (95% CI: 0.49 to 2.15) p-value = 0.95. Clinical Question: Is nitrate administration to patients with right ventricular myocardial infarction (RVMI) associated with increased adverse events compared with nitrate administration to patients with myocardial infarctions only in other regions? Reference: Wilkinson-Stokes M, Betson J, Sawyer S. Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis. Emerg Med J. February 2023. Population: Adult patients diagnosed with acute MI Exclusions: Patients with coronary vasospasm were specifically excluded. Nitrates are an effective primary treatment for coronary vasospasm, and the inclusion of these patients may skew results toward a finding of increased nitrate safety. Exposure: Receiving nitrates in any dose and by any route. Comparison: Patients with acute right-sided myocardial infarctions to patients with acute MI involving any other anatomic distribution Outcome: Primary Outcome: All forms of adverse outcomes reported in the identified literature. The primary meta-analysis excluded studies of low quality, but a secondary analysis was also performed including identified studies that were deemed of lower meth

Reference: Zaoutis T, et al. Short-course Therapy for Urinary Tract Infections in Children: the SCOUT randomized clinical trial. JAMA Pediatr. Aug 2023 Date: October 30, 2023 Dr. Ellie Hill Guest Skeptic: Dr. Ellie Hill is a pediatric emergency medicine physician at Children’s National Hospital in Washington, DC and Assistant Professor of Pediatrics and Emergency Medicine at George Washington University School of Medicine and Health Sciences. Her research interests include improving the diagnosis of urinary tract infections in children. Case: A 4-year-old girl comes to the emergency department complaining of pain with urination. She has not had any fevers or flank pain. The last time she had these symptoms a year ago, she was diagnosed with a urinary tract infection (UTI) and started on antibiotics. You obtain a urinalysis that demonstrates 43 white blood cells, positive leukocyte esterase, and positive nitrites. You tell the family the results of the urinalysis and let them know that she likely has another UTI, and you plan to prescribe some antibiotics. Her parents reply, “Last time she had to take over a week of antibiotics for her UTI, and she had bad diarrhea. Is it possible that we do a shorter treatment if she needs antibiotics?” Background: Does it seem like antibiotic courses are getting shorter these days? We covered short-course treatment for pediatric pneumonia in the SAFER trial with Dr. Andrew Tagg back on SGEM #338 and the SCOUT-CAP trial on SGEM #359. UTIs are one of the most common bacterial infections in childhood that we see in the emergency department [1]. The American Academy of Pediatrics (AAP) released guidelines for the management of febrile infants and children 2 to 24 months back in 2011 [2]. In those guidelines, they included the statement “The clinician should choose 7 to 14 days as duration of antimicrobial therapy.” However, the optimal antibiotic duration for the treatment of UTI is still uncertain [3]. Clinical Question: What is the efficacy of short-course (5-day) vs standard-course (10-day) antibiotic therapy for children with urinary tract infections? Reference: Zaoutis T, et al. Short-course Therapy for Urinary Tract Infections in Children: the SCOUT randomized clinical trial. JAMA Pediatr. Aug 2023 Population: Children 2 months to 10 years with and without febrile UTI exhibiting clinical improvement after 5 days of antimicrobials Excluded: Second uropathogen (>104 CFU by catheterization or suprapubic aspiration, or >5x104 CFU by clean catch), hospitalization for bacteremia, admission to ICU, urine culture with pathogen resistant to initially prescribed antimicrobial, catheter-associated UTI, history of UTI within 30 days, phenylketonuria, congenital or anatomy abnormality of the GU tract other than grade I to II vesicoureteral reflux, duplicated collecting systems, or hydronephrosis, previous GU surgery, unable to tolerate PO medications, immunocompromise, Type I hypersensitivity or anaphylaxis to study products, gestation <36 weeks for children younger than 2, inability to attend follow up Intervention: Additional 5 days of antimicrobial therapy (10 days total, standard course) Comparison: Additional 5 days of placebo (5 days total, short-course) Outcome: Primary Outcome: Treatment failure is defined as symptomatic UTI at or before the first follow-up visit (day 11 to 14) Secondary Outcomes: UTI after first follow-up visit, asymptomatic bacteriuria, positive urine culture, gastrointestinal colonization with resistant organisms Trial: Multicenter, randomized, double-masked, placebo-controlled noninferiority clinical trial Authors’ Conclusions: “In this randomized clinical trial, children assigned to standard-course therapy had lower rates of treatment failure than children assigned to short-course therapy. However, the low failure rate of short-course therapy suggests that it could be considered as a reasonable option for children exhibiting clinical improvement after 5 days of antimicrobial treatment.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Unsure The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. Yes All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. Unsure Financial conflicts of interest. A few doctors had grants from pharmaceutical companies but reported that they were not related to this particula

Reference: Snyder BD, Van Dyke MR, Walker RG, et al. Association of small adult ventilation bags with return of spontaneous circulation in out of hospital cardiac arrest. Resuscitation 2023. Date: January 11, 2024 Guest Skeptic: Dr. Chris Root is an EMS fellow in the Department of Emergency Medicine at the University of New Mexico Health Sciences Center in Albuquerque, NM. He is also a flight physician with UNM’s aeromedical service, Lifeguard Air Emergency Services. Prior to earning his MD, he worked as a paramedic in the New York City 911 system. Case: You are dispatched to an out-of-hospital cardiac arrest (OHCA). The patient is a 54-year-old man who collapsed in front of his family after complaining of chest pain for several hours. On your arrival, first responders from the fire department are performing high-quality basic cardiac life support. You continue with compressions and defibrillations and your partner places an advanced airway. Your EMS agency has equipped you with small-volume adult bag-valve masks (BVMs), the first responders have been utilizing a standard adult BVM thus far during the resuscitation. Your partner asks you which of the two BVMs you should use to continue the resuscitation. Background: There is continuing debate regarding the appropriate ventilation strategy for OHCAs. Common commercially available BVMs can deliver volumes that exceed normal tidal volumes. Some have argued in favor of using smaller BVMs to avoid hyperventilation. The issue of BVM ventilation in the context of pre-oxygenation for endotracheal intubation was discussed on SGEM#281. Airway management in OHCA has also been covered in SGEM#247 and SGEM#396. We have looked at OHCA more than a dozen times on the SGEM. For a full list of check out the links below to the SGEM blogs: SGEM#50:Under Pressure Journal Club: Vasopressin, Steroids and Epinephrine in Cardiac Arrest SGEM#54:Baby It’s Cold Outside: Pre-hospital Therapeutic Hypothermia in Out of Hospital Cardiac Arrest SGEM#59:Can I Get a Witness: Family Members Present During CPR SGEM#64:Classic EM Paper: OPALS Study SGEM#107:Can’t Touch This: Hands on Defibrillation SGEM#136:CPR – Man or Machine? SGEM#143:Call Me Maybe for Bystander CPR SGEM#152:Movin’ on Up – Higher Floors, Lower Survival for OHCA SGEM#162:Not Stayin’ Alive More Often with Amiodarone or Lidocaine in OHCA SGEM#189:Bring Me to Life in OHCA SGEM#238:The Epi Don’t Work for OHCA SGEM#247:Supraglottic Airways Gonna Save You for an OHCA? SGEM#275:10th Avenue Freeze Out – Therapeutic Hypothermia after Non-Shockable Cardiac Arrest SGEM#306:Fire Brigade and the Staying Alive APP for OHCAs in Paris SGEM#314:OHCA – Should you Take ‘em on the Run Baby if you Don’t get ROSC? SGEM#329:Will Corticosteroids Help if…I Will Survive a Cardiac Arrest? SGEM#336:You Can’t Always Get What You Want – TTM2 Trial SGEM#344:We Will…We Will Cath You – But should We After an OHCA Without ST Elevations? SGEM#353:At the COCA, COCA for OHCA SGEM#380:OHCAs Happen and you’re head over heels – Head elevated during CPR? SGEM#396: And iGel myself I’m over you, cus I’m the King (tube) of wishful thinking. Clinical Question: Is using a small adult BVM during resuscitation of out of hospital cardiac arrest associated with return of spontaneous circulation? Reference: Snyder BD, Van Dyke MR, Walker RG, et al. Association of small adult ventilation bags with return of spontaneous circulation in out of hospital cardiac arrest. Resuscitation 2023. Population: Adult patients treated with an advanced airway for non-traumatic OHCA in a single urban EMS system in the US between 2015 and 2021 Excluded: "Age <18, received basic life support (BLS) only, termination of resuscitation due to advance directives, ALS interventions prior to EMS arrival, insufficient capnography data, cricothyrotomy, advanced airway placed while patient had spontaneous circulation, airway was managed with BVM only, or did not receive CPR while under EMS ALS care.” Exposure: Small bag ventilation with a Mercury Medical CPR-2 Comparison: Large bag ventilation with unspecified “large” BVM Outcome: Primary Outcome: Return of spontaneous circulation (ROSC) at the end of EMS care. This was defined as the time point when the EMS crew entered the receiving ED or termination of resuscitation in the field. Secondary Outcomes: Ventilation rate and mean end-tidal CO2 (ETCO2) value during CPR Type of Study: Retrospective, observational cohort analysis of two prospectively acquired registries managed by one institution’s quality improvement staff. Authors’ Conclusions: “Use of small adult ventilation bags was associated with a lower likelihood of ROSC at the end of EMS care in non-traumatic, adult OHCA.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes

Reference: Remick KE, et al. National Assessment of Pediatric Readiness of US Emergency Departments during the Covid-19 Pandemic. JAMA Netw Open. July 2023 Date: Dec 11, 2023 Guest Skeptic: Dr. Rachel Hatcliffe is a pediatric emergency medicine attending at Children's National Hospital in Washington, DC. Her research focuses on prehospital care of children with anaphylaxis. Guest Authors: Dr. Kate Remick Dr. Kate Remick is a pediatric emergency medicine physician and Assistant Professor of Pediatrics at Dell Medical School at the University of Texas at Austin. She is an executive lead for the EMS for Children Innovation and Improvement Center. She has held leadership positions with state and national professional organizations to promote high quality emergency care for children. Dr. Hilary Hewes is a pediatric emergency medicine physician and an Associate Professor of Pediatrics at the University of Utah/Primary Children’s Hospital with interests in prehospital care, pediatric trauma and injury prevention, and disaster medicine and preparedness. She is the co-Principal Investigator for the EMS for Children Data Center. Dr. Hilary Hewes Dr. Marianne Gausche-Hill is a pediatric emergency medicine physician and the interim CEO of the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center. She is also a Professor of Pediatrics and Emergency Medicine at David Geffen School of Medicine at UCLA. She is nationally known for her work as an EMS researcher and educator. Case: After your shift in the emergency department (ED) one day, the medical director pulls you aside. She says that they’ve noticed a slight increase in the number of sick pediatric patients coming in recently and the difficulty in finding a hospital to accept the ones who need admission. As a seasoned clinician, she wants your opinion and asks you, “How prepared do you think we are in handling sick children?” and “Do you have any thoughts about how we can improve?” Dr. Marianne Gausche-Hill Background: Back in August of 2022, we announced the start of #SGEMPeds for SGEM Season 11. One of the key motivations was the recognition that we needed to get out of the ivory towers of academic pediatric emergency medicine centers as most children are cared for outside of academic centers. We wanted to spread the gospel of evidence-based medicine so that children get the best care, based on the best evidence, regardless of where they receive care. But does that always happen? Are general emergency departments ready to care for children? Two previous studies conducted assessing the state of nationwide pediatric readiness were conducted in 2003 and 2013. [1,2] Today we're covering the third study. Pediatric readiness is important because it is associated with decreased mortality in ill and injured children. [3, 4] Conflict of Interest Disclosure: Dennis is an Emergency Medical Services for Children (EMSC) fellow in the Knowledge Management domain. Clinical Question: What was the state of pediatric readiness in emergency departments across the United States during the COVID-19 pandemic? Reference: Remick KE, et al. National Assessment of Pediatric Readiness of US Emergency Departments during the Covid-19 Pandemic. JAMA Netw Open. July 2023 Population: ED leadership across the United States. It included 3,647 readiness assessments performed, representing 14.1 million annual pediatric ED visits. Excluded: EDs that are not open 24 hours a day or 7 days a week. Veterans Affairs and prison hospitals. Intervention: Web-based open assessment questionnaire containing 92 questions. Comparison: Previous pediatric readiness scores. Outcome: Primary Outcome: Weighted pediatric readiness score (WPRS, range 0-100); Adjusted WPRS (exclude points for QI plan and Pediatric Emergency Care Coordinator aka PECC) Secondary Outcomes: Changes in WPRS from 2013 to 2021, evaluate factors associated with pediatric readiness. Authors’ Conclusions:“These data demonstrate improvements in key domains of pediatric readiness despite losses in the healthcare workforce, including pediatric emergency care coordinators, during the COVID-19 pandemic, and suggest organizational changes in EDs to maintain pediatric readiness. This comprehensive assessment found that the presence of PECCs, QI plans for children, and staffing the ED with board-certified EM/PEM physicians were associated with higher pediatric readiness and provides an opportunity for all EDs to initiate organizational changes that can enhance their pediatric capability.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes. Was the cohort recruited in an acceptable way? Yes. Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Unsure Have the authors identified all-important confounding factors? Yes. Was the follow up of subjects compl

