The Skeptics Guide to Emergency Medicine

Date: June 12th, 2022 Reference: Finfer et al. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. NEJM 2022. Guest Skeptic: Dr. Aaron Skolnik is an Assistant Professor of Emergency Medicine at the Mayo Clinic Alix School of Medicine and Consultant in the Department of Critical Care Medicine at Mayo Clinic Arizona. He is board certified in Emergency Medicine, Medical Toxicology, Addiction Medicine, Internal Medicine-Critical Care, and Neurocritical Care. Aaron is a full-time multidisciplinary intensivist. He is the Medical Director of Respiratory Care for Mayo Clinic Arizona and is most proud of his position as medical student clerkship director for critical care. Case: A 62-year-old man is brought in by EMS from home with lethargy and hypotension. Chest x-ray is clear, labs are remarkable for a leukocytosis of 16,000 with left shift; exam is notable for left flank pain and costovertebral tenderness. Straight catheter urinalysis is grossly cloudy, and pyuria is present on microscopy. Blood pressure is 85/50 mmHg. You wonder which IV fluid should you order? Background: There has been a longstanding debate about which intravenous fluid is the best for volume resuscitating critically ill patients. We’ve known for some time that albumin is bad for injured brains, and that hydroxyethyl starch solutions have been associated with kidney injury and mortality. Since then that debate has broadly centered on the choice between what we will call “abnormal saline” (0.9% sodium chloride), and balanced crystalloid solutions, meaning those with a chloride composition closer to plasma such as lactated ringer’s or Plasma Lyte 148. Early work suggested potential harm from 0.9% saline, that may be partly driven by kidney injury associated with the administration of high-chloride content IV fluids. In the last few years, the pendulum has swung back and forth. Two large, cluster-randomized trials (SMARTand SALT-ED) showed a small benefit to the use of balanced crystalloids in preventing a composite outcome of Major Adverse Kidney Events within 30 days (aka MAKE-30). Then, the BaSICS trial (a multicentred RCT done in 75 Brazilian ICUs) came along and compared saline to Plasma-Lyte at what the authors deemed slow and fast infusion rates. We reviewed that last time on SGEM#347. There was no interaction between fluid type or rate of infusion with the primary outcome of 90-day survival. Among 19 secondary outcomes, which should only be considered hypothesis generating, SOFA scores and neuro SOFA scores at day seven were worse in the balanced crystalloid group. Now we have the PLUS trial, from Australia and New Zealand to add to the medical literature on this issue. Clinical Question: Is the 90-day mortality in critically ill adult patients lower with the use of Plasma-Lyte 148, a balanced crystalloid solution, for fluid resuscitation and therapy, than with the use of normal saline? Reference: Finfer et al. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. NEJM 2022. Population: Patients 18 years or older, admitted to 53 ANZ ICUs over 38 months, whom the treating clinician deemed to need fluid resuscitation and were expected to be in the ICU on three consecutive days. Exclusions: Patients with specific ICU fluid requirements, those who received disqualifying fluid prior to enrollment (> 500 mL in the ICU), those at imminent risk for death or with life expectancy < 90 days, and those at risk for cerebral edema. Intervention: Plasma-Lyte 148 for all resuscitation episodes while in ICU for up to 90 days after the first episode of fluid resuscitation Comparison: 0.9% saline for all resuscitation episodes while in ICU for up to 90 days after the first episode of fluid resuscitation Outcome: Primary Outcome: All-cause mortality within 90 days after randomization Secondary Outcomes: Peak serum creatinine level during the first seven days after randomization, the maximum increase in creatinine level during ICU stay, receipt of new renal-replacement therapy, receipt and duration of treatment with vasoactive drugs, duration of mechanical ventilation in the ICU, length of ICU and hospital stays, and death from any cause during ICU stay, during hospital stay, and within 28 days after randomization. Trial: Double-blind, parallel-group, randomized, controlled trial. Authors’ Conclusions: “We found no evidence that the risk of death or acute kidney injury among critically ill adults in the ICU was lower with the use of [Plasmalyte 148] than with saline.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes 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). Yes The patients in both groups were similar with respect to prognostic facto

Date: May 24th, 2022 Reference: Broder et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department. AEM May 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com Case: A 33-year-old male presents to the emergency department (ED) complaining of abdominal pain. He states he has had the same pain for more than 10 years, and no one has ever been able to figure out what is going on. He doesn’t have any specific symptoms today, including no fever, vomiting, diarrhea, or urinary symptoms. His vital signs are normal. His abdomen is diffusely tender, but without any surgical findings. You review his chart and note that he has had five CTs performed in the last year at your hospital alone, all of which were negative. You are worried about the cumulative radiation dose he has received but find it hard to exclude significant pathology on history and physical. After all, even patients with chronic abdominal pain can develop a new acute issue like appendicitis. Background: The Society of Academic Emergency Medicine (SAEM) has launched an initiative called GRACE which stands for Guidelines for Reasonable and Appropriate Care in the Emergency Department. GRACE-1 The first GRACE publication looked at low risk chest pain, and in my opinion, they filled a very valuable role. Most guidelines focus on a single emergency visit in isolation, but a patient who presents to the emergency department recurrently with the same symptoms may require a different approach. In the context of recurrent chest pain, they made eight key recommendations. The SGEM bottom line was there is moderate level of evidence that ACS can be excluded in adult patients with recurrent, low-risk chest pain using a single hs-troponin below a validated threshold without further diagnostic testing in patients who have a CCTA within the past two years showing no coronary stenosis. The writing group of GRACE-2 wanted to look at clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the ED. Through consensus, four questions were developed and then a systematic review of the literature was performed. This literature was then synthesized to come up with recommendations, following GRADE methodology. GRADE stands for Grading of Recommendations, Assessment, Development, and Evaluation, it was pioneered at McMaster University, in creating rigorous, transparent, and trustworthy guidelines on common clinical problems for EM physicians that are not always directly studied in EM research activities. There can be many presentations for low-risk abdominal pain. We have covered cannabis hyperemesis on SGEM#318 and SGEM#46 and pediatric gastroenteritis on SGEM#254. Clinical Question: What are the recommendations for managing patients with low-risk, recurrent, previously undifferentiated abdominal pain in the ED? Dr. Joshua Broder Reference: Broder et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department. AEM May 2022 This is an SGEMHOP episode which means we have the lead author on the show. Dr. Joshua Broder is the Residency Program Director and Vice Chief for Education In the Division of Emergency Medicine Duke University School of Medicine. Authors’ Conclusions: “No direct evidence exists to direct the care of patients with low-risk recurrent undifferentiated abdominal pain in the ED. Improved definitions are required to better define this population, and clinically relevant outcomes of interest should be described and studied with rigorous research methodology to inform future clinical guidelines.” Quality Checklist for a Guideline: The study population included or focused on those in the emergency department? Yes An explicit and sensible process was used to identify, select and combine evidence? Yes The quality of the evidence was explicitly assessed using a validated instrument? Yes An explicit and sensible process was used to the relative value of different outcomes? Yes The guideline thoughtfully balances desirable and undesirable effects? Yes The guideline accounts for important recent developments? Yes The guidelines has been peer-reviewed and tested? Yes/No Practical, actionable and clinically important recommendations are made? Yes The guideline authors’ conflicts of interest are fully reported, transparent and unlikely to sway the recommendations of the guidelines? Yes Key Recommendations: We don't have a key result section but what we do have is the key recommendations. It is important to understand the definitions created by the guideline committee for terms "low-risk, undifferentiated and recurrent". Listen to the SGEM podcast to hear Josh comment on each of these four recommendations. Recommendation