Reference: Roussel et al. Overnight stay in the emergency department and mortality in older patients, JAMA Intern Med 2023 Date: December 18, 2023 Guest Skeptic: Dr. Chris Carpenter, Vice Chair of Emergency Medicine at Mayo Clinic. Case: An 85-year-old patient (Ms. McG) presents to your emergency department (ED) after being found by family on the ground at her independent living facility. Her family was concerned because she has had multiple recent falls, and she wasn’t answering the telephone that morning. They found her in a pool of blood with a scalp laceration and complaining of left hip pain. Although she had exhibited occasional disorientation and gradually diminishing physical activity over the last 5-years, she was still functionally independent. While your ED evaluation, computed tomography (CT) imaging of her head and spine demonstrated no traumatic injury and an x-ray of her pelvis showed no fracture or dislocation, she was unable to bear weight due to her hip pain, so you ordered a CT to further evaluate for occult fracture. Advanced imaging was unavailable until morning by the time that test was ordered. Suspecting an occult fracture, you consult Orthopedic surgery for admission, but they wanted to wait for the CT the next day. You then consult Internal Medicine/Hospitalist who also want to wait for CT imaging in case the admission is more appropriate on the Orthopedic surgery service. After all these consultant calls it is now after midnight and you are concerned that the patient will be in the ED all night and what the consequences of a preventable episode of overnight ED boarding might have on the patient and the rest of the department since the waiting room still has 20 patients awaiting evaluation. Background: Falling is the most common cause of traumatic injury resulting in older adults presenting to the ED [1]. Approximately 20% of falls result in injuries, and falls are the leading cause of traumatic mortality in this age group [2-4]. Older adults who are admitted to the hospital after a fall will be readmitted to the hospital within one-year in 44% of cases and 33% will die within one-year. Because it is such a serious topic, we have covered it several times on the SGEM: SGEM#89: Preventing Falling to Pieces SGEM Xtra: Don’t Bring Me Down – Preventing Older Adult Falls from the Emergency Department SGEM#351: How to Stop Geriatrics from Free Fallin’ GEMCast: How to Help Prevent the Next Fall in Your Older Patients Geriatric ED Collaborative Falls Resources: Falls and Mobility EDs are becoming more and more crowded. The Canadian Association of Emergency Physicians (CAEP) flagged this issue 10 years ago in 2013. They published a position statement with several suggested solutions. Unfortunately, things have only gotten worse, and it does not seem to be an isolated problem in Canada. The American College of Emergency Physicians (ACEP) held a summit of stakeholders across health care in September of 2023. They got together a wide range of leaders in various organizations to discuss potential solutions to what is called “boarding” of patients. Perhaps we should define the term boarding as we are using it in the context of emergency medicine. It is when patients have been assessed and deemed to need admission to hospital. However, there are no beds available in the hospital and the patient remains in the ED. They can end up waiting for hours, days or even have their entire in-patient hospital care delivered in the ED. The Joint Commission is an organization in the US that sets standards to improve safety in healthcare. They have identified the boarding of patients in the ED as a significant safety risk. In 2012, they said patients should not remain in the ED after the decision to admit to hospital of more than four hours [5]. It has been reported that waiting longer than four hours can result in downstream harms which include but are likely not limited to increased medical errors, compromises to patient privacy, and increased mortality [6]. Kelen et al said boarding is like a canary in a coal mine for the healthcare system and is more likely to happen when hospital occupancy rates exceed 85% to 90% [7]. That comment about the canary reminds me of a tweet by one of my mentors, Dr. Alan Drummond. He has been warning about this problem of overcrowding for years and emphasizes that it is a system problem not just a problem in the ED. Al Drummond posted some sad news on the site formerly known as Twitter saying that "The F-ing canary was dead." There was a study published in the EMJ last year talking about an increased mortality associated with longer wait times in the Nasional Health Service in the UK [8]. They observed an increase in all-cause mortality in the next month for patients who waited more than 5 hours to be admitted. This was not a unique observation and other researchers have published similar findings including our friends Jesse Pines and Peter Viccellio [9-10]. Clinical Q

Date: December 12, 2023 Reference: OCFP News. More Than Four Million Ontarians Will Be Without a Family Doctor by 2026. Nov 7, 2023 Guest Skeptic: Dr. Mahaleh Mekalai Kumanan attended Dalhousie University for her undergraduate studies, Master of Health Administration degree and medical school before completing her residency at the University of Western Ontario. She is currently the President of the Ontario College of Family Medicine (OCFP). This is an SGEM Xtra. I had the opportunity to interview the President of the OCFP about the current state of family medicine and some possible solutions. Please consider listening to the SGEM Podcast and hear what Dr. Kumanan has to say. It has been an interesting couple of months. The College of Family Physicians of Canada (CFPC) in September widely communicated they were going to implement an additional year of training for family medicine residents. There was an outcry from individuals and organizations (SRPC, CFMC, RDC, OMA & Ministers of Health) asking the CFPC to pause and reconsider. This included a statement from the OCFP. To its credit the CFPC listened, reflected, and responded in a very appropriate way. The CFPC President (Dr. Mike Green) apologized and announced they are not implementing an additional year of training. This took a great deal of insight and humility. Well done CFPC. Now it is time to address some immediate issues with Family Practice. Some listeners may be wondering why we are discussing this on an emergency medicine podcast. Well, it is because we are all on Team Patient. Family Medicine is the foundation of healthcare. Without strong primary care patients will eventually end up in the ED. I suspect Ontario is not the only province and Canada is not the only country struggling with these problems. As of September 2022, data by INSPIRE-PHC posted on the Ontario Community Health Profiles Partnership (OCHPP) shows nearly 2.3 million Ontarians are without a family doctor – that’s up from 1.8 million in March 2020, or up from 1.6 million in 2018. INSPIRE-PHC research, led by Dr. Kamila Premji, also shows 1.74 million Ontarian's have a doctor who is nearing retirement. In addition, the number of medical school graduates choosing to pursue family medicine is the lowest it’s been in 15 years. Using updated research, the OCFP now predicts that Ontario will exceed its previous forecast as the crisis in family medicine intensifies. Approximately 1 in 4 Ontarian's – or 4.4 million – will be without a family doctor by 2026. OCFP: Three Solutions to the Crisis Ensure Ontarians have a family doctor working alongside a team, so patients can get the help they need faster. Improve the accessibility of care by increasing the time that family doctors can spend providing direct patient care. Ensure every Ontarian has a family doctor by recruiting and retaining more family doctors within the province. Research shows that patients with access to comprehensive team-based primary care, led by a family doctor, have better health outcomes, fewer visits to the hospital/emergency department/specialty care, and overall are more satisfied with their care. The Ontario government needs to commit to ensuring every family doctor and their patients have access to a team. Ontarians who have family doctors working in teams have far greater access to the care they need because their physicians are supported by nurses, pharmacists, dietitians, social workers and more. Having easy access to a team of health care providers led by a family physician means patients can get the right care from the right provider – and frees up time for family doctors to focus on patients that most need their expertise. Right now, 70 per cent of family doctors and their patients do not have access to team-based support. The second solution the OCFP suggests is to improve the accessibility of care by increasing the time that family doctors can spend providing direct patient care. This has got to be about the mountain of paperwork. Family doctors say they can spend up to 25% of their week on administrative work. This is time that could be spent providing direct patient care. We need to give family doctors more time to spend on direct patient care. There are several policy solutions including EMRs, centralized referrals and minimizing forms. On average, family doctors spend 19 hours a week on administrative tasks such as writing sick notes and filling out lengthy insurance forms. Simple measures such as eliminating sick note requirements and standardizing insurance forms, would mean more time treating patients. The third solution brought forward by the OCFP is to ensure every Ontarian has a family doctor by recruiting and retaining more family doctors within the province. There is an incredible amount of institutional knowledge out there considering walking away from primary care. We need to keep them engaged. 1.3 million Ontarians live without a doctor. And 1-in-5 family physicians plan on r

Reference: Punches et al. Patient Perceptions of Microaggressions and Discrimination Towards Patients During Emergency Department Care. AEM Dec 2023 Date: December 14, 2023 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Case: A 57-year-old Chinese woman presents to the emergency department (ED) with chest pain. She speaks some English, but it is her second language. It is a very busy day, and you proceed to ask her questions in rapid succession. You roll your eyes when you must repeat yourself and ask in a louder and louder voice in order to get a response. Background: Patient experiences of care are associated with health outcomes and may impact perspectives of ED care and the patient recovery process.(1-5) Perceptions of discrimination in healthcare are linked to delays in seeking medical treatment, nonadherence to clinician recommendations, and mistrust of clinicians and the healthcare system.(6-7) We looked at deaf and hard-of-hearing patients in the ED on SGEM#383. Microaggressions are discriminatory behaviors that may be subtle or unintentional but may disempower affected individuals leading to differential care and worse healthcare outcomes.(7-10) Discrimination, implicit bias and microaggressions are common in healthcare encounters involving persons from marginalized groups.(11-17) Microaggressions and discrimination towards patients have been studied in other healthcare settings, but there has been little research on this topic that specifically investigates EDs.(10-11) The ED is a unique part of the healthcare system due to its inherent chaotic environment, time constraints and lack of prior patient-staff interaction. Clinical Question: How can patient perceptions of microaggressions that occur during an ED visit inform potential interventions and prevent future occurrences? Reference: Punches el al. Patient Perceptions of Microaggressions and Discrimination Towards Patients During Emergency Department Care. AEM Dec 2023. As this is a qualitative study, we will use a modified PICO question (PIC): Population: Adult, English speaking patients visiting one of two urban emergency departments in a Midwest US city. Interest: Exploring patient experiences of discrimination during their ED visit. Context: Improving patient care and reducing microaggressions from ED staff This is an SGEMHOP episode, and it is our pleasure to introduce Dr. Lauren Southerland. She is an Associate Professor in the Department of Emergency Medicine at The Ohio State University. Her research interests include clinical process improvement in the ED and implementation science, and she focuses on the care of vulnerable populations, most often older adults or others lacking capacity or capabilities. This study used a mixed methods sequential explanatory approach whereby the researchers collected quantitative data on experiences of discrimination using the DMS tool, followed by qualitative data through a semi-structured interview. Dr. Lauren Southerland As many of us have over the past four years, we were looking at our emergency care and interested in whether our practice was contributing to disparities. Additionally, many of us in medicine have witnessed or experienced microaggressions, and we wondered if our ED care was contributing to patients feeling discriminated against. So, we looked at the available research and found that no one really had a good answer for our question, and the obvious solution to us was to ask patients about their experiences. The sequential, mixed methods design came about because we didn’t want to do interviews during the ED visit, as that could make patients feel uncomfortable or like they were reporting on their healthcare workers. But we also know that once someone leaves the ED to go home it is often hard to get them to answer the phone or call back for an interview. So, we added in the quick discrimination in medical settings scale so that we could obtain some information about our current care in case we couldn’t get many interviews. It also allowed us to compare the quantitative and the qualitative evidence, which led us to some interesting conclusions. That is also why we have 48 people completing the quantitative portion but only obtained 30 final interviews. We had some expected loss to follow up. Another process that worked well was that we did not randomize people to participation. We did not want an average sample of views. We used purposive sampling, were we specifically looked for a people of different ages, genders, race and ethnicities to provide a breadth of viewpoints. What struck me the most is that I learned more about my own research biases. I went into this study on biases and microaggressions with some preconceived biases. I thought we would hear a lot of stories of gender and racial discrimination. And some of that o

Date: November 20, 2023 Reference: Jones et al. Time to reflect on open-label placebos and their value for clinical practice. PAIN October 2023 Caitlin Jones PhD Guest Skeptic: Dr. Caitlin Jones is a Postdoctoral Research Associate at Sydney University’s institute for Musculoskeletal Health. Her research evaluates the benefits and harms of treatments for musculoskeletal conditions with a particular interest in high-risk treatment options such as opioid medicines and spinal cord stimulators for pain. She has a goal to improve patient outcomes and reduce harm from inappropriate treatments. We have an interesting back story on how we met. Dr. Sergey Motov and I did a structured critical appraisal of the OPAL trial (SGEM#419). You were the lead author on that study. You pointed out we missed some details in our review and provided some additional information. We were happy to hear from you and updated the SGEM episode based upon your comments. Not everyone has been so receptive to your study and your feedback. Thanks for appraising OPAL and for engaging with me about it. There were lots of varied responses to OPAL. Most were positive and interested. Some had opinions that the trial doesn’t reflect their practice or their patients, so it’s not relevant to them (reasonable position). Some are furious that we would even suggest that opioids don't work and they are certain this is part of a corrupt evil agenda (I don’t engage with this stance because nothing I can say will change their minds). I do engage when it’s just a genuine misunderstanding, or someone has missed some details.Everyone is free to make up their own mind about how they will or won’t apply these findings into their clinical practice, but I do feel an obligation to correct misunderstandings when I see them. After our exchange I looked up some of your other publications. One of them caught my eye as being very thought-provoking. It looked at open label placebo being used in clinical trials. The title of the paper was Time to reflect on open-label placebos and their value for clinical practice [1]. What got you interested in that topic? A lot of my research compares treatments for MSK pain to placebo to establish efficacy (how well it works). In my field we often find, sadly, that some of the treatments used for decades in clinical practice don’t show effects above that of the placebo when someone finally tests them properly. There’s been increasing chatter about OLPs with a few editorials written in big journals, and an increase in publications on the topic, so it is clearly gaining traction in the clinical and research community. A lot of my work so far has been about testing treatments that have been used for decades without proper testing, and then when we finally test them, we discover we were doing more harm than good all this time. Open label placebos as a clinical treatment are new enough that there is time to intervene and advocate for some thorough testing before they become common place in clinical care. I don’t want this to be another thing where we realize in 50 years’ time that we were harming not helping. SGEM listeners are probably familiar with the placebo effect, but can you give us a brief definition or description? The placebo effect is the positive effect on outcomes stemming from positive expectations around receiving a treatment, but not the treatment itself. Placebo in a research context is the gold standard comparison in efficacy trials that can provide an estimate of the treatment effect, filtering out all the biases and contextual effects that aren’t directly caused by the treatment of interest, so we are left with an estimate of the direct effects of the treatment itself. Then along came some research which caused some excitement. They reported that you could elicit a placebo effect without deceiving the patients (ie telling them it is a placebo) [2]. Yes, some very interesting research came out that even when you tell people they are getting a placebo, they still seemed to cause some positive effects. That was really appealing to a lot of people who believed in the power of placebo, but felt the main barrier to usage was with unethical element of deception – suddenly no deception seemed necessary. Open Label I love talking nerdy and the methods section is my favourite section of a publication. So, what were the fundamental misunderstandings of the open label placebo (OLP) and research methodology? Mismeasuring / over inflating the placebo effect by confusing response for effect Lack of blinding in trials, plus positive preamble, overinflates OLP group and deflates control group effects. Sampling bias, advertising for mind-body treatments and having participants self-select(only examining people with a pre-existing belief or interest). Not including co-design or input from the people who we think would be most likely to receive this (conditions hard to diagnose and treatg. chronic pain, chronic fatigue) I understand

Reference: Shaikh N, et al. Identifying children likely to benefit from antibiotics for acute sinusitis: a randomized clinical trial. JAMA July 2023 Date: October 17, 2023 Dr. Alasdair Munro Guest Skeptic: Dr. Alasdair Munro is a clinical research fellow specializing in pediatric infectious disease at the University of Southampton. He is currently involved with clinical trials of vaccines and antibiotics. Case: A 4-year-old girl presents to your emergency department (ED) with fever and nasal drainage. Her vaccinations are all up to date. Symptoms have been present for the past 12 days. She initially had some cough and congestion which was diagnosed as a viral upper respiratory infection by her primary care doctor. Her symptoms have persisted and yesterday she developed fever (temperature of 38.3°C) and nasal drainage. On physical examination, she has nasal congestion with yellow-colored nasal discharge. The family says to you, “She’s been sick for almost 2 weeks and the color of her nasal drainage changed to yellow. Does this mean she has a bacterial infection that needs antibiotics?” Background: Distinguishing between sinusitis and viral upper respiratory infections in children is challenging. The symptoms often overlap. The latest clinical practice guidelines from the American Academy of Pediatrics (AAP) on the diagnosis and management of acute bacterial sinusitis in children was published in 2013 [1]. Based on those guidelines, a presumptive diagnosis of bacterial sinusitis can be made when a child with URI symptoms has: persistent illness (nasal discharge, daytime cough) lasting more than 10 days without improvement worsening course (new or worsening nasal discharge, daytime cough, or fever after initial improvement) severe onset (fever ≥39°C, purulent nasal discharge for at least 3 consecutive days) This recommendation only has an evidence quality of B. We don’t routinely perform sinus aspiration on children, but it is thought that the most common pathogens involved in sinusitis include Streptococcus pneumoniae Hemophilus influenzae, or Moraxella catarrhalis. Untreated sinusitis is associated with complications such as pre septal cellulitis, orbital cellulitis. In bad cases, there can be intracranial involvement that includes cavernous venous thrombosis, osteomyelitis, meningitis, or intracranial abscess. However, in the interest of antibiotic stewardship. We also do not want to be prescribing antibiotics for viral illnesses. This issue was covered on SGEM #263. We should be thinking about implementing strategies to reduce the unnecessary prescribing of antibiotics in the emergency department. Clinical Question: What are the potential benefits and harms of antibiotic treatment for children diagnosed with acute sinusitis and does it depend on bacterial pathogen colonization or color of nasal discharge? Population: Children aged 2 to 11 years with persistent or worsening acute sinusitis (as per AAP practice guideline) and symptom score of => 9 on Pediatric Rhinosinusitis Scale (PRSS) [2]. This scale ranges from 0-40 with higher scores representing more severe symptoms. Persistent = nasal symptoms, cough or both for 11 - 30 days without improvement. Worsening = period of improvement followed by worsening nasal symptoms or daytime cough, or new onset fever on days 6 - 10. Exclusion: severe presentation (presence of both colored nasal discharge and fever ≥39°C for 3 or more consecutive days, history of asthma, active wheezing, solely cough, history of allergic rhinitis, immotile cilia syndrome, cystic fibrosis, immunodeficiency, allergy to study medications, concurrent infections, systemic antibiotic use within the previous 15 days, prior sinus surgery, families did not have access to phone or were not English/Spanish speaking Intervention: 10 days of Amoxicillin/Clavulanic acid Comparison: Matching placebo Outcome: Primary Outcome: Symptom burden (PRSS) during first 10 days after diagnosis Secondary Outcome: Treatment failure defined as (1) an increase in PRSS score of greater than 20% from enrollment at any time, (2) a decrease of less than 2 points in the PRSS score from enrollment to day 3, (3) a decrease in PRSS score of less than 20% from enrollment to day 4, (4) a decrease in PRSS score of less than 20% from enrollment on 2 consecutive occasions on days 5 to 11, or (5) a decrease in PRSS score by less than 50% from enrollment to the end-of-study follow-up visit. Acute otitis media (AOM). Receipt of another systemic antibiotic Safety: Non-susceptible pathogen at follow up (S pneumonia or H influenzae). Clinically significant diarrhea (3 or more watery stools for 1 day or 2 watery stools on each of 2 consecutive days). Rash. Other resource utilization. Missed work days. Type of Study: A multi-center, double-blind, placebo-controlled, randomized clinical trial. Authors’ Conclusions: “In children with acute sinusitis, antibiotic treatment had minimal benefit for those without nasopharyngeal bacterial

Date: November 22, 2023 Reference: Stopyra et al. Delayed First Medical Contact to Reperfusion Time Increases Mortality in Rural EMS Patients with STEMI. AEM November 2023. Guest Skeptic: Dr. Lauren Westafer an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the cofounder of FOAMcast and a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and a research methodology editor for Annals of Emergency Medicine. Case: A 72-year-old man with a history of high blood pressure and diabetes calls emergency medical services (EMS) for chest pressure and dyspnea that started 1 hour ago. Upon EMS arrival, they find the patient is sweaty with normal vital signs. A 12-lead electrocardiogram (ECG) demonstrates ST elevations in leads II, III, and aVF with ST depressions in leads I and aVL and the team begins transport to the nearest percutaneous coronary intervention (PCI) capable hospital. Background: We have covered the issue of heart attacks several times on the SGEM. These include looking at the HEART score, troponin testing and cardiovascular disease in women. One aspect we have not addressed is rural. SGEM#151: Groove is in the HEART Pathway SGEM#160: Oh Baby, You’re Too Sensitive – High Sensitivity Troponin SGEM#280: This Old Heart of Mine and Troponin Testing SGEM#370: Listen to your HEART (Score) SGEM#400: A Little Bit of Heart and Sport and Sports Related Sudden Cardiac Arrest in Women SGEM Xtra: Unbreak My Heart – Women and Cardiovascular Disease Current guidelines target a time between first medical contact (FMC) like EMS on-scene and stent or balloon deployment (PCI) of 90 minutes or less. If time from FMC to PCI is anticipated to be greater than 120 minutes, the guidelines recommend systemic thrombolysis rather than PCI [1]. I’ve published on this issue with a project we called “barn door-to-needle time” [2]. We looked at 101 STEMI patients from two rural EDs. The median door-to-ECG time was 6 minutes, door-to-physician time was 8 minutes and DTN time was 27 minutes; 58% of patients received thrombolytics within 30 minutes. Regional systems of care have been designed to rapidly recognize patients with STEMI and direct STEMI patients to timely reperfusion. Many hospitals do not provide PCI, prolonging transportation times, which disproportionately affects rural patients. There are several distinct time intervals in the care of patients with STEMI and it is unclear which steps in pre-PCI care of patients contribute to avoidable delays. Clinical Question: Is there an association between in-hospital mortality and time between first medical contact and primary percutaneous coronary intervention in rural patients who present with a STEMI? Reference: Stopyra et al. Delayed First Medical Contact to Reperfusion Time Increases Mortality in Rural EMS Patients with STEMI. AEM November 2023. Population: Patients ≥ 18 years of age who were transported to one of three tertiary care hospitals by a rural EMS agency and received primary percutaneous coronary intervention (PCI) for STEMI. Rural agency was defined by US census codes (2014) Excluded: Patients <18, those who had prehospital cardiac arrest, and those who were transferred between hospitals Exposure: 90-minute first medical contact to PCI goal (defined as time between the time recorded as EMS personnel arrival on scene and the time the angioplasty or stent was deployed Comparison: Greater than 90 minute first medical contact to PCI Outcome: Primary Outcome: All-cause in-hospital mortality during the index hospitalization Secondary Outcomes: Prehospital time intervals stratified by index hospitalization mortality. Type of Study: A retrospective cohort study from eight rural North Carolina EMS agencies between January 2016 to March 2020. Dr. Michael Supples This is an SGEMHOP episode, and it is my pleasure to introduce Dr. Michael Supples. He is an assistant professor of emergency medicine and faculty within the emergency medical services fellowship at Wake Forest School of Medicine in North Carolina. He is double boarded in EM and EMS and focuses on prehospital research. Responds Authors’ Conclusions: “Death among rural patients with STEMI was four times more likely when they did not receive PCI within 90 minutes.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Not very precise. Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with o

Date: November 2, 2023 Reference: Coventry et al. Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies. Emerg Med J. Aug 2023 Guest Skeptic: Dr. Matt Schmitz is an Orthopaedic Surgeon who sub-specializes in adolescent sports and hip preservation. He will soon be transitioning out of the US military after a 20-year career in the Air Force and is soon to be Clinical Professor of Orthopaedics at UC San Diego. DISCLAIMER: THE VIEWS AND OPINIONS OF THIS BLOG AND PODCAST DO NOT REPRESENT THE UNITED STATES GOVERNMENT OR THE US MILITARY. Case: A 24-year-old manual labourer presents to the emergency department (ED) after drinking a few too many beers, having a disagreement with another beer drinker and gets knocked down. The mechanism was described as a classic FOOSH (fall on outstretched hand) injury. Examination reveals pain along the wrist and in his anatomical snuffbox. However, the x-rays read as “normal” by radiology. Background: Fractures of the scaphoid are the most common carpal fractures presenting to the ED. One of the best systematic reviews and meta-analyses on the topic discussing the diagnostic accuracy of the history, physical examination and imaging is by Carpenter et al from AEM 2014 [1]. We went into some detail on SGEM#385. Many potential scaphoid fractures are immobilized but this can be a detriment to job, school, and activities of daily living. Initial Xray’s pick up only about 17% of fractures [2]. Having patients follow-up in a couple of weeks for repeat x-rays can pick up about 7% more [3]. MRIs have greater diagnostic accuracy [1] but may not be available in some areas and can be expensive and not always readily available. A CT scan is not as accurate as an MRI but does come with a different type of cost, radiation exposure [1]. Clinical Question: What to do with a patient who presents with a FOOSH injury and has a normal x-ray; are there clinical exam findings that can help rule in/rule out a scaphoid fracture? Reference: Coventry et al. Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies. Emerg Med J. Aug 2023 Population: Patients with a clinical suspicion of having a scaphoid fracture but a normal initial x-ray Excluded: Studies that did not have enough information to create a 2x2 table even after contacting study authors. Intervention: Various physical examination maneuvers Comparison: N/A Outcome: Diagnostic accuracy expressed as sensitivities, specificity, and likelihood ratios Authors’ Conclusions: “No single feature satisfactorily excludes an occult scaphoid fracture. Further work should explore whether a combination of clinical features, possibly in conjunction with injury characteristics (such as mechanism) and a normal initial radiograph might exclude fracture. Pain on supination against resistance would benefit from external validation.” Quality Checklist for Systematic Review Diagnostic Studies: The diagnostic question is clinically relevant with an established criterion standard. Yes The search for studies was detailed and exhaustive. Yes The methodological quality of primary studies were assessed for common forms of diagnostic research bias. No The assessment of studies were reproducible. Yes There was low heterogeneity for estimates of sensitivity or specificity. No 6. The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision-making models. No Results: They searched the worlds literature, followed the PRISMA guidelines and found eight studies of which four included a small number of children. There were 1,685 wrist injuries included in the SRMA of which there were 123 (9%) occult scaphoid fractures (normal initial x-rays). Most studies were reported as having an overall low risk of bias. Key Results: There was no physical examination that could rule-out an occult scaphoid fracture with any confidence. Primary Outcome: Diagnostic accuracy The best test for both positive and negative likelihood ratios as the pain on supination against resistance test based upon one small study of only 53 patients with 9 occult fractures (17%) LR+ 45.0 (95% CI; 6.5 to 312.5) LR- 0.1 (95% CI; 0.0 to 0.7) 1) Selection Bias: The authors mention that findings on physical examination contributed to the clinical suspicion of a fracture. This could be a source of selection bias. The definition according to the Centre for Evidence Based Medicine at Oxford University “occurs when individuals or groups in a study differ systematically from the population of interest leading to a systematic error in an association or outcome”. 2) Prevalence: Sensitivity depends on the spectrum of disease, while specificity depends on the spectrum of non-disease. So, you can falsely raise sensitivity if the clinical practice has lots of very sick people (sicker than who you see in the ED). Specificity can look great if you have no sick patients in t