Date: May 13th, 2022 Reference: Abril et al. The Relative Efficacy of Seven Skeletal Muscle Relaxants. An Analysis of Data From Randomized Studies. J Emerg Med 2022 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 and specifically the use of ketamine. His twitter handle is @PainFreeED. Case: A 45-year-old man without a significant past medical history presents to your emergency department (ED) with two days of severe lower back pain after shoveling some dirt. The pain is 10/10 in intensity, gets worse with bending, turning, and prolonged walking. He denies numbness or paresthesia in both lower extremities, as well as bowel or bladder dysfunctions. A heating pad and acetaminophen has not helped with the pain. On examination, he is in moderate distress and has prominent tenderness to palpation at the bilateral paralumbar region and intact neurovascular examination. You diagnose him with a lumbar muscle strain and plan to prescribe him a non-steroidal anti-inflammatory (NSAID) while setting expectations. However, the patient wonders if you can give him something that can relax his back muscles and take his pain away. Background: Low back pain (LBP) is one of the most encountered ailments in clinical practice and is responsible for 2.6 million visits to U.S. EDs annually (1). Many patients with acute LBP experience substantial improvement in the first month, but up to one third report persistent back pain, and 1 in 5 report some limitations in activity. These persistent symptoms are associated with high costs, including those related to health care, and indirect costs from missed work or reduced productivity (2). Many pharmaceutical treatments besides opioids have been tried to address acute LBP pain with limited success (SGEM#87 and SGEM#173). These include: acetaminophen (Williams et al Lancet 2014), steroids (Balakrishnamoorthy et al Emerg Med J 2014) and benzodiazepines (Friedman et al Ann Emerg Med 2017). Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line medication therapy for patients with LBP despite a lack of evidence of efficacy (Machado et al Ann Rheum Dis 2017), There are several non-pharmaceutical treatments that have also been tried to treat LBP. They include: CBT and mindfulness (Cherkin et al JAMA 2016), chiropractic (Paige et al JAMA 2017), physical therapy (Paolucci et al J Pain Research 2018) and acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013). Unfortunately, none of these other treatment modalities has high-quality evidence supporting their use. Skeletal muscle relaxants (SMRs) are a frequently used in the ED and at discharge for acute back pain management and include methocarbamol, cyclobenzaprine, orphenadrine, carisoprodol, tizanidine, metaxalone, and baclofen. Estimates suggest up to 35% of patients with nonspecific low back pain are prescribed SMRs, with orphenadrine, and methocarbamol being used in more than 250,000 U.S. ED visits for low back pain annually (3-5). Despite their branding as muscle relaxants, the anti-spasmodic and analgesic effects of SMRs are predominantly due to unknown mechanism of action. Clinical Question: What is the efficacy of skeletal muscle relaxant administration in addition to an NSAID in treating acute low back pain? Reference: Abril et al. The Relative Efficacy of Seven Skeletal Muscle Relaxants. An Analysis of Data From Randomized Studies. J Emerg Med 2022 Population: Patients were considered for inclusion if they were 18– 69 years of age and presented to the ED primarily for management of acute LBP. This was defined as pain of two weeks’ duration or less originating between the lower border of the scapulae and the upper gluteal folds, and received a diagnosis consistent with nontraumatic, non-radicular, musculoskeletal LBP, as determined by the attending emergency physician. All patients had already received a dose of an NSAID. Exclusions: Radicular pain, pain duration for greater than two weeks, direct trauma to the back within the previous month, or a history of experiencing LBP on average more than several times per year, pregnancy, breastfeeding, allergy to study medications. Intervention: One of seven skeletal muscle relaxants (metaxalone, tizanidine, baclofen, diazepam, orphenadrine, methocarbamol, or cyclobenzaprine) Comparison: Placebo Outcome: Primary Outcome: Improvement in the Roland-Morris Disability Questionnaire (RMDQ) between ED discharge and the 1-week follow-up. The RMDQ goes from 0 to 24 with a 5-point improvement on this scale generally considered clinically significant. Secondary Outcomes: Moderate or severe LBP 1 week after the ED visit and medication adverse effects, assessed by asking patients to report any symptoms from the medications and dichotomizing their responses (yes/no). Authors’ Conclusions:

Date: April 19th, 2022 Guest Skeptic: Sarah Mojarad is a Lecturer in Advanced Writing, #SciComm, & Mis/disinfo topics • Kavli Fellow • Reed Awardee. Sarah Mojarad This is an SGEM Xtra episode. When planning a brief trip to Los Angeles for the EMRAP One Conference, I remembered that Sarah is from LA. I thought to myself, perhaps she would come on the SGEM as a special guest. I'm happy to say Sarah graciously accepted the invitation. We recorded the episode sitting outside on the patio at the Luskin Conference Centre. It is an example of how twitter can be a great way for making new friends. When I reached out to Sarah for a topic for the podcast she suggested five tips for science communication (SciComm) using social media. She shared with me a short YouTube video she had made for students interested in SciComm. We based our discussion on that video. It is clearly not an exhaustive list of tips but it did serve as the basis of our discussion. You can hear our conversation on the SGEM Xtra Podcast. Five Tips for Science Communication Tip #1: Be Yourself I think this is such an important piece of advice. Authenticity really resonates with people. One of the best compliments I received recently was from a wonderful dental student named Ellie from Schulich School of Medicine and Dentistry. We met at an Interprofessional Educational event, and she said it was so great to meet someone IRL who is so much like their twitter feed. Follow me and you will find out I am a huge advocate for evidence-based medicine (EBM), love Star Trek TOS, have a dog named Loki the Dog of Mischief, upset other physicians like neurologists when discussing the evidence for tPA in acute ischemic stroke, I think the 80’s is the best era for music/movies, and have been known to play BatDoc at times. Tip #2: Don't’ Be Afraid of Failing Another great tip. One of the best presentations I gave was about my many failures. The joke was that first grade was the longest two years of my life because I needed to repeat grade one. I failed to get into medical school the first time. I felt guilty and inadequate when I could not complete my orthopaedic residency. These and so many other “failures” that cause a lot of pain over the years. However, as Maya Angelou said: “Without defeats, how do you really know who the hell you are? If you never had to stand up to something - to get up, to be knocked down, and to get up again - life can walk over you wearing football cleats. But each time you do get up, you're bigger, taller, finer, more beautiful, more kind, more understanding, more loving. Each time you get up, you're more inclusive. More people can stand under your umbrella.” Tip #3: Find A Mentor I have had many mentors over the years. These include amazing people like: Dr. Kirsty Challen, Dr. Andrew Worster, Dr. Dara Kass, Dr. Michelle Johnson, Dr. Rick Bukata, Dr. Chris Carpenter and many, many more people who have helped me get where I am today. Sir Isaac Newton Tip #4: What Do You Want to Say? What is your message? Do you have a story, a narrative or goal in mind? My goal for the SGEM is to provide structured critical appraisals of the recent literature and probe it for its validity. We are trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. Ultimately, the goal is for patients to get the best care, based on the best evidence. Tip #5 How Do You Want to Say It? I want to make critical appraisal, clinical epidemiology, and biostatistics fun, engaging and exciting. I try to do this with 80’s music, memes, twitter polls, the keener contest, and other things. I learned a lot from Ross Fisher and his P Cubed Presentation initiative on how to create better presentations. I really like the way Melanie Trecek-King from Thinking is Power does her SciComm. She has a great educational approach and posts some useful tools for critical thinking like the FLOATER acronym. I’ve also learned from Dr. Brian Goldman to be more kind online. It follows the Spinoza philosophy of not ridiculing or bewailing or scorning people on twitter but rather trying to understand them. Some Dangers of SciComm Mansplaining I’ve seen a lot of women mansplained on twitter. For those who do not know mansplaining is a pejorative term meaning "to comment on or explain something to a woman in a condescending, overconfident, and often inaccurate or oversimplified manner". It is often done by a male layperson to a woman who is an expert in the field he is mansplaining to her. Examples include experts like Dr. Jennifer Gunter on gynecology, Dr. Megan Ranney on the science of gun safety, and Dr. Michelle Cohen on gender equity in the house of medicine. Harassment There was a recent disturbing article published in Science about scientists who have spoken out during this current global pandemic and have been threatened. The title of the article was In the Line of Fire. It talks about how CO