Reference: Roland D, Munro A. Time for paediatrics to screen out sepsis “screening.” BMJ. June 2023 Date: Sept 12, 2023 Guest Skeptic: Dr. Damian Roland is a Consultant at the University of Leicester NHS Trust and Honorary Professor for the University of Leicester’s SAPPHIRE group. He specializes in Paediatric Emergency Medicine and is a passionate believer and advocate of FOAMed. Damian is also part of the Don’t Forget the Bubbles Team. Dr. Damian Roland Background: For anyone who has ever taken care of a decompensating child with septic shock, it’s unlikely you’ve forgotten the experience. So we have a lot of respect for sepsis and the importance of early recognition to prevent morbidity and mortality. Despite the medical community’s experience with sepsis over the years, there is still much that is unclear about the diagnosis and management of sepsis: How is sepsis diagnosed? What is the optimal fluid to give? How much fluid should be given? When should pressors be started? What pressors should be used? What is the optimal timing of antibiotic therapy? We have covered the topic of sepsis a few times on the SGEM SGEM #371: All of My Lovit, Vitamin C Won’t Work for You SGEM #346: Sepsis-You were Always on My Mind SGEM Xtra: Petition to Retire the Surviving Sepsis Campaign Guidelines SGEM #207: Ahh (Don’t) Push It- Pre-hospital IV Antibiotics for Sepsis SGEM #174: Don’t Believe the Hype- Vitamin C Cocktail for Sepsis SGEM #168: Hypress-Doesn’t got the Power SGEM #92: Arise Up, Arise Up (EGDT vs Usual Care for Sepsis) SGEM #90: Hunting High and Low (Best MAP for Sepsis Patients) SGEM #69: Cry Me a River (Early Goal Directed Therapy) Process Trial Damian and Dr. Alasdair Munro make the bold claim in an opinion article in the BMJ titled, Time for paediatrics to screen out sepsis “screening.” Despite us being very careful in trying to identify children with sepsis, there is a lot of uncertainty. So, we're diving into some of those controversies and gray areas. Some key topics are highlighted below, but tune into the podcast to listen to all the great conversation and pearls of wisdom from Dr. Roland. Why Sepsis is a Challenge in Children’s Acute/Emergency Care? The definition of "sepsis" is not clear. Sepsis may be more due to the body's response to infection than the infection itself. It's possible to have a pathogen in the bloodstream, but not have sepsis because there is not cardiac dysfunction or capillary leakage Children with sepsis may not have a pathogen isolated, and children with a pathogen isolated may not be "septic." What has been the Approach to Sepsis Recognition and Treatment? Sepsis occurs along a spectrum. Recognizing severe sepsis is not difficult in the child that appears acutely ill. Distinguishing the children in the middle of that spectrum is a challenge. There is variation in screening tools and scoring systems for sepsis across healthcare systems. The principle of evaluating for deranged physiology (abnormal vital signs) in combination with fever and infection risk is more ubiquitous. There are differences in application. Screening tools are imperfect. There are many false positives and false negatives. There is no "holy grail" of screening tools. We spoke about the utility of the following in detecting and ruling out sepsis: lactate inflammatory markers (CRP, ESR, procalcitonin) viral PCR testing height of fever We also spoke some of the evidence behind management strategies for sepsis that included: IV fluids Inotropes Antibiotics Recent Controversies and Evidence Many of us are familiar with the Surviving Sepsis campaign/International guidance. After release a group of doctors expressed some concerns due to: conflicts of interest making strong recommendations based on weak evidence criticism regarding the bundling of care that does not consider clinical judgement Infectious Disease Society of America (IDSA) did not endorse the Surviving Sepsis campaign guidelines due to different interpretation of the major studies that lead to the recommendations. Our guidelines tend to lack sensitivity and specificity. While there are significant consequences of missing a sepsis diagnosis, the incidence of sepsis is relatively rare. Why is "Sepsis Screening" an Incorrect Lexicology? A "sepsis screen" was used to describe a bundle of tests. In the example of a febrile 6-week old, a "sepsis screen" involves blood culture, urine, inflammatory markers, and possibly lumbar puncture. The definition evolved when guidance came in that told us what to do if the child presents with certain parameters to evaluate children with a risk of sepsis. Screening tests should have some key principles: known denominator of condition being treated test should be acceptable test should have good characteristics (clearly identify disease) Sepsis screening does not meet these criteria. What can/should we do? We need to look into the conditions in wh

Date: October 26, 2023 Reference: Jones et al. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial placebo-controlled trial. Lancet July 2023 Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department, specifically the use of ketamine. His twitter handle is @PainFreeED. Case: A 37-year-old man without a significant past medical history presents to the emergency department (ED) with a chief complaint of lower back pain that started three days prior to the ED visit after unloading a truck with furniture. He states that pain is severe (7/10 in intensity), sharp, constant, non-radiating, and is exacerbated by any movement. The patient is unable to go to work due to pain and is experiencing severe limitations in his daily activities. He denies any weakness or numbness of the lower extremities or bowel or bladder dysfunction. You perform a physical examination and note prominent tenderness to palpation at bilateral lumbar paraspinal regions with normal neuro-vascular examination. You engage the patient in shared decision making about his most likely diagnosis (muscle strain) and treatment approach such as a short course of non-steroidal anti-inflammatory drugs (Ibuprofen) and gradual physical activity as tolerated. The patient, however, believes that ibuprofen will not touch his pain and insists on receiving an opioid-containing medication. Background: Low back pain and neck pain are extremely common conditions worldwide [1]. We have covered the issue of back pain several times on the SGEM including: SGEM#87:Let Your Back Bone Slide (Paracetamol for Low-Back Pain) SGEM#173: Diazepam Won’t Get Back Pain Down SGEM#240: I Can’t Get No Satisfaction for My Chronic Non-Cancer Pain SGEM#304: Treating Acute Low Back Pain – It’s Tricky, Tricky, Tricky SGEM#366: Relax, Don’t Do It – Skeletal Muscle Relaxants for Low Back Pain Back pain and neck pain are leading causes of disability on a global scale [2,3]. The substantial disability burden imposes enormous costs both directly on healthcare systems, and indirectly through productivity losses [4,5]. Not only are these conditions common and painful they are difficult to treat. Many pharmacologic treatments have been tried with limited efficacy. Acetaminophen (Williams et al Lancet 2014) Muscle relaxants (Friedman et al JAMA 2015) NSAIDs (Machado et al Ann Rheum Dis 2017) Steroids (Balakrishnamoorthy et al Emerg Med J 2014) Benzodiazepines (Friedman et al Ann Emerg Med 2017) Many non-pharmacologic therapies have also been tried with limited efficacy. Cognitive Behavioral Therapy and mindfulness (Cherkin et al JAMA 2016) Chiropractic (Paige et al JAMA 2017) Physical therapy (Paolucci et al J Pain Research 2018) Acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013) One treatment modality, opioids, can be effective but comes with very real potential harms. The American College Physicians (ACP) has a 2017 policy on guidelines for treating non-radicular low back pain (Qaseem et al Annals of Int Med). Their third recommendations states: Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence) The American College of Emergency Physicians (ACEP) has addressed the issue of opioid use in patients being discharged home after an acute episode of pain. They give a Level C Recommendations saying: Do not routinely prescribe, or knowingly cause to be co-prescribed, a simultaneous course of opioids and benzodiazepines (as well as other muscle relaxants/sedative-hypnotics) for treatment of an acute episode of pain in patients discharged from the emergency department (Consensus recommendation). Despite guidelines and policy recommendations for prudent short-term opioid use only after other analgesics fail [6], opioid medications are frequently prescribed as the initial treatment for patients presenting with acute low back pain or neck pain. Estimates suggest up to two-thirds of these patients in Australia may receive opioids first-line [7]. Opioid prescription rates remain high in many countries including the USA. One study reported 43 prescriptions dispensed per 100 people in the US in 2020, though efforts have been made recently to curtail this use [8]. The prevalent use of opioids for acute back and neck pain is concerning given the lack of direct, high-quality evidence supporting efficacy [9]. Clinical Question: Is a short course of an opioid analgesic effective at reducing pain severity and improving function and quality of life in patients with acute non-specific low back pain or nec

Date: October 20, 2023 Reference: Cai et al. Implementation of a Clinical Management Tool for Spinal Epidural Abscess Early Diagnosis. AEM October 2023. Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals. Case: You are in your group meeting and have heard about a case at a nearby emergency department (ED) where the diagnosis of a spinal epidural abscess was delayed, and a substantial settlement has been made out of court. Your group director is concerned with avoiding the same thing happening in your department and wants to know if you should implement an evidence-based clinical management tool (CMT) to reduce delays in diagnosis. Background: Spinal epidural abscess (SEA) is a diagnosis which can seem easy to make in retrospect. The majority of time (55%) the diagnosis of SEA often involves an error with a median length of time to diagnosis of 12 days according to one study [1]. Diagnostic delays were found to be present in 75% of SEA patients with only a minority (10-15%) of patients present with the “classic triad” of fever, back pain and neurologic deficit [2]. Another study reported that the 90% of patients misdiagnosed on their first ED visit [3] likely due to the non-specific and variable initial presentation, and the number of patients with back pain of benign origin seen in EDs [4]. SEA is the condition with proportionately the highest misdiagnosis rate in ED per a recent systematic review, and long-term sequelae for patients with associated medico-legal costs are high [5]. However, there is a need for clinicians to not let SEA become the next pulmonary embolism with high rates of over investigation. We’ve looked at back pain on the SGEM before, mostly in terms of treatments. SGEM#366 concluded that we could not recommend the routine use of skeletal muscle relaxants, SGEM#304 agreed that adding acetaminophen to ibuprofen did not improve one-week outcomes, while SGEM#173 concluded the same about diazepam (there’s a theme here!). We’ve also looked at the rational use of imaging on SGEM#283 (the Ottawa subarachnoid haemorrhage rule is highly sensitive but has very poor specificity). In SGEM#181, we were unconvinced of the value of routine use of whole body CT in trauma patients, and right back in 2015 on SGEM#106 discussing the Canadian CT head rule and the New Orleans Criteria. However, we’ve not previously looked at the intersection of non-traumatic back pain and rational investigation. CLINICAL QUESTION: DOES IMPLEMENTATION OF A CLINICAL MANAGEMENT TOOL IMPROVE TIME TO DIAGNOSIS AND CHANGE TESTING RATES FOR SPINAL EPIDURAL ABSCESS? Reference: Cai et al. Implementation of a Clinical Management Tool for Spinal Epidural Abscess Early Diagnosis. AEM October 2023. Population: Adults attending at continuously-staffed EDs in a health network covering 15 states, 2016-19. Excluded: Facilities not collecting radiology or lab order data, facilities without 6 months of data before and after intervention. Intervention: Implementation of a literature-based Clinical Management Tool (CMT). Comparison: Periods before and during the implementation of the CMT. Outcomes: Primary Outcome(s): 1. The proportion of patients with SEA with a potentially related visit in the previous 30 days and 2. For those with a prior visit, number of days from first visit to diagnosis. Secondary Outcomes: Utilization rates for CT, MRI, Xray, ESR and CRP. Type of Study: Implementation study. Dr. Anglea Cai This is an SGEM HOP and we are pleased to have the lead author on the show, Dr. Angela Cai. She is a Clinical Assistant Professor of Emergency Medicine at the University of Pennsylvania. She completed this work during her Innovation Fellowship at US Acute Care Solutions. Prior to that she trained at Kings County EM Residency in Brooklyn and the University of North Carolina Chapel Hill for her medical and business degrees. Authors’ Conclusions: “Back pain CMT implementation was associated with an increased rate of recommended imaging and laboratory testing in back pain. There was no associated reduction in the proportion of SEA cases with a related prior visit or time to SEA diagnosis.” Quality Checklist for Observational Cohort Studies: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Unsure Have the authors identified all-important confounding factors? No Was the follow up of subjects complete enough? Yes How precise are the results? Confidence intervals are relatively broad, from minus 4.5 to plus 6% for the change in primary outcome. Do you believe the results? Yes Can the results be applied to the local population? Yes/No Do the results of this study fit with other available evidence? No Funding? No funding source reported, although one author