Date: April 16th, 2022 Reference: Blom et al. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ 2021 Guest Skeptic: Dr. Matt Schmitz, Pediatric Orthopedics, Adolescent Sports Medicine and Young Adult Hip Preservation Surgeon at San Antonio Military Medical Center in Texas. Disclaimer: The views and opinions of this blog and podcast do not represent the United States Government or the US Military. Case: A 55-year-old man comes into the emergency department (ED) for increasing knee pain and decrease in function. He’s had an anterior cruciate ligament (ACL) repair and used to run marathons. However, he is finding it more difficult to even put his socks on. Physical exam shows varus deformity at the knee, decreased range of motion, crepitus, no locking and neurovascularly intact distal. X-rays show severe, tri-compartment arthritis. Background: Musculoskeletal complaints are one of the most common presentations to emergency departments. Often emergency physicians are assessing, treating, and answering patients question about orthopedic surgical procedures. How good is the evidence for the most common elective procedures? Before we answer that question, let’s remind everyone that only a small number (2.8%) of interventions published in SRMA and relevant to emergency medicine have unbiased and strong evidence for improved outcomes (SGEM#361). This is a broader problem in medicine. Tricoci et al. JAMA Feb 2009 looked at the ACC/AHA guidelines from 1984 to 2008. They found 53 guidelines with 7,196 recommendations. Only 11% of recommendations were considered Level A, 39% were Level B and 50% were Level C. An update was published by Fanaroff et al in JAMA 2019. The level of high-quality evidence had not changed much when looking at the ACC/AHA guidelines from 2008-2018. There were 26 guidelines with 2,930 recommendations. Now Level A recommendations were down to 9%, Level B 50% and Level C 41%. Time to turn our skeptical eye to the evidence for elective orthopaedic procedures. Clinical Question: What is the effectiveness of common elective orthopaedic procedures compared with no treatment, placebo, or non-operative care? Reference: Blom et al. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ 2021 Population: Meta-analyses of randomised controlled trials Exclusions: Network meta-analyses (when pairwise meta-analyses were available), narrative reviews, systematic reviews that did not pool data or do a meta-analysis, and meeting abstracts Intervention: Surgery Comparison: No treatment, placebo, or non-operative care Outcome: Quality and quantity of evidence behind the ten most common elective orthopaedic surgeries and comparisons with the strength of recommendations in relevant national clinical guidelines. Authors’ Conclusions: “Although they may be effective overall or in certain subgroups, no strong, high quality evidence base shows that many commonly performed elective orthopaedic procedures are more effective than non-operative alternatives. Despite the lack of strong evidence, some of these procedures are still recommended by national guidelines in certain situations.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes/Unsure The search for studies was detailed and exhaustive. Yes The primary studies were of high methodological quality. Yes The assessment of studies were reproducible. Yes The outcomes were clinically relevant. Yes There was low statistical heterogeneity for the primary outcomes. Unsure The treatment effect was large enough and precise enough to be clinically significant. Yes, No and Unsure Results: The ten most common elective orthopaedic procedures were identified using a literature search, an assessment of Hospital Episode Statistics procedure frequency counts, and discussions with expert orthopaedic surgeons. Ten Most Common Elective Orthopaedic Procedures arthroscopic anterior cruciate ligament reconstruction arthroscopic meniscal repair of the knee arthroscopic partial meniscectomy of the knee arthroscopic rotator cuff repair arthroscopic subacromial decompression carpal tunnel decompression lumbar spine decompression lumbar spine fusion total hip replacement total knee replacement Key Result: Only two out of ten common procedures, carpal tunnel decompression and total knee replacement, showed superiority over non-operative care. They identified no RCTs that specifically compared total hip replacement or meniscal repair with non-operative care. The six other common orthopaedic procedures showed no benefit over non-operative care. 1. Jadad Decision Algorithm: This is probably an unfamiliar process to most SGEM listeners. It is a process proposed in the late 1990’s to help decision-makers select from among discordant reviews [1]. Since its publication, the Jadad decisions algorithm is now commonly used to interp