Reference: Brennan L et al. Time to change the reference ranges of children’s physiological observations in emergency care? A prospective study. J Paediatr Child Health. March 2023 Date: July 12th, 2023 Guest Skeptic: Dr. Vicki Currie is a paediatric emergency medicine registrar in the West Midlands in the United Kingdom. She is also a member of the Don’t’ Forget the Bubbles team where she serves as the editor for the monthly research round up, Bubble WRAP. Dr, Vicki Currie Case: A 5-year-old boy presents to the emergency department (ED) with his parents for fever and fatigue. He has had three days of high fevers at home. His parents report that he has also had a decreased appetite and does not seem interested in drinking liquids. He is usually a happy, active boy but has been very tired over the past day and the parents are having increasing difficulty getting him to wake up. When his vital signs are taken, he is noted to have a temperature of 40°C, a heart rate (HR) of 142 beats per minute (bpm), respiratory rate (RR) of 32 breaths per minute, and blood pressure of 98/60 mmHg. His capillary refill time is three seconds. His parents look at the monitor and ask you, “Is that heart rate normal for him? It seems awfully high. We have been reading online about something called sepsis that can be deadly. Does he have sepsis?” Background: We have looked at pediatric vital signs on the SGEM back in 2014 with PedEM superhero Dr. Anthony Crocco (SGEM#98). That episode reviewed the 2011 Fleming et al systematic review for the normal ranges of HR and RR in children from birth to 18 years of age. The publication provided useful graphs for clinicians on what is normal. Vital signs can be an important objective measurement while assessing a patient. They are often incorporated into many early warning systems, risk-stratification systems, and treatment protocols. Abnormal vital signs may be indicators of potential decompensation. Specifically, heart rate and respiratory rates are used in early attempts to detect sepsis. Children’s vital signs can differ based on age. However, there remains variation regarding what the “normal” ranges of vital signs can be for pediatric patients. Vital sign ranges from common guidelines such as Pediatric Advanced Life Support (PALS) [1] or Advanced Pediatric Life Support (APLS) [2] can differ. Clinical Question: How does a derived distribution of heart and respiratory rates for children compare to APLS and other national guidance? Reference: Brennan L, Heal C, Brown S, Roland D, Rowland AG. Time to change the reference ranges of children’s physiological observations in emergency care? A prospective study. J Paediatr Child Health. March 2023 Population: Children 0-16 years recruited consecutively from October 2017 to September 2020 from three emergency departments and one urgent care centre in England- serving populations with significant inequalities in health and life expectancty. Excluded: none (although impossible values were excluded- Impossible’ values were HR below 50, and RR below 9 or above 90. This did equate to a significant number of records (>11,000 HR and >10,000 RR) Intervention: Anonymized data for patients’ heart rates and respiratory rates Comparison: Reference standards in Advanced Paediatric Life Support (APLS) Outcome: The authors had three aims with their study Comparison of the distribution of heart and respiratory rates from study to APLS ranges Proportion of patients from this study that would meet “severe” cut-off threshold compared to guidelines from the UK Sepsis Trust [3] and National Institute for Health and Care Excellence (NICE) [4] Comparison of distribution of heart and respiratory rates from study to previously published, large data sets [5-7]. Authors’ Conclusions: This study’s data set suggests normal heart rate ranges proposed by the APLS and others is too low and therefore “abnormal” measurement encompass too large a proportion. The respiratory rate of this data set was more consistent with the guidelines and other published data sets. Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Unsure Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? No Was the follow up of subjects complete enough? Unsure How precise are the results? Unsure Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Funding of the Study. No conflicts of interest reported Results: Their initial data set included 235,909 records. After excluding entries with missing or impossible values, there were 191,292 records of HR and 191,147 records of RR included in the final analysis. Median age

Date: September 28, 2023 Reference: Jarman et al. Sex Differences in Guideline-Consistent Diagnostic Testing for Acute Pulmonary Embolism Among Adult Emergency Department Patients Aged 18-49. AEM September 2023 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: During a shift in the emergency department (ED), you see two patients with pleuritic chest pain, one female and one male. Pulmonary embolism (PE) is a diagnosis you are considering for both. After d-dimer testing your female patient, you order a CT scan of the chest for the male patient. One of the nurses on shift asks you why you didn’t order a d-dimer for the male, like you did the female patient. Background: PE is commonly considered during ED workups for chest pain and shortness of breath (1). We have covered the topic of PE more than ten times on the SGEM: SGEM#51: Home (Discharging Patients with Acute Pulmonary Emboli Home from the Emergency Department) SGEM#118: I Hope you Had a Negative D-dimer (ADJUST PE Study) SGEM#126: Take me to the Rivaroxaban – Outpatient treatment of VTE SGEM#163: Shuffle off to Buffalo to Talk Thrombolysis for Acute Pulmonary Embolism SGEM#184: We Weren’t Born to Follow-Up – The PEITHO Long-Term Follow-up Study SGEM#219: Shout, Shout, PERC Rule Them Out SGEM#276: FOCUS on PE in Patients with Abnormal Vital Signs SGEM#277: In the Pregnant YEARS – Diagnosing Pulmonary Embolism SGEM#282: It’s All ‘bout that Bayes, ‘Bout that Bayes- No Trouble – In Diagnosing Pulmonary Embolism SGEM#295: Teacher, Teacher – Tell Me How to Do It (Diagnose a PE) SGEM#323: Mama I’m Comin’ Home – For Outpatient Treatment of a Pulmonary Embolism Many patients may be able to have PE ruled out without imaging, after risk stratification with one of several decision tools (2). A very common clinical decision instrument is the Well’s Criteria. It has seven items with each item having a weighting from 1 to 3. The score is added up and then can be applied in a three-tiered model (low, moderate, or high risk) two-tiered model (PE is unlikely or likely). Another common tool is the revised Geneva Score (rGS). It is an eight-item clinical decision instrument for risk stratification. Each item in this tool also has different weight assigned to the items. Patients are considered low, intermediate, or high-risk depending on their total score. Neither of these two scores considers the sex of the patient for risk stratification. However, sex differences exist in the workup of PE, with females receiving more diagnostic testing, but with a lower diagnostic yield. Female patients are also more likely to undergo diagnostic imaging, and females who undergo imaging are less likely to be diagnosed with PE (3-5). Clinical Question: Are male and female patients equally likely to receive care consistent with guidelines for suspected PE? Reference: Jarman et al. Sex Differences in Guideline-Consistent Diagnostic Testing for Acute Pulmonary Embolism Among Adult Emergency Department Patients Aged 18-49. AEM September 2023 Population: Patients 18-49 years of age presenting with chest pain, shortness of breath, hemoptysis, or syncope alone or in combination Excluded: Pregnancy or incomplete ED visits Exposure: Objective testing for PE Comparison: Sex (male or female) Outcome: Primary Outcome: Receipt of guideline-consistent care based on revised Geneva Score (rGS) Secondary Outcomes: Rates of d-dimer testing, d-dimer positivity, rates of CT-pulmonary artery scanning (CTPA), overall yield of testing. Type of Study: A retrospective cohort study conducted at two U.S. academic tertiary care hospitals Dr. Angela Jarman This is an SGEMHOP episode which means we have the lead author on the show. Dr. Angela Jarman is an Assistant Professor and the Director of Sex & Gender in Emergency Medicine at UC Davis. She joined the faculty there after completing a two-year fellowship in Sex & Gender in Emergency Medicine at Brown University, where she also earned a Master of Public Health degree. Authors’ Conclusions: “In this cohort, females were more likely than males to receive care consistent with current guidelines and less likely to be diagnosed with PE.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Yes Was the follow up of subjects complete enough? Yes How precise are the results? Seem precise where CIs are provided Do you believe the results? Yes Can the results be applied to the local population? Probably Do the results of this study fit with other available evidence? Yes Funding of the Study. It was supported by three grants (American Hear

Reference: Snelling et al. Ultrasonography or radiography for suspected pediatric distal forearm fractures. New England Journal of Medicine June 2023 Date: July 19, 2023 Guest Skeptic: Dr. Casey Parker is a Rural Generalist that includes in his practice emergency medicine, anesthesia, and critical care. He is also a fully-fledged ultrasonographer. Casey currently splits his time between Broome, a small rural hospital in the remote Kimberley region of Western Australia, and a large tertiary ED in sunny Perth. He has been a guest skeptic on the SGEM multiple times. He is also the creator of the amazing #FOAMed website, Broome Docs. Dr. Casey Parker Case: It is a steady Saturday afternoon in your rural emergency department (ED). The triage nurse calls you to have a look at a child who has arrived with his parents in ED after falling from a bouncy castle at a birthday party. He is six years old and appears to be in pain with his left wrist swaddled in an ice pack. He tells you that he was attempting “a double backflip like Spiderman” when he landed heavily on the outstretched hand - this happened about an hour ago. Clinically there is some swelling and tenderness over the distal radius but no deformity. He has good perfusion and no neurological symptoms in the hand. Because it is a small, rural ED there is no radiographer on site but they can be called in if we would like to get an X-ray…. or there is a portable bedside ultrasound machine in the next room ready to go. The child’s mother tells you that the X-ray tech was also at the party having a great time with her children. So, the question is: should we call in our x-ray tech in and disrupt her party fun or just use the ultrasound machine to diagnose this possible fracture? Background: We have covered pediatric wrist fractures a few times on the SGEM. This includes SGEM#19 way back in 2013 reporting a bandage wrap is a safe alternative to traditional casting for children with greenstick fractures. More recently, the amazing Dr. Tessa Davis covered the FORCE trial on SGEM #372 which looked at buckle fractures and compared immobilization in a cast or splint vs. a soft bandage and they found no difference in pain scores or functional outcomes. The use of bedside ultrasound to diagnose uncomplicated wrist injuries in children has been studied in several diagnostic prospective, observational trials to compare its accuracy to traditional plain film X-rays [1-5]. Most of these trials have shown diagnostic sensitivity and specificity above 90% when compared to X-ray as a gold standard. This same research team from Queensland in Australia have also published a paper describing the learning curve for novices in detection of forearm fractures in kids [6]. In 2022 Mobasseri et al published a review of 9 such diagnostic studies and concluded that from an orthopedic perspective that the accuracy was not acceptable, the lack of a randomized controlled trial meant that there was not enough data to support the use of ultrasound over X-ray as an initial diagnostic test [7]. There have been no randomized trials that have compared the patient-centered, functional outcomes after a wrist injury based upon the choice of initial diagnostic test modality. Clinical Question: In children with non-deformed distal forearm injuries, does the use of ultrasound as an initial diagnostic test result in inferior functional outcomes? Reference: Snelling et al. Ultrasonography or radiography for suspected pediatric distal forearm fractures. New England Journal of Medicine June 2023 Population: Children between 5 and 15 years of age who presented to the ED with an isolated, acute, clinically non-deformed, distal forearm injury for which imaging for a suspected fracture was indicated Excluded: obvious angulation/deformity (soft tissue swelling allowed), injury >48hr prior, external X-rays obtained, known bone disease, concern for non-accidental trauma, additional injuries requiring X-rays, congenital forearm abnormality, no credentialed clinician available, developmental delay or behavior prohibiting clinical assessment Intervention: Bedside ultrasound carried out and interpreted by a trained clinician (doctors, nurse practitioners and physiotherapists) Comparison: X-ray Outcome: Primary Outcome: Functional outcome at four weeks (± 3 days) post injury as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) score Secondary Outcomes: PROMIS scores at 1 week and 8 weeks post injury. They also analyzed the children by age cohorts 5 to 9 years and 10 to 15 years old There was also an analysis of the diagnostic accuracy of the ultrasound vs. X-rays. Satisfaction at 4 and 8 weeks (5-point Likert scale with lower scores indicating greater satisfaction) Pain at 1, 4, and 8 weeks using the FACES pain scale Frequency of complications Frequency of radiography Length of stay and treatment time in the ED Trial: Multicenter, open-label, noninferiority, randomized, controlled tria

Date: August 30, 2023 Reference: Griffey et al. The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics. AEM August 2023 Dr. Suchismita Datta Guest Skeptic: Dr. Suchismita Datta. She is an Assistant Professor and Director of Research in the Department of Emergency Medicine at the NYU Grossman Long Island Hospital Campus. This is the last show for Season#11. It has been a great year with the addition of PedEM SuperHero Dr. Dennis Ren. We have some exciting news to cap off the end of this amazing year. Suchi will be joining the SGEM faculty as part of the Hot Off the Press team. Case: A 28-year-old male with a history of type-1 diabetes mellitus presents to the emergency department (ED) with increase in thirst and light headedness. He is otherwise healthy. Blood glucose in triage is 489 mg/dl (27.2 mmol/L). Venous blood gas (VBG) shows an acidosis with a pH of 7.21. Electrolytes show a gap of 21. The patient’s symptoms begin to improve after initial intravenous (IV) fluid administration of one litre of 0.9% saline. The patient states he has had multiple “diabetic emergencies” in the past and usually ends up in the intensive care unit (ICU) on a drip. He is wondering, “Hey doc, do I have to go back to the ICU strapped to an IV pole?” The flow nurse has similar questions for you and wants to know if she should clear out a bed in the critical care bay so that the patient can have appropriate nursing requirements for an insulin infusion. Your resident is eager to go ahead and sign off on the diabetic ketoacidosis (DKA) insulin order set and the ICU attending’s “Spidey senses” are going off. They are on the phone asking you if you already have another admission for them on this busy day. However, the ICU is full and the patient will likely be boarding in your ED for a bit before coming upstairs. Just as all this is happening, you notice how the waiting room is filling up and you can hear the sirens of approaching ambulances becoming louder. You take a deep breath, and you think to yourself…let the squid games begin. Background: DKA is a common yet potentially fatal condition seen in patients with type 1 diabetes. It accounted for roughly 8.9 ED visits /1000 adults with diabetes [1]. DKA results in over 500,000 annual hospital days with estimated annual hospital costs of over $5 billion [2]. Dr. Nathan Kuppermann Despite how common and expensive the management of DKA can be, we have only looked at it once on the SGEM. That was an episode covering the practice changing randomized control trial published in NEJM by Dr. Nathan Kuppermann from the PECARN Team for pediatric DKA [3]. They reported that the type of intravenous fluids (0.45% NaCl or 0.9% NaCl) or speed of infusion did not appear to make a clinically important difference (SGEM#255). Because of the complexity of care around managing DKA, the typical approach is an insulin drip with ICU level of care for all degrees of severity. Increased resource utilization around this can prolong ED length of stay, especially in the context of a busy hospital or a global pandemic. However, over the past 20 years, there is burgeoning evidence that fast-acting subcutaneous insulin analogs could be a potential treatment option for mild to moderate severity DKA including a 2016 Cochrane SRMA [4]. If proven to be a safe and effective management strategy, this would eliminate the need for an insulin drip and opens new options for management and disposition of DKA patients from the ED. Using fast-acting subcutaneous insulin could streamline care in the ED and decrease the length of stay (LOS) in the department. This reduction in LOS is desirable for many reasons including overcrowding, prolonged wait times, and the availability of ICU beds for other critical patients. Clinical Question: Can a patient with mild to moderate severity DKA be safely managed with subcutaneous fast acting insulin analogs on a non-ICU floor with blood glucose monitoring every two hours, and ultimately decrease ED length of stay? Reference: Griffey et al. The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics. AEM August 2023 Population: Non-pregnant, adults (18 years and older) who are presenting with mild to moderate [MTM] DKA Excluded: Pregnant patients, patient younger than 18, patients with concurrent infections, patients with active co-morbidities [ESRD, CHF, active use of immunosuppressants), concerns for myocardial infarction, altered mental status, need for surgery, or at the discretion of ED team if patient deemed to be too sick for the designated floor [which was an OBS floor run by hospitalist]. Intervention: SQuID protocol – Sub Q insulin and admission to predesignated floor Comparison: MTM patients who receive traditional treatment during intervention period, MTM patients who received traditional treatment pre-intervention period, and MTM patients who received traditional treatment pre-COVID [three t

Date: August 20th, 2023 Reference: Milne WK, Challen K, Young T. Skeptics' Guide to Emergency Medicine Season #10 Book Dr. Kirsty Challen Guest Host: Dr. Kirsty Challen is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). She completed undergrad and postgrad training in North West England, acquiring a History of Medicine BSc, a PhD in Health Services Research, an anesthesiologist husband and four children along the way. She is Chair of the Royal College of Emergency Medicine Women in Emergency Medicine group, and involved with the RCEM Public Health and Informatics groups. Kirsty also produces all those wonderful Paper in a Pic Infographics summarizing each SGEM episode. Dr. Tayler Young Guest Skeptic: Dr. Tayler Young is a second year Family Medicine resident at Queen’s University in Kingston, Ontario, Canada. Her interests are quality improvement, Free Open Access Medical Education (FOAMEd) and point of care ultrasound (POCUS). This is an SGEM Xtra to announce that SGEM Season #10 is now available as a FREE pdf book. The SGEM provided the content and Tayler designed the book. She has designed infographics for the Emergency Medicine Ottawa Blog and has summarized SGEM Season #8 and Season #9 with the Avengers and Batman themes. Tayler chose a Harry Potter theme for Season #10 as she is a huge fan of the films and the books. Her favorite character is Norbert the dragon who was secretly hatched by Hagrid in Book 1. Kirsty's favourite character from the Harry Potter series (being a woman in academic EM, still a male-dominated world – see SGEM #352 on the gender pay gap and our Xtra from October 2021 with the wonderful Dr. Suchi Datta about gender inequity) is Hermione Granger. She is the competent skilled witch who faces pushback for knowing the answers and ostracism for not fitting in. She also confesses to having a soft spot for Neville Longbottom, who is quietly ignored and disregarded until trouble really happens and he comes through with the sword of Gryffindor. SEASON #10 Foreword by Dr. Kirsty Challen Harry Potter arrived in our consciousness in 1997 as an unsupported orphan venturing into the magical world for the first time, facing the ever-present but initially under-appreciated threat of Voldemort with Ron and Hermione. The Skeptics Guide to Emergency Medicine was a few years behind, emerging into the #FOAMEd-o-sphere in 2012, but as Harry and his world developed through the books, so has the SGEM. This 10th Edition arrives as advocates of Evidence-Based Medicine continue to tackle the forces of misinformation and pseudoscience. Like Voldemort rising slowly back to power, many in the Ministry of Magic office of academic medicine failed to spot or believe the level of influence social media would have in the world of 2023. Ken Milne was an early adopter of using social media to narrow the knowledge translation gap and reduce the time it takes for quality research to percolate into clinical practice. This isn’t always easy; as Dumbledore says in the Goblet of Fire “there will be a time when we must choose between what is easy and what is right”. As clinicians it might sometimes seem easier to adopt the line of least resistance; blindly and unthinkingly to follow the “rules” of specialty guidelines or the preferences of consultants. But things are not always what they seem; many initially promising treatments fail to translate to benefit in the longer term and it can be tricky to know which is the Scabbers (apparently benign and well received, eventually found to be treacherous and deadly) and which is the Snape (initially unpleasant but at his core hugely valuable). Dr. Dennis Ren As Harry’s group of friends and allies grew wider through the books, so Ken has grown the SGEM faculty; the rotating cast of the SGEM-HOP has been joined by Dennis Ren leading SGEM-PEDS and an ever-increasing number of guest skeptics from many backgrounds (no exclusion of the mudbloods here) ensuring a clinician- and patient-relevant gaze is cast on the medical literature. The structured critical appraisal provides readers and listeners with a Marauder’s Map to see through the complexity and (sometimes) obfuscation of published articles and reach their own, sometimes surprising, conclusions. Like Voldemort (or Harry) some things never seem to die; this 10th edition features the perennial topics of where, if anywhere, thrombolytic agents should feature in the management of ischemic stroke, plus whether the choice of crystalloid for resuscitation really matters at all. New topics with wider relevance also appear, including the strength of the overall evidence base in Emergency Medicine and Orthopedics, and the persistent gender gap in EM remuneration. Even Ron Weasley recognises “when in doubt, go to the library”. Emergency clinicians are well advised “when in doubt, listen to or read the SGEM”. You too can be a skeptic, Harry! SGEM S

Date: August 14, 2023 Reference: Ma et. al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet 2023 Guest Skeptic: Dr. Mike Pallaci is a Professor of Emergency Medicine (EM) for the Northeast Ohio Medical University, and an Adjunct Clinical Professor of EM for the Ohio University Heritage College of Osteopathic Medicine. He has been program director for two EM residency programs, and is currently a core faculty member for the EM residency at Summa Health System in Akron, OH, where he also serves as the Medical Director of the Virtual Care Simulation Lab. This episode originated because of a thread Mike posted on the social media site formerly known as Twitter. The tweet said: “I am sick and tired of some non-EM docs/specialists slamming EM when we don’t aggressively lower BP in ICH.” It certainly got a lot of attention. It got a lot of attention both on the positive side (mostly from EM docs who share the frustration) and on the negative side from some neurologists who didn’t seem to particularly care for the premise of the tweet or for the generally positive response. It started out with venting on Twitter about an unpleasant interaction with one of Mike's partners and turned into a week-long discussion that culminated in an invitation to be the guest skeptic on the SGEM to critically appraise INTERACT-3. Mike backed up his position on blood pressure (BP) lowering using evidence. Specifically, he pointed out that the evidence behind the guidelines re BP management in intracranial hemorrhage (ICH) is relatively weak. This received a mixed response on Twitter. Most EM physicians shared the frustration and made positive comments. Some neurologists disagreed with the premise of the tweet and challenged it. I responded by posting the 2013 SGEM episode on INTERACT-2 (SGEM#73) which showed no statistical difference between intensive (<140 mmHg) and guideline directed (<180 mmHg). In 2017, the SGEM reviewed the ATACH-2 trial (SGEM#172) which showed similar results. A meme was also posted of Charlton Heston from the classic movie the Ten Commandments. It emphasized that GUIDElines are not GODlines. The literature should inform and guide our care, but it should not dictate our care. This is a core principle of evidence-based medicine (EBM). Often the available evidence on a specific medical question is weak. We still need to apply our clinical judgement and ask the patient about their values and preferences. Case: A 67-year-old male presents to the emergency department obtunded with left hemiplegia. Symptoms began just prior to presentation. His blood pressure (BP) is 194/110 mmHg. CT reveals a hemorrhage in the right internal capsule, suggestive of acute hypertensive hemorrhagic stroke. Should the blood pressure be treated? If yes, what should the target blood pressure be? How quickly do we want to get there? And are there any other physiologic variables we want to be aggressive about controlling in the early treatment window? Background: We have covered the common issue of elevated BP after ICH on SGEM#73 and SGEM#172. The 2022 AHA/ASA guidelines give several recommendations on this topic. The class (strength) of their recommendation is 2a/2b based upon Level B and Level C quality of evidence. It is really important to pay attention to the specific language used in the guidelines. First of all, as we’ve already covered, a guideline is something developed by humans giving their best interpretation of the evidence to serve as a guide, not something given to Moses on Mount Sinai. But that point aside, the basis of this discussion was that the strength of the evidence behind these guidelines and the strength of the recommendations in the guidelines themselves are frequently misunderstood and/or misrepresented by our consultants. The specific language used in the guidelines is as follows: “In patients with spontaneous ICH in whom acute BP lowering is considered, initiating treatment within 2 hours and reaching target within 1 hour can be beneficial to reduce the risk of HE and improve functional outcome” They give this a Class 2a recommendation, “Moderate”: is reasonable, can be beneficial; Level of Evidence C-LD (Limited Data). We would say than it would also be reasonable not to acutely lower the BP “In patients with spontaneous ICH of mild to moderate severity presenting with SBP between 150 and 220 mmHg, acute lowering of SBP to a target of 140 mmHg with the goal of maintaining in the range of 130 to 150 mmHg is safe and may be reasonable for improving functional outcomes.” This was a Class 2b recommendation, “Weak”: may be reasonable, may be beneficial, effectiveness not well established; Level of Evidence B-R (Randomized; moderate quality evidence from 1 or more RCTs or meta-analyses of moderate-quality RCTs). Listeners to the SGEM know when the word “may” is used it c