Date: April 7th, 2022 Reference: Wong et al. Sensitivity of diffusion-weighted magnetic resonance imaging in transient global amnesia as a function of time from symptom onset. AEM April 2022 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. Case: A 65-year-old man presents to your emergency department with his wife. She tells you that he woke up normally this morning, but after breakfast he began asking the same questions repetitively and was amnestic to the answer, seemingly unable to form new memories. He remained completely awake and alert and otherwise appeared well. There was no history of recent trauma, infectious symptoms, or any other illness. Background: Transient global amnesia (TGA) is an idiopathic acute neurological disorder that presents with sudden onset anterograde memory loss. It was first described as a syndrome in 1956 by Courjon and Guyotat and also by Bender [1,2]. Fisher and Adams formally described as TGA in 1964 [3]. The usual presentation is a patient between 50 and 70 years of age who are cognitively and neurologically intact but asking repetitive questions, unable to form new memory. Symptoms do not last very long and resolve within 24 hours. The incidence has been reported as 23.5 per 100,000 people per year [4] and is more common in people who get migraine headaches [5]. TGA is often precipitated by physical or emotional stressors, pain, the Valsalva maneuver, hot or cold-water immersion or sexual intercourse [6] Diagnosing TGA combines items put forward by Hodges and Warlow and Caplan [7-9]. This results in seven diagnostic criteria for TGA. Diagnostic Criteria for Transient Global Amnesia Attack is witnessed Clear-cut anterograde amnesia during the attack No neurologic symptoms or signs during the attack other than amnesia (no clouding of consciousness or loss of personal identity) No neurologic physical examination findings others than anterograde amnesia Memory loss is transient (resolution within 24 h) No epileptic features and no active epilepsy (defined as no seizure within 2 years or on antiepileptic medication) No recent head injury A diagnostic algorithm has been published for patients with sudden onset of anterograde amnesia [6]. Included in this differential is transient epileptic amnesia, transient ischemic attack, stroke, metabolic disorders, psychogenic disorders, and post traumatic amnesia. The workup can include laboratory testing, EEGs, ECGs, echocardiogram and advanced neuroimaging. Clinical Question: What is the sensitivity of diffusion-weighted magnetic resonance imaging (DW-MRI) as a function of time from symptom onset compared to clinical diagnosis of TGA? Reference: Wong et al. Sensitivity of diffusion-weighted magnetic resonance imaging in transient global amnesia as a function of time from symptom onset. AEM April 2022 Population: Adult patients 16 years of age and older with a diagnosis of TGA based on the existing clinical criteria Intervention: Evaluation with DW-MRI at varying time intervals post symptom onset Comparison: No comparison as no studies of patients without DW-MRI were included Outcome: Sensitivity of DW-MRI in diagnosis of TGA Dr. Matt Wong This is a back-to-back SGEMHOP episode. We did the March episode at the end of last month and the April episode is the first week of this month. We are pleased to have the lead author on the show. Dr. Matthew Wong is an emergency physician and educator at Beth Israel Deaconess Medical Center, and an Assistant Professor at Harvard Medical School. Authors’ Conclusions: “DW-MRI lesions are uncommon in patients with TGA early after symptom onset, but the sensitivity (i.e., positivity rate) of DW-MRI increases with time. Despite the limited quality of existing evidence, obtaining an early DW-MRI in patients with clinical diagnosis of TGA in the acute setting is likely a low-yield test.” 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 were reproducible. Yes There was low heterogeneity for estimates of sensitivity or specificity. No The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision-making models. No Results: They identified 23 studies in their search with a total of 1,688 patients who met inclusion criteria. All studies were case series of adult patients clinically diagnosed with TGA who underwent DW-MRI. Key Result: The sensitivity of DW-MRI in diagnosing TGA increases with time. In the first 12 hours from symptom onset, sensitivity of DW-MRI is 15.6%. It improves thereafter to sensitivities between 66 and 83%, with very wide confidence intervals for all point estimates. There is also significant hete

Date: March 31st, 2022 Reference: Butt et al. Take-Pause: Efficacy of mindfulness-based virtual reality as an intervention in the pediatric emergency department. AEM March 2022 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 is a pulmonary embolism and implementation science researcher. Lauren won the 2021 SAEM FOAMed Excellence in Education Award. Case: A 15-year-old male presents to the pediatric emergency department (ED) with right ankle pain sustained while twisting his ankle during dance practice. The right ankle is swollen and tender. He rates his pain a 5 on the FACES scale and is awaiting examination by the treating clinician. Background: Pediatric emergency department (ED) visits and related procedures can invoke pain and anxiety among children. Patients who experience adequate pain relief during their ED stay have significant reductions in distress, improved rapport with their physician, improved intent to comply with discharge instructions and higher levels of personal and caregiver satisfaction. Children represent one group of patients that are less likely to receive adequate analgesia (Brown et al, Selbst and Clark). This phenomenon is known as oligoanalgesia or poor pain management through the underuse of analgesia. Dr. Anthony Crocco We have covered pediatric pain with PEM super hero Dr. Anthony Crocco on SGEM#78 who did a RANThony on this issue. Dr. Samina Ali is a PEM super (s)hero who was on SGEM#242 looking at intranasal (IN) ketamine vs fentanyl on pain reduction for extremity injuries in children. The bottom line from that trial was IN ketamine appears to be non-inferior to IN fentanyl for efficacy, but with more adverse events. Many clinicians utilize distraction techniques to reduce pain and anxiety in children during their ED visits [4]. However, there are no prospective randomized trials using virtual reality (VR) as a distraction technique while awaiting physician evaluation. Clinical Question: Does a 5-minute virtual reality program reduce situational anxiety in the pediatric ED? Reference: Butt et al. Take-Pause: Efficacy of mindfulness-based virtual reality as an intervention in the pediatric emergency department. AEM March 2022 Population: Patients ages 13-17 years who presented to the pediatric ED with mild to moderate acute pain (pain score 2-6 on FACES pain scale) Exclusions: Patients with developmental delays, inability to speak English, prone to motion sickness, significant visual/hearing impairment, pregnancy, parental refusal, received analgesic ≤4 hours prior to ED arrival, or inability to use the pain scale. Intervention: Virtual reality “Take Pause” program for 5 minutes Comparison: Passive distraction technique with hospital-owned iPad with pre-downloaded age-appropriate games for 5 minutes Outcome: Primary Outcome: Difference in the change in situational anxiety level between groups 15 minutes after intervention using the Spielberger State – Trait Anxiety Inventory (STAI: Y-6 item) Secondary Outcomes: Mean difference in pain score on the FACES scale, heart rate, respiration rate from baseline to 15 minutes after intervention Trial: Prospective, randomized, single-blind trial Mahlaqa Butt This is an SGEMHOP episode which means we have the lead author on the show. Mahlaqa Butt, MPH is a third-year medical student at New York Institute of Technology-College of Osteopathic Medicine and a clinical research associate at the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn NY. She has co-authored 11 peer-reviewed emergency medicine research publications primarily focused on opioid-free pain management in the ED. She will be pursuing a residency in emergency medicine this fall. Authors’ Conclusions: “Take-Pause, offering an active and immersive distraction technique, is more effective than a passive distraction approach to lower anxiety levels in adolescent ED patients.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes 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). No The patients in both groups were similar with respect to prognostic factors. Unsure All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No 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. No The treatment effect was large enough and precise enough to be clinically significant. Unsure Financial conflicts of interest. The authors stated they had no potential conflicts to disclose. Results: They enrolled

Date: March 26th, 2022 Guest Skeptic: Professor Melanie Trecek-King Associate professor of biology at Massasoit Community College in Massachusetts. Founder and creator of Thinking Is Power. Reference: Trecek-King M.A Life Preserver for Staying Afloat in a Sea of Misinformation. Skeptical Inquirer March/April 2022 Prof Trecek-King This is an SGEM Xtra episode. I met Melanie through our online interactions on Twitter. She posts excellent tweets about critical thinking. I then discovered her amazing website called Thinking is Power. We also discovered through our social media interactions that were were both Feynman fans. I asked Melanie to come on the show and discuss her recent article in Skeptical Inquirer and explain the acronym she created called FLOATER. Melanie explains that FLOATER grew out of James Lett’s “A Field Guide to Critical Thinking” (Lett J. Skeptical Inquirer 1990), in which he summarized the scientific method with the acronym FiLCHeRS (Falsifiability, Logic, Comprehensiveness of evidence, Honesty, Replicability, and Sufficiency of evidence). The FLOATER acronym stands for Falsifiability, Logic, Objectivity Alternative explanation, Tentative conclusion, Evidence, and Replicability. This was the basis for her article in Skeptical Inquirer. Melanie published her first article in the January/February edition called "Teach Skills, Not Facts". Listen to the SGEM Xtra podcast to hear Melanie explains each of the seven tools/rules that make up the FLOATER acronym. Tool 1: Falsifiability It must be possible to think of evidence that would prove the claim false. It seems counterintuitive, but the first step in determining if a claim is true is to determine if you can prove it wrong. Tool 2: Logic Arguments for the claim must be logical. They can be deductive or inductive arguments. We should try and not commit logical fallacies when arguing positions. Tool 3: Objectivity The evidence for a claim must be evaluated honestly. Tool 4: Alternative Explanations Other ways of explaining the observation must be considered. Tool 5: Tentative Conclusions In science, any conclusion can change based on new evidence. Tool 6: Evidence The evidence for a claim must be reliable, comprehensive, and sufficient. Tool 7: Replicability Evidence for a claim should be able to be repeated. We have a reproducibility crisis in science. We ended this SGEM Xtra show with a quote from Marie Curie. I think Melanie is an amazing skeptic and educator. It was an absolute pleasure to have her on the show as the guest skeptic. 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 Additional Readings: Kahan et al. Science Curiosity and Political Information Processing. Political Psychology. January 2017 Kahan DM. Why Smart People Are Vulnerable to Putting Tribe Before Truth. Scientific America. December 2018 Trecek-King M. Teach Skills, Not Facts. Skeptical Inquirer. January/February 2022

Date: March 3rd, 2022 Reference: Macnow et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatrics 2021 Guest Skeptic: Dr. Catherine Varner is an Assistant Professor and Clinician Investigator in the Department of Family and Community Medicine at the University of Toronto. She is an emergency physician at Mount Sinai Hospital and a Clinician Scientist and the Deputy Director of the Schwartz-Reisman Emergency Medicine Institute. Dr. Varner's research interests are in concussion and pregnancy care in the ED. Case: An 18-year-old female presents to the emergency department (ED) after falling off a moving snowmobile and hitting her head on the ground. It was a witnessed fall; she was wearing a helmet at the time and there was no loss of consciousness. There were no other injuries reported and she is found to have a GCS score of 15 after the injury. The Acute Concussion Evaluation–Emergency Department (ACE-ED) Tool is used, and she scores a 2 for headache and feeling foggy. She knows about taking it easy physically for the next couple of days but wonders if she must stay off her computer as well? Background: Concussions or mild traumatic brain injury (mTBI) are commonly diagnosed in the Emergency Department (ED). Most patients recover within the first week; however, 15-30% of patients develop persistent post-concussive symptoms. An issue that often comes up with minor head injuries is do we need to get advanced imaging. A paper by Dr. Ian Stiell and his group gave us a tool to help us decide who to scan with the now infamous clinical decision instrument called the Canadian CT Head Rule [1]. This classic paper was published in Lancet 2001 and reviewed on SGEM#106. Another issue that comes up is whether children need strict rest after a concussion. SGEM#112 reviewed a small study by Thomas et al published in Pediatrics 2015 asking if there was a benefit to recommending strict rest after a child has a concussion [2]. The bottom line from that episode was that in children with concussion, two days of rest followed by a gradual return to activity is preferred over five days of rest followed by a gradual return to activity. The longer strict rest period appears to cause more post-concussive symptoms. Our episode together looked at the impact of light exercise in adults with mild concussions on the likelihood of developing persistent symptoms up to 30 days following their injury (SGEM#331). We found there was not a statistical difference between light activities like walking and 48 hours of rest with gradual return to activity as tolerated. Our conclusions were that early light exercise may be encouraged as tolerated at ED discharge following mTBI, but this guidance is not sufficient to prevent persistent concussion symptoms [3]. The Acute Concussion Evaluation–Emergency Department (ACE-ED) tool is an instrument used by ED clinicians to diagnose a concussion and identify risk factors for prolonged recovery. It is both helpful for diagnosis and future management of symptoms. When a patient is recovering from a concussion, whether you are using ACE or another symptom scoring tool like the Postconcussion Symptom Scale or the Rivermead Post-concussion Symptom Questionnaire, future health care providers caring for the concussion patient may refer to the quantitative assessment of the patient’s symptoms in the acute phase of the injury. Clinical Question: Does screen time in the first 48 hours after concussion have an impact on the duration of concussive symptoms? Reference: Macnow et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatrics 2021 Population: Patients aged 12 to 25 years presenting to the emergency department within 24 hours of sustaining a concussion according to the Acute Concussion Evaluation–Emergency Department (ACE-ED) tool (Giola et al 2008) Exclusions: Attending physician declined participation; their guardian was not present; the patient was younger than 18 years, or they (or their parent or guardian) were not fluent in English; intoxication; had a GCS score < 15; had intracranial abnormalities identified on imaging; had pre-existing intellectual disability, severe psychiatric illness, severe neurological conditions, or substantial previous neurological surgery; or required neurosurgical intervention, intubation, or hospital admission. Intervention: Patients were asked to abstain from screen time for 48 hours after injury. This was the screen time abstinent group. Comparison: Patients were permitted to engage in screen time in the first 48 hours after injury. This was the screen time permitted group. Outcome: Primary Outcome: Number of days until functional resolution of concussive symptoms, which was defined as the first day with a total score of three points or lower on the Post-Concussive Symptom Scale (PCSS) Secondary Outcomes: Amount of screen and sleep time during the intervention period, the day of re

Date: February 24th, 2022 Reference: Parish et al. An umbrella review of effect size, bias, and power across meta-analyses in emergency medicine. AEM 2021 Guest Skeptic: Professor Daniel Fatovich is an emergency physician and clinical researcher based at Royal Perth Hospital, Western Australia. He is Head of the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research; Professor of Emergency Medicine, University of Western Australia; and Director of Research for East Metropolitan Health Service. Case: A resident has been following the literature over their four years of training. They have already seen several things come into fashion and go out of fashion during this short time. This includes therapeutic hypothermia for out-of-hospital cardiac arrest (OHCA), tranexamic acid (TXA) for epistaxis and electrolyte solutions for mild pediatric gastroenteritis. They wonder how strong the evidence is for much of what we do in emergency medicine. Background: There are many things in medicine that could be considered myth or dogma. We have covered some of these over the 10 years. Topical anesthetic uses of 24-48 hours for mild cornea abrasions will cause blindness- No (SGEM# 315) Epinephrine for adult out-of-hospital cardiac arrests (OHCAs) results in better neurologic outcomes – No (SGEM#238) TXA for intracranial hemorrhage, isolated traumatic brain injury, post-partum hemorrhage or gastrointestinal bleed results in better primary outcomes - No (SGEM#236, SGEM#270, SGEM#214, and SGEM#301) Therapeutic hypothermia in adult OHCA saves lives – No (SGEM#336) Electrolyte solutions are needed in mild pediatric gastroenteritis - No (SGEM#158) A lot of medical practice is based on low quality research. Tricoci et al. JAMA Feb 2009 looked at the ACC/AHA guidelines from 1984 to 2008. They found 53 guidelines with 7,196 recommendations. The results were only 11% of recommendations were considered Level A, 39% were Level B and 50% were Level C. The definitions used for each level of evidence are as follows: An update was published by Fanaroff et al in JAMA 2019. The level of high-quality evidence had not changed much when looking at the ACC/AHA guidelines from 2008-2018. There were 26 guidelines with 2,930 recommendations. Now Level A recommendations were down to 9%, Level B 50% and Level C 41%. This lack of evidence is not isolated to cardiology. A recent study looked at the top ten elective orthopaedic procedures. It was an umbrella review of meta-analyses of randomized control trials (RTCs) or other study designs if no RCTs existed (Blom et al BMJ 2021). The comparison was the clinical efficacy of the most common orthopaedic procedures with no treatment, placebo, or non-operative care. The primary outcome was the quality of the evidence for each procedure. Only two out of ten common procedures, carpal tunnel decompression and total knee replacement, showed superiority over non-operative care. Clinical Question: What is the effect of faults such as underpowered studies, flawed studies (i.e. methodologic and statistical errors, poorly designed studies) and biases in the field of therapeutic interventions in the emergency medicine literature? Reference: Parish et al. An umbrella review of effect size, bias, and power across meta-analyses in emergency medicine. AEM 2021 Population: SRMAs 1990-2020 in the top 20 journals under the google scholar subcategory: emergency medicine; emergency medicine meta-analyses from JAMA, NEJM, BMJ, The Lancet, and the Cochrane Database of Systematic Reviews; emergency medicine topics across all PubMed journals; and an extraction of all studies from the Annals of Emergency Medicine Systematic Review Snapshots (SRS) series. Exclusions: Articles were excluded if they did not include a quantitative synthesis (meta-analysis); did not contain at least two summarized studies; did not make a comparison between two groups to assess an effect size; did not report an effect size as at least one of mean difference or standardized mean difference (SMD; Cohen's d), odds ratio (OR), risk ratio (RR), hazard ratio (HR), or transformations of these effect sizes; were meta-analyses of diagnostic accuracy studies; or were not related to the practice of emergency medicine. Intervention: Data supplement 1 lists all 431 MAs derived from 332 published SRMAs. Comparison: Includes placebo, usual care, nothing. Outcomes: Identify broad patterns in study parameters (effect size, power, mortality benefit and potential bias). Dr. Austin Parish We are fortunate to have the lead author on this episode even though it is not an SGEMHOP. Dr. Austin Parish is the Chief Resident in Emergency Medicine at the Lincoln Medical Center, Bronx NY. He is also a researcher for the Meta Research Innovation Center at Stanford (METRICS) Authors’ Conclusions: “Few interventions studied within SRMAs relevant to emergency medicine seem to have strong and unbiased evidence for improving outcomes. The fiel

Date: February 21st 2022 Reference: Kim et al. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. AEM February 2022. Guest Skeptic: Dr. Kirsty Challen (@KirstyChallen) is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). 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 is also the creator of the wonderful infographics called #PaperinaPic. Case: You are in discussion with your emergency department (ED) manager about the number of patients boarding for hours to days and you are both aware that many of these patients are attending with mental health crises. You wonder whether a model of care involving a specifically designed unit would improve their patient experience and ED boarding times. Background: We have covered mental health issues only a few times on the SGEM. The latest SGEM Xtra was a very powerful episode with Dr. Tim Graham sharing his story of burnout, anxiety, and depression. This was based upon his article published in the Canadian Medical Association Journal (CMAJ). We also had Dr. Tyler Black on that episode to provide his expertise as a suicidologist. ED visits in the US for mental health conditions has increased by 44% from 2006 to 2014. Inadequately resourced provision for emergency mental health care is familiar to health care professionals in multiple jurisdictions and patients can spend days in the ED waiting for inpatient admission. We've talked about mental health issues in SGEM #252 in 2019. In that episode we concluded that clinician gestalt was likely to be as accurate and efficient in screening for suicidality as a specific tool (Convergent Functional Information for Suicidality screening tool). Also, in SGEM #313 we recognised that three or more ED attendances for alcohol-related issues was associated with a 1-year mortality risk of over 6%. Clinical Question: Does the implementation of a dedicated interdisciplinary unit for mental health patients presenting to an ED with suicidal ideation or a suicide attempt reduce inpatient admissions and ED boarding time? Reference: Kim et al. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. AEM February 2022. Population: Adults presenting to a single academic tertiary referral ED in Iowa with suicidal ideation or after a suicide attempt – determined using administrative data.. Excluded: Patients that were medically unstable, needed co-management of a medical condition, were incarcerated, actively violent or judged by the provider to be intoxicated. Also, patients with mental health conditions other than suicidal ideation or attempt. Intervention: Post-establishment of EmPATH unit Nov 2018 – May 2019. Comparison: Pre-establishment of EmPATH unit Nov 2017 – May 2018. Outcome: Primary Outcome: Proportion of patients admitted to inpatient psychiatric unit (direct from ED, via EmPATH Unit or by transfer). Secondary Outcomes: Any admission including psychiatry, intensive care, or medicine; complete vs incomplete psychiatric admission; hospital length of stay in those with a bed requested; ED length of stay; use of restraints in ED, scheduled follow-up, 30-day ED return; restraint use; code green Dr. Allie Kim This is an SGEMHOP episode which means we have the lead author on the show (Dr. Kim). And as a special treat we also have the senior author (Dr. Lee). Dr. Allie Kim graduated from emergency medicine residency at the University of Iowa last July and now works as an attending physician at Unity Point Health hospitals in Des Moines, Iowa. We also have senior author Dr. Sangil Lee who is a Clinical Associate Professor of Emergency Medicine at the University of Iowa. The state of Iowa has only a handful of inpatient psychiatric units. The University of Iowa, where the EmPATH unit was implemented, is one of them. We see patients from all over the state, plus even out of state, and with the increase in numbers of mental health presenting to our emergency department, the sheer percentage of our patients needing inpatient psychiatric care was high. And, as many of us have seen, patients may wait in their ER bed for days until an inpatient bed became available. This “boarding” of patients delayed their psychiatric care and left less room for us to see other patients. Dr. Sangil Lee The EmPATH program we created, in conjunction with the Department of Psychiatry, is an open concept unit with the capacity to treat 12 adults. Patients must be medically cleared first in the ED, and also be behaviorally appropriate, to enter the EmPATH unit. Once in the unit, there are psychiatrists, nurses, and social workers to help patients. Average