Reference: Easter JS et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Annals of Emergency Medicine 2014. Date: July 10, 2023 Guest Skeptic: Dr. Joe Mullally is a paediatric trainee in the Welsh paediatric training program and interested in Paediatric Emergency Medicine. He is a student in the Paediatric Emergency Medicine Masters Program through Queen Mary University in London in collaboration with the Don’t Forget the Bubbles team. Dr. Joe Mullally Background: Children have big heads proportionally to their body compared to adults which makes them more at risk of traumatic brain injury (TBI). Computerized tomography (CT) is commonly used in the emergency department in the diagnosis of TBI. But we’re always trying to balance the potential harms and potential benefits in medicine. A CT scan does mean radiation to the pediatric brain which can increase the risk of leukemia or brain cancer later [1]. Thankfully, clinically important intracranial injuries are rare in children [2]. So, should we CT scan children with minor head injury? The SGEM covered pediatric concussions and head imaging in SGEM #112 and the NEXUS II Pediatric Head CT Decision Instrument in SGEM #225. Today we’re talking about three other popular clinical decision rules (PECARN, CATCH, and CHALICE). But we also want to know, how do those rules compare to physician judgement? Clinical Question: What is the diagnostic accuracy of clinical decision rules and physician judgment in identifying clinically important traumatic brain injuries (TBI) in children with minor head injury? Reference: Easter JS et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Annals of Emergency Medicine 2014. Population: Children less than 18 years of age presenting with head injury to a level 2 pediatric trauma center in the United States between 2012-2013. These children have to have 1) history of signs of blunt injury to the head 2) GCS scores ≥13, 3) injury within the previous 24 hours prior to presentation, 4) physician concern for potential TBI Excluded: Heightened TBI risk (GCS<13, brain tumors, ventricular shunts, on anticoagulants, or had bleeding disorders), or if they presented >24 hours after injury Intervention: CT vs no CT Comparison: Comparison of PECARN, CHALICE, CATCH, physician judgement, and physician practice Outcomes: Primary Outcome: “Clinically important TBI” defined as death from TBI, need for neurosurgery, need for intubation >24hrs for TBI, or hospital admission >2 nights for TBI. Secondary Outcomes: TBI on scan TBI requiring neurosurgery (craniotomy, elevation of skull fracture, monitoring of intracranial pressure, or intubation for elevated intracranial pressure) Type of Study: Single center prospective cohort study Authors’ Conclusions: “Of the 5 modalities described (PECARN, CATCH, CHALICE, physician judgment and physician practice), only physician practice and PECARN identified all clinically important TBIs, with PECARN being slightly more specific. CHALICE was incompletely sensitive but the most specific of all rules. CATCH was incompletely sensitive and had the poorest specificity of all modalities.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Unsure Have the authors identified all-important confounding factors? Yes Was the follow up of subjects complete enough? Yes How precise are the results? Fairly precise Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Funding of the Study. No financial conflicts of interest. Results: During the study period, 1,526 children with head injury presented to the ED, and they enrolled 1,062 (70%). The enrolled group had a median age of 6.1 years and 64% were male with 95% presenting with GCS of 15. In comparison the non-enrolled group had a median age of 5 years, 58% male, and 99% had GCS of 15. In summary, the enrolled group was a little bit older, with slightly higher proportion being male, and a bit fewer having GCS of 15. They ended up excluded another 53 mostly because they presented >24 hours from time of injury ending up with a total of 1,009 children included in the study. Key Results: Only PECARN clinical decision rule and physician practice had 100% sensitivity for detecting clinically important TBI. Fifty-two (5%) had injuries seen on CT scan. The most common were skull fractures but there were a few subarachnoid and subdural hemorrhages as well. Twenty-one (2%) had clinically important TBI. Only four (0.4%) required neurosurgical intervention. Selection

Date: July 21, 2023 Reference: McDonald et al. Patterns of change in prehospital spinal motion restriction: a retrospective database review. AEM July 2023 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Case: A 42-year-old is struck in the face by a slowly moving I-beam at work. He has a brief loss of consciousness (LOC) and then awakens and is ambulatory on scene. Emergency Medical Services (EMS) is called and on arrival the patient is walking but has obvious facial trauma and is complaining of some neck pain. He has midline neck tenderness but no limb numbness or paresthesia. As an EMS crew member, you are tasked with deciding what method of spinal motion restriction to use. Background: We have covered head injuries including concussions multiple times on the SGEM. This has included looking at the Canadian CT Head Rules/Tools (SGEM#106, SGEM#266, and SGEM#272). We have also covered concussions (SGEM#112, SGEM#331, and SGEM#362). Another core element of emergency department (ED) and pre-hospital care is the assessment for potential spinal injuries [1,2]. Patient care and positioning has evolved over time, previously routine spinal immobilization (SI) was with a cervical spine collar, placement on a long, rigid backboard, and straps or head blocks. Over time this has evolved to spinal motion restriction (SMR) with more variable use of cervical collars, patient positioning, and accessories such as head rolls and tape [3-4]. This has evolved due to recognition of some of the adverse effects of immobilization as well as limitations to its benefits. The role of the cervical collar itself varies by jurisdiction and it is not entirely clear which devices and procedures are most effective at reducing potentially harmful spinal motion [5-11]. Existing research on SMR confirms decreases in the use of long backboards and increases in collar-only treatment [12-14]. Some of this research has observed substantial under-treatment among patients who met criteria for precautions, as well as some patients with confirmed injuries who received no treatment from EMS [15-16]. Other studies have observed no increase in the diagnosis of cervical spine injuries, however, variable practice and the possibility of patients not receiving appropriate treatment remains a concern [17-18]. In order for standards for acute management of spinal injuries to progress, we must optimize patient protection and limit harm [19]. Clinical Question: How has the rate of pre-hospital spinal immobilization/spinal motion restriction changed from 2009 to 2020? Reference: McDonald et al. Patterns of change in prehospital spinal motion restriction: a retrospective database review. AEM July 2023 Population: EMS patients with traumatic injuries Excluded: None Intervention: Spinal immobilization/spinal motion restriction Comparison: This is a retrospective review and includes several changes over time, thus the comparison is the change in rate over time of SMR Important Changes Were: In 2009, selective spinal immobilization using NEXUS criteria was implemented. In July 2012, changing documentation required paramedics to record the indications for SI/SMR in all cases. In November 2014, cases of isolated penetrating trauma were exempted from SMR. In April 2016, treatment guidelines were revised to allow for collar-only treatment in low-risk scenarios (patient ambulatory prior to paramedic arrival) Outcome: Primary Outcome: Rate of spinal immobilization/spinal motion restriction Secondary Outcomes: Rates of splinting and wound care as proxy measures of the incidence of trauma care over time. Patient and practice-related factors associated with potential changes over time. Patient related factors include age, sex, acuity, mechanism of injury and indications for treatment. Practice-related factors included cervical collar size, patient positioning, the proportion of collar only use, rate of treatment of penetrating trauma. Type of Study: Retrospective database review Neil McDonald This is an SGEMHOP and we are pleased to have the lead author on the show. Neil McDonald is an Advanced Care Paramedic in Winnipeg, MB, where he works as a Training Officer and Research Coordinator for the Winnipeg Fire Paramedic Service. He also holds a PhD in Applied Health Sciences and a cross appointment as Lecturer in the Department of Emergency Medicine within the Rady Faculty of Health Sciences at the University of Manitoba. Authors’ Conclusions: “This study shows decreasing SI/SMR treatment and changing patient and practice characteristics. These patterns of care cannot be attributed solely to formal protocol changes. Similar patterns and their possible explanations should be investigated elsewhere.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an app

Date: July 21, 2023 Reference: Prekker et al. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. NEJM 2023 Guest Skeptic: Dr. Jeff Jarvis is the Chief Medical Officer and System Medical Director for the Metropolitan Area EMS Authority in Fort Worth, Texas, also known as MedStar. He is board certified in both Emergency Medicine and Emergency Medical Services. Jeff discusses the application of research in EMS on his podcast The EMS Lighthouse Project. Case: You are an emergency physician caring for a 65-year-old male with a history of hypertension and diabetes who presented with altered mental status, fever, and labored breathing. You’ve found that he is septic and in respiratory failure and needs intubation. Your assessment is that the patient will likely be a physiologically, but not anatomically, difficult airway. You’ve assured appropriate physiologic optimization and pharmacologic preparation and are ready to intubate. Should you go with video or direct laryngoscope? Background: We have looked at this issue of intubation multiple times on the SGEM. The most recent discussion was about the use of etomidate as an induction agent (SGEM#405). The conclusion from that episode was it’s still uncertain if using etomidate decreases the patient-oriented outcome of survival with good neurologic function in critically ill patients requiring emergent endotracheal intubation. Missy Carter The SGEM has also covered prehospital intubation using supraglottic devices for out-of-hospital cardiac arrests (OCHAs) with PA Missy Carter (SGEM#247 and SGEM#396). The take home message from those two episodes was that the airway is less important in adult OHCAs. We should focus more on high-quality CPR and early defibrillation for shockable rhythms and less on type of supraglottic airway device. Chip Lange PA Using a bougie to increase the first pass success (FPS) rate was discussed on SGEM271. It showed the use of a bougie was associated with an increase in FPS. A hypothesized option of adding point of care ultrasound (POCUS) to our various methods of confirming correct placement of the endotracheal tube was covered on SGEM#249 with PA Chip Lange. We felt transtracheal sonography represents a potential fast and accurate way to help confirm endotracheal tube placement in conjunction with other methods. Intubation FPS is associated with fewer adverse events, most importantly hypoxia, hypotension, and cardiac arrest. Traditionally, intubation was performed using direct laryngoscopes (DL) in which the soft tissues of the airway were physically displaced allowing direct visualization of the larynx, epiglottis, and vocal cords followed by passage of an endotracheal tube. The challenging part of intubation using DL is usually visualization of the laryngeal structures while tube passage is relatively easy. Video laryngoscopes (VL) have been developed to improve the challenging part of DL, ie visualization. Literature and clinical experience demonstrate that visualization is typically improved with VL, however, tube passage can be more challenging because the laryngeal structures are indirectly visualized. The debate of DL vs VL goes back over a decade. We covered the issue with guest skeptic Dr. Steve Carroll on SGEM#75 (Video Killed Direct Laryngoscopy). That was an RCT from Baltimore Shock Trauma center comparing the two modalities. The primary outcome was no statistical difference in survival to hospital discharge between the two groups. The SGEM bottom line at the time was VL leads to the same outcome as DL in trauma patients. VL takes longer to accomplish and may be associated with higher mortality in patients with severe head injuries, however this relationship will require more study to confirm. The literature comparing FPS between DL and VL is mixed with some trials, primarily earlier ones, demonstrated either no improvement with VL or superiority with DL, and others, primarily later ones, demonstrating improvement with VL. As the availability and experience with VL has grown, the question remains… does DL or VL use result in higher FPS. Clinical Question: In adult patients needing intubation in an ED or ICU, is FPS higher with DL or VL? Reference: Prekker et al. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. NEJM 2023 Population: Adult patients 18-years-old and older seen in one of 17 academic ED or ICU needing endotracheal intubation for any reason. Exclusions: Under 18, pregnant, a prisoner, or there was inadequate time to allow for study randomization and enrollement. They were also excluded if, in the opinion of the treating physician, use of VL or DL is clearly either indicated or contra-indicated. In other words, the physician must feel that there is equipoise between DL and VL meaning that they have substantial uncertainty about whether DL or VL would result in better chances of FPS.Prehospital intubations were not included, nor were intubations performe

Date: 15 June 2023 Guest Skeptic: Dr. Samina Ali is a pediatric emergency medicine physician, clinician scientist, and Professor of Pediatrics and Emergency Medicine at the University of Alberta in Edmonton. Her research focuses on improving assessment and treatment of pain in children. She is an executive member of Pediatric Emergency Research Canada (PERC), pain content advisor for TREKK and faculty member of BEEM. Dr. Samina Ali Background: Pain, a common acute and chronic complaint that we see a lot in the emergency department. Whether it is a broken bone, a laceration, abdominal pain, sickle cell vaso-occlusive pain episode, emergency department physicians are familiar with patients experiencing pain, but do we always do a good job at addressing it? The answer is no, especially in vulnerable groups like the seniors [1], certain ethnicities [2], patients with mental health issues [3], and pediatric patients [4,5]. While addressing pain, we sometimes must perform medical procedures which lead to…more pain. This issue is magnified in children where even placement of an IV can be traumatic and painful for a child who does not understand why they’re getting poked. The emergency department can be a painful place to be… We have covered pediatric pain management on the SGEM multiple times. Peds EM superhero, Dr. Anthony Crocco from McMaster University, did one of his rants on pediatric pain. SGEM#78: Sunny Days (Pediatric Pain Control) SGEM#123: Intranasal Fentanyl – Oh What a Feeling SGEM#242: Pain, Pain, Go Away – IN Ketamine vs. IN Fentanyl for Pediatric Pain Management SGEM#378: Keepin’ It REaL when Treating Pediatric Migraine Patients SGEM Xtra: RANThony#3 - Paediatric Pain It is estimated that 1 in 5 children develop chronic pain before childhood. Pediatric pain is one of the costliest chronic conditions, even more so than asthma and obesity [6]. When admitted, children experience an average of 6.3 painful procedures per day and this goes up to 12 in the ICUs! Although evidence-based best practices for addressing pain in children have been published all over the world, we still often fall short. Some of the most serious consequences of untreated pain in children occur much later than the procedure itself. For example, a child who is scared to get an IV: One might think we can hold the child down, bundle them up, and just quickly get it over with, as they need their antibiotics/iv fluids. On that day, we might hear crying and stress from the child, but they will likely settle down and we have successfully delivered out treatment. But there are consequences to this. Poor pain management contributes to avoiding medical care in the future and even vaccine hesitancy [8,9]. This same child, if unvaccinated, may present with serious vaccine-preventable illnesses, require more time and resources for every fever. There is also psychological trauma for the patient, their families, and the healthcare workers who care for them. Sometimes, healthcare workers think that treating children’s procedural pain takes up precious ED time, like waiting for a topical anesthetic to work. In fact, using pain relief for procedural pain leads to less repeat procedures, better ED flow and shorter lengths of stay. Importantly, children who experience chronic pain are more likely to have mental illness, opioid use, and socioeconomic disparities in adulthood. Canada creates 15% of the world’s pediatric pain research, so it made sense that we would be the first country in the world to create a national standard. This new standard is divided up into four main themes. Make pain matter: creating a framework to provide better pain care and employing continuous Quality Improvement (QI) Make pain understood: education and knowledge sharing Make pain visible: pain assessment Make pain better: individualized care plans & multi-modal pain strategies Tune into the podcast to hear Dr. Ali's answers to my questions below: Working Group and Technical Group Members There were many stakeholders involved in the creation of this standard (emergency medicine, anesthesia, psychologists, and chronic pain physicians, nurses, physical therapists, pharmacists, child life, patients, and families. Working with such a multi-disciplinary group, was there any insight provided by a non-physician member that you found particularly enlightening? Make Pain Matter The framework includes six main points: People-centred care and building trust Policies for pediatric pain management Culture of patient safety and incident reporting Pain education curriculum Variety of validated pain assessment tools Goals and objectives for QI around pediatric pain management. Can you give some examples at your own institution of these practices in action? There are many challenges healthcare is currently facing. How do you convince organizational leaders that pediatric pain management should be a priority? Make Pain Understood This section emphasizes education around health ineq