Date: February 15th, 2022 Guest Skeptic: Dr. Tim Graham is a Clinical Professor of emergency medicine at the University of Alberta, and Associate Chief Medical Information Officer, Edmonton Zone, of Alberta Health Services from Edmonton, Alberta. Reference: Graham T. Physician heal thyself. CMAJ 2021 TRIGGER WARNING: As a warning to those listening to the podcast or reading this blog post, there may be some things discussed that could be upsetting. The SGEM is a free open access project trying to cut the knowledge translation down to less than one year. It is intended for clinicians providing care to emergency patients, so they get the best care, based on the best evidence. Some of the material we are going to be talking about on this episode could trigger some strong emotions. If you are feeling upset by the content, then please stop listening to the podcast or reading the blog. There will be resources listed at the end of the blog for those looking for assistance. Dr. Tim Graham This is an SGEM Xtra episode. Tim approached me about an article he wrote and published in the Canadian Medical Association Journal (CMAJ). The title of the article was "Physician, heal thyself" and was in the humanities section of the October 2021 issue. This article resonated with many people and was the 6th most read CMAJ article of 2021. Tim thanked his wife, Dr. Samina Ali, in the CMAJ article and on the podcast. Samina has been a guest skeptic on the SGEM. She is the one who suggested Tim share his story to reach an even wider audience. In this SGEM Xtra episode, Tim tells his experience with burnout. This is a topic we have discussed many times on the SGEM and I have shared my personal experience with burnout. SGEM Xtra: The Water is Wide SGEM#289: I Want a Dog to Relieve My Stress in the Emergency Department SGEM Xtra: CAEP Wellness Week 2019 SGEM Xtra: On the Edge of Burnout SGEM Xtra: Don’t Give Up – The Power of Kindness SGEM#178: Mindfulness – It’s not Better to Burnout than it is to Rust SGEM Xtra: Five Tips to Avoid Emergency Medicine Burnout A 2015 study by Shanafelt et al of US physicians showed that more 50% had at least one symptom of burnout. The highest prevalence of burnout was reported by emergency physicians. COVID19 has been hard on the health care system. Medscape just published a 2021 survey of 13,000 physician from 29 specialties and emergency physicians were still #1 reporting the highest level of burnout. People have made a distinction between burnout and moral injury. Journalist Diane Silver describes moral Injury as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.” It is something that tears us apart at the fabric of what it is to be a physician. Tim discusses how he started getting suicidal ideations and what he did to try and address these thoughts. This included seeking professional help, medication, and lifestyle changes. Some interventions helped more than others. Tim reports he is now in the best place mentally and physically than he has been in many years. Tim also gives some advice to prevent others from going through a similar experience. This includes a wellness tool kit that starts with a healthy diet, regular exercise and good sleep. Two things he found really helpful were meditation and yoga. Suicidologist: Dr. Tyler Black When preparing this SGEM Xtra episode, I suggested to Tim we get an expert in mental health to give us some more information on the topic. I'm not an expert in this area and reached out to Dr. Tyler Black. Tyler is a suicidologist, emergency psychiatrist and pharmacologist from Vancouver. Dr. Tyler Black Tyler provided a definition for suicidologist. He discussed burnout and the association with suicidal ideation in physicians (Menon et al JAMA 2020. Tyler gave some potential reasons why physicians do not seek mental health care (stigma, colleges/regulatory bodies, access to care, etc). He also described how we can help each other and ourselves stay mentally healthy. Tyler was also asked what he would do if given a blank cheque to address this problem of physician burnout. He would spend the money on research and getting scribes to interact with the EMR and not buy muffins for the break room. Tim was asked at the end of the podcast what he would tell his younger self. I challenge the SGEM audience to think about what you would say to your younger self. Here is what Tim would say: "I would tell young me that no matter how important I think work is, I am really just another cog in the never-ending gears of the health care system. Once internalized, this knowledge was liberating, and it gave me permission to prioritize myself and my well-being. In the end, if you die tomorrow, your employer will replace you, but your loved ones cannot." 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 te

Date: February 7th, 2022 Reference: Williams et al. Short- vs standard-course outpatient antibiotic therapy for community-acquired pneumonia in children: the scout-cap randomized clinical trial. JAMA Pediatrics 2022 Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. Case: A three-year-old boy presents to the emergency department (ED) with fever and cough. On exam, he is breathing a little fast and his oxygen saturation is 94% on room air but otherwise appears comfortable. You appreciate some decreased breath sounds and crackles on your lung exam. You make a clinical diagnosis of community-acquired pneumonia (CAP) and plan to send him home with a 10-day course of amoxicillin. His mother asks you, “Last time he took antibiotics for that long, he had terrible diarrhea. Do you think we can do fewer days of antibiotics and still treat the pneumonia?” Background: We have covered the topic of pediatric community-acquired pneumonia before on the SGEM #338 (Are Children with CAP Safe and Sound if Treated for 5 days rather than 10 days of antibiotics?) with Dr. Andrew Tagg on the Canadian SAFER Trial [1]. This trial suggested that a 5-day course of antibiotics was not non-inferior to the traditional 10-day course of antibiotics for children with CAP treated as outpatients. Things were much simpler when I started my pediatric training. I learned that a well-appearing child presenting to clinic with fever, slight tachypnea, and focal lung exam findings could be diagnosed with pneumonia by history and physical exam alone and go home with 10 days of amoxicillin BID. But now for some reason, this topic feels more complicated…maybe because there are so many different ways people go about diagnosing pneumonia and such variability in the reliability of physical exam findings [2,3]. Since we covered the SAFER trial, we have also had the CAP-IT [4] trial from the United Kingdom and Ireland which evaluated both high and low-dose amoxicillin for the treatment of CAP over three or seven days. They found that both a lower dose and a shorter duration of antibiotic therapy was non-inferior to higher dose, longer duration antibiotic therapy. They did find that cough persisted longer with the group that received a shorter duration of antibiotic therapy but overall adherence to medication was better in the group receiving a shorter duration of antibiotics. Why so many pneumonia studies? Ultimately, we want to find that balance of treating an infection but avoiding antibiotic-associated adverse effects and antibiotic resistance. So where is that sweet spot? Clinical Question: Is a 5-day course of antibiotics superior to a 10-day course for the treatment of non-severe community-acquired pneumonia in children with respect to clinical outcomes, adverse effects, and antimicrobial resistance? Reference: Williams et al. Short- vs standard-course outpatient antibiotic therapy for community-acquired pneumonia in children: the scout-cap randomized clinical trial. JAMA Pediatrics 2022 Population: Children 6 to 71 months of age from 8 US cities diagnosed with uncomplicated CAP demonstrating early clinical improvement (no fever, tachypnea, severe cough) on day 3 to 6 of their initially prescribed oral beta-lactam therapy. Excluded: Severe pneumonia (Hospitalization, radiographic evidence of parapneumonic effusion, empyema, lung abscess, pneumatocele or Microbiologically confirmed Staph aureus or Strep pyogenes pneumonia. Parenteral or combination antibiotic therapy. Undergoing surgery or invasive airway procedures 7 days prior to diagnosis of CAP. Beta-lactam allergy. Concurrent bacterial infection necessitating >5 days of antibiotics. Aspiration pneumonia, bronchiolitis, bronchitis, acute asthma exacerbation. Chronic medical conditions. History of pneumonia within prior 6 months Intervention: Short 5 days course of previously prescribed antibiotic therapy (amoxicillin, amoxicillin with clavulanate, cefdinir) with 5 days of placebo Comparison: Standard course of 10 days of previously prescribed antibiotic therapy Outcomes: Primary Outcome: End of treatment response adjusted for duration of antibiotic risk (RADAR) at the first outcome assessment visit (OAV1) which occurred on study days 6 to 10. This was a 2-step process: Desirability of outcome ranking (DOOR) based on adequate clinical response, resolution of symptoms, presence, and severity of antibiotic-associated adverse effects. Ranked overall experience based on actual reported treatment duration Secondary Outcomes: RADAR at the second outcome assessment visit (OAV2) on study days 19 to 25. A portion of participants also consented to throat swab collection at the second outcome assessment visit to evaluate antibiotic resistance genes in oropharyngeal flora. Trial: Prospective, multicenter randomized double-blind placebo-controlled superiority clinical trial. Authors’ Conclusions: “In this study, among children responding

Date: January 25th, 2022 Reference: Beyde et al. Efficacy of empiric antibiotic management of septic olecranon bursitis without bursal aspiration in emergency department patients. AEM January 2022 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: You’re working in your busy freestanding emergency department (ED) getting absolutely crushed handing out COVID19 tests like candy and are relieved to see a patient with something different. A 27-year-old male construction worker building a local house presents with a tender, warm, erythematous olecranon and you diagnose him with septic olecranon bursitis. You offer to drain the bursa and get him back to work ASAP, and the patient looks very anxious and asks if you really must. Background: We have covered skin and soft tissue infections multiple times on the SGEM. The most recent time was with guest skeptic and SAEM FOAMed Excellence in Education Award winner Dr. Lauren Westafer (SGEM#348). We reviewed Dr. David Talan and colleagues’ study that was the October 2021 SGEM Hot Off the Press. That study investigated if a single-dose long-acting intravenous antibiotic could reduce hospitalization in patients with skin infections. The SGEM bottom line from that episode was in hospital systems with access to IV dalbavancin and the ability to establish expedited telephone and in-person follow up, this clinical pathway is associated with a decrease in hospitalizations for patients with moderately severe cellulitis. A couple of other SGEM episodes have looked at the management of cellulitis including SGEM#131 and SGEM#209. The treatment of abscesses has been covered four times on the SGEM (SGEM#13, SGEM#156, SGEM#164 and SGEM#311). The latest episode looked at the loop technique to drain uncomplicated abscesses. One topic we have not looked at is infected bursa. It’s estimated that about half of olecranon bursitis cases are septic[1]. Often, diagnostic aspiration is performed, but complications include fistula formation, further infection, and need for bursectomy [2-6]. Often the workup of septic bursitis is based upon anecdotal evidence [7]. This is likely due to the lack of high-quality evidence to direct our care. One area with limited information is the efficacy of empiric antibiotics without bursal aspiration. Clinical Question: What is the efficacy and outcomes associated with empiric antibiotic therapy, without aspiration, for septic olecranon bursitis? Reference: Beyde et al. Efficacy of empiric antibiotic management of septic olecranon bursitis without bursal aspiration in emergency department patients. AEM January 2022 Population: Adults >18 years old with olecranon bursitis Excluded: Declined authorization, underlying fracture, or surgery on the joint within 3 months Exposures: Antibiotics, aspiration, surgery or admission to hospital Comparison: None Outcome: Primary Outcome: Complicated versus uncomplicated bursitis resolution (Uncomplicated was defined as bursitis resolution without the need for bursal aspiration, surgery, or hospitalization) Secondary Outcome: Descriptive statistics of the cohort Study Design: Retrospective observational cohort study Dr. Ronna Campbell This is an SGEMHOP episode which means we have the senior author on the show. Dr. Ronna Campbell is an emergency physician practicing since 2007 in Rochester, MN. She enjoys mentoring medical students, residents and others in research. Authors’ Conclusions: “Eighty-eight percent of ED patients with suspected septic olecranon bursitis treated with empiric antibiotics without aspiration had resolution without need for subsequent bursal aspiration, hospitalization, or surgery. Our findings suggest that empiric antibiotics without bursal aspiration may be a reasonable initial approach to ED management of select patients with suspected septic olecranon bursitis.” 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? Fairly wide 95% CI around some of the point estimates 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? NCATS/NIH grant Results: 264 patients included in the study, 229 with three months of follow up, 220 with six months. The age ranged from 42-69 years with 85% male. The most common presenting symptoms were swelling (94%), erythema (77%), and pain (85%). Key Results: Most patients with suspected septic olecranon bursitis had an uncomplicated

Date: January 22nd, 2022 Reference: Yu et al. Inhaled budesonide for COVID-19 in people at high risk of complications in the community in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial. Lancet 2021 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com. Case: A 65-year-old woman with a history of diabetes, hypertension, and gastroesophageal reflux disease (GERD) presents with three days of fever, cough, and myalgias. She is fully vaccinated against COVID-19. Her husband tested positive for COVID-19 yesterday, and she used a home rapid test this morning that is also positive. Her vitals signs are all normal and she feels well enough to isolate at home. As you are preparing to discharge her, she asks if there is anything you can prescribe her to help. She thinks her friend might have been prescribed a puffer of some sort. Background: I’ve tried not to focus too much on COVID-19. There are many great FOAMed resources that have done a good job of covering the topic. The SGEM has only done a few shows over the two years including: Debate regarding a universal mandate for masks early in the pandemic with Dr. Joe Vipond (SGEM Xtra: Masks4All in Canada Debate) Skeptical review of the early therapeutics with Dr. Sean Moore for the Canadian Association of Emergency Physicians (CAEP) Town Hall (SGEM Xtra: COVID19 Treatments – Be Skeptical) Diagnostic accuracy of various tests for COVID19 with Dr. Chris Carpenter (SGEM#299: Learning to Test for COVID19) Structured critical appraisal of the DANMASK trial with Dr. Joe Vipond (SGEM#309: That’s All Joe Asks of You – Wear a Mask) The First10EM has done more than 30 blog posts about COVID-19 at this point, with a lot more to come. I know we all wish COVID-19 would just go away. But unfortunately, wishful thinking won’t help us, but hopefully science will. There is strong evidence that systemic steroids improve outcomes in patients with severe COVID-19 (First10EM: Steroids for COVID). This has raised the question of whether inhaled steroids might be helpful. After all, the infection is primarily in the lungs. Early in the pandemic, there was some observational data that concluded that inhaled steroids were associated with an increased mortality from COVID-19 in patients with asthma and COPD (Schultze Lancet Resp Med 2020). However, the most likely explanation was not causal. Sicker patients are prescribed steroids more often, and so the association is not surprising. The STOIC trial was an initial phase 2 open-label randomized control trial of inhaled budesonide for patients with mild symptoms of COVID-19 (Ramakrishnan et al Lancet Resp Med 2021). It did report positive results. Their primary outcome was a ‘COVID-19 related’ urgent care visit, emergency department assessment, or hospitalization, and was significantly reduced in the budesonide arm (15% vs 3%, p=0.009). However