Date: July 6, 2023 Reference: Hanula R et al. Evaluation of oseltamivir used to prevent hospitalization in outpatients with influenza: a systematic review and meta-analysis. JAMA Int Med 2023. Guest Skeptic: Dr. Anand Swaminathan is an Assistant Professor of Emergency Medicine at Staten Island University Hospital. Managing editor of EM:RAP and Associate Editor at REBEL EM. Case: A 57-year-old woman with hypertension, hyperlipidemia and type-2 diabetes mellitus presents to the emergency department (ED) with fever, cough, myalgias, headache and congestion. It’s flu season and you’ve already seen 15 people with the same symptoms. Her vitals look good: Temperature 38.5C, heart rate 102 beats/minute, blood pressure 143/88 and oxygen saturation of 99% on room air. She is breathing comfortably without any increased work of breathing. You send off COVID and flu swabs and the results come back as positive for influenza. She looks well enough to go home but asks if she should be prescribed oseltamivir (Tamiflu) because some of her friends have been given it recently by their doctors. Background: Oseltamivir was approved by the FDA in 1999 based on evidence from trials funded by the maker of the drug, Roche. Safety issues popped up soon after widespread use of the drug including neuropsychiatric effects as well as the more common adverse effects of nausea and vomiting. The Cochrane collaboration published analyses of the available data in 1999, 2003 and 2006. In 2009, the Cochrane group questioned Roche about the completeness of the data and after four years of requests, finally got access to all the data in 2013 and updated their review in 2014. We covered this SRMA on SGEM#98. The 2014 Cochrane review found an improvement in time to first alleviation of symptoms in adults by about 17 hours coupled with several side effects including nausea, vomiting, headaches, and neuropsychiatric effects. Despite these findings, the World Health Organization (WHO), Infection Disease Society of America (IDSA) and the Center for Disease Control and Prevention (CDC) all continue to recommend use of oseltamivir, particularly in patients at increased risk of hospitalization and bad outcomes. There was a large unblinded RCT of over 3,000 patients published in the Lancet in 2020. It looked at patients presenting to their primary care physician with influenza. The results were those treated with oseltamivir recovered about one day earlier than the control group but experienced more nausea and vomiting. This was critically appraised on SGEM#312. A subgroup analysis of the Lancet RCT showed that older, sicker patients with comorbidities and longer previous symptom duration recovered 2–3 days sooner. While this is interesting it should be considered hypothesis generating. Wallach et al JAMA Intern Med 2017, previously reported that subgroup claims are often not corroborated by subsequent studies and rarely confirmed. Also, Yusuf et al JAMA 1991 stated: “the overall trial result is usually a better guide to the direction of effect in subgroups than the apparent effect observed within a subgroup.” When it comes to children suspected of influenza and ill enough to be admitted to hospital there was an observational study looking at the impact of oseltamivir (JAMA Ped 2022). SGEM Peds expert Dr. Dennis Ren did a structed critical appraisal of that study on SGEM#397. The bottom line from that episode was we do not have high-quality evidence to support the routine use of oseltamivir in the treatment of children admitted to hospital with suspected influenza. Clinical Question: Is oseltamivir effective in preventing hospitalization from influenza in adults and adolescent outpatients? Reference: Hanula R et al. Evaluation of oseltamivir used to prevent hospitalization in outpatients with influenza: a systematic review and meta-analysis. JAMA Int Med 2023. Population: RCTs of outpatients 12 years and older diagnosed with natural influenza infections based on clinical history and laboratory evidence (PCR or 3x increase in antibody titers at 30 days). Exclusions: Observational studies Intervention: Oseltamivir 75 mg BID X 5 days Comparison: Placebo or standard care Outcome: Primary Outcome: Hospitalization during the treatment or follow-up period for any cause or duration (Emergency department visits did not count). Secondary Outcomes None Safety Outcomes: Adverse events including nausea, vomiting, diarrhea, cardiac, psychiatric, neurologic or a composite of any gastrointestinaI symptoms Authors’ Conclusions: “In this systematic review and meta-analysis among influenza-infected outpatients, oseltamivir was not associated with a reduced risk of hospitalization but was associated with increased gastrointestinal adverse events. To justify continued use for this purpose, an adequately powered trial in a suitably high-risk population is justified.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes The

Date: July 1, 2023 Reference: PATCH-Trauma Investigators and ANZICS Clinical Trial Group. Prehospital Tranexamic Acid for Severe Trauma. NEJM 2023. Guest Skeptic: Dr. Salim Rezaie is a community emergency physician in San Antonio, TX. He is the Creator and founder of REBEL EM, a free, critical appraisal blog that tries to cut down knowledge translation gaps of research to bedside clinical practice (https://rebelem.com). Case: A 48-year-old man involved in a motor vehicle collision (MVC) is being evaluated by paramedics. He was entrapped in his vehicle for over one hour, had an initial blood pressure of 78/46 mmHg, and appeared to have a seat belt sign with deformities to bilateral lower extremities. His Glasgow Coma Scale (GCS) score is 13 with obvious head trauma as well. Emergency Medical Services (EMS) calls in ahead of time to warn the facility that they are 20 minutes out, to give report about the patient, and ask whether they should give tranexamic acid (TXA) pre-hospital. Background: We have looked at the use of TXA many times on the SGEM. Most of the times the RCTs we critically appraised did not demonstrate superiority for their primary outcome. This has included: Post-Partum Hemorrhage (WOMAN): SGEM#214 Gastrointestinal Bleeding (HALT-IT): SGEM#301 Intracranial hemorrhage (TICH-2 and ULTRA): SGEM#236 and SGEM#322) Isolated Traumatic Brain Injury (CRASH-3): SGEM#270 Pre-Hospital TBI: SGEM#305 Epistaxis (NoPAC): SGEM#321 There is some evidence of efficacy for TXA in epistaxis (SGEM#55, SGEM#210, and SGEM#395). There is also the CRASH-2 trial from 2010 which was reviewed with our good friend Dr. Anand Swaminathan (SGEM#80). That classic practice changing paper showed a 1.5% absolute decrease in death in trauma patients receiving TXA vs placebo (NNT = 66). Despite these results, many clinicians remained skeptical of the benefit of TXA in trauma patients. One of the major criticisms of the CRASH-2 trial was it was performed in under-resourced trauma systems and therefore may not be generalizable to care in advanced trauma systems. Clinical Question: In advanced trauma systems, does the prehospital use of TXA increase the rate of survival with a favorable functional outcome in patients at risk for trauma-induced coagulopathy? Reference: PATCH-Trauma Investigators and ANZICS Clinical Trial Group. Prehospital Tranexamic Acid for Severe Trauma. NEJM 2023. Population: Adults (>18 years of age) with suspected severe traumatic injuries at risk for trauma induced coagulopathy (Assessed using the Coagulopathy of Severe Trauma [COAST] score) that could receive TXA within three hours of injury. Coagulopathy of Severe Trauma (COAST Score) Intervention: TXA 1g intravenous (IV) bolus over 10 minutes followed by 1g over 8 hours Comparison: 9% saline (same volume as TXA) administered as bolus and infusion over 8 hours Outcome: Primary Outcome: Survival with a favorable functional outcome at six months assessed using the Glasgow Outcome Scale – Extended (GOS-E) Secondary Outcomes: Death within 24 hours, 28 days, and 6 months after injury Safety: Risk of thromboembolic phenomenon (deep vein thrombosis, pulmonary embolism, myocardial infarction, or stroke) Glasgow Outcome Scale – Extended (GOS-E) Type of Study: International, randomized, double-blind, placebo-controlled trial Authors’ Conclusions: “Among adults with major trauma and suspected trauma-induced coagulopathy who were being treated in advanced trauma systems, prehospital administration of tranexamic acid followed by an infusion over 8 hours did not result in a greater number of patients surviving with a favorable functional outcome at 6 months than placebo.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Unsure The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. Yes All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. No Financial Conflicts of Interest. No Results: They included 1,310 trauma patients. The mean age was 44 years, 70% male, 92% had blunt trauma and the median Injury Severity Score was 29. Key Results: No statistical difference in favourable functional outcome at six months. Primary Outcome: Favorable functional outcome at six months TXA (53.7%) vs Placebo (53.5%); Risk Ratio (RR) 1.00; 95% CI 0.9 to 1.12 Secondary Outcomes: 24 Hour Mortality: TXA (9.7%) vs Placebo (14.1%); RR 0.69; 95% CI 0.51

Date: June 16, 2023 Reference: Reed et al. Pilot Testing Fentanyl Test Strip Distribution in an Emergency Department Setting: Experiences, Lessons Learned, and Suggestions from Staff. AEM June 2023 Guest Skeptic: Dr. Lauren Westafer is an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the cofounder of FOAMcast and a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and a research methodology editor for Annals of Emergency Medicine. Case: A 27-year-old right hand dominant patient presents to the emergency department (ED) with a 2.5 cm left forearm abscess. They have no fever, chills, or signs of compartment syndrome. You perform an incision and drainage of the abscess with significant improvement in pain. The patient reports injection use of opioids, last use was a few hours ago. The patient currently has no signs of withdrawal and is interested in potentially starting on methadone; however, the patient is not ready to start the medication right now. Background: We have addressed the issue of substance use disorder a few times on the SGEM. This included looking at alcohol misuse and opioid misuse. SGEM#55: Drugs in My Pocket (Opioids in the Emergency Department) SGEM#241: Wake Me Up Before You Go, Go – Using the HOUR Rule SGEM#264: Hooked on a Feeling - Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain SGEM#313: Here Comes a Regular to the ED SGEM#374: Bad Habits – Medications for Opioid Use Disorder in the Emergency Department Rises in opioid overdose deaths have been attributed, at least in part, due to increases in fentanyl contaminating the illicit opioids in the United States. EDs are an important touch point for individuals with opioid use disorder (OUD), given the number of encounters for overdose and complications associated with drug use. Although some patients may be ready for medication such as buprenorphine or methadone, which can be initiated in the ED, some patients may not be ready for either medication. In these cases, harm reduction practices, strategies that mitigate complications from drug use, are critical. Fentanyl test strips (FTS) have been suggested as one harm reduction strategy to reduce opioid overdose deaths. The American College of Emergency Physicians (ACEP) endorses greater harm reduction education for emergency physician . Fentanyl test strips can be used by people who use drugs (PWUD), prior to use, to detect the presence of fentanyl. Individuals can then use that information to decide if or how much of the drug to use. Clinical Question: What are the perspectives of clinicians and other staff distributing fentanyl test strips to people who use drugs in an ED setting? Reference: Reed et al. Pilot Testing Fentanyl Test Strip Distribution in an Emergency Department Setting: Experiences, Lessons Learned, and Suggestions from Staff. AEM June 2023 Study design: This was a qualitative study assessing staff perceptions of a pilot of distribution of fentanyl test strips. Staff meeting inclusion criteria (below) were invited to participate and rec Population: English speaking ED clinician (physician, nurse, advanced practice provider, technician, social worker, certified recovery specialist) distributing fentanyl test strips through the pilot program. Intervention: Interviews at two points in time, three weeks and three months after distribution of FTSs began Comparison: Not applicable Megan Reed PhD This is an SGEMHOP episode, and it is my pleasure to introduce Dr. Megan Reed. She is a PhD with a Master’s in Public Health. Megan currently works at the College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA. Authors’ Conclusions: “Implementing FTS distribution may improve patient rapport while providing patients with tools to avoid a fentanyl overdose. Participants generally reported positive experiences distributing FTS within the ED but the barriers they identified limited opportunities to make distribution more integrated into their workflow. EDs considering this intervention should train staff on FTS, how to identify and train patients, and explore mechanisms to routinize distribution in the ED environment.” Quality Checklist for Randomized Clinical Trials: Was there a clear statement of the aims of the research? Yes Is a qualitative methodology appropriate? Yes Was the research design appropriate to address the aims of the research? Yes Was the recruitment strategy appropriate to the aims of the research? Yes Was the data collected in a way that addressed the research issue? Yes Has the relationship between researcher and participants been adequately considered? No Have ethical issues been taken into consideration? Yes Was the data analysis sufficiently rigorous? Unsure Is there a clear statement of findings? Yes How valuable is the research? Valuable Funding/COI: Funding from Bloomberg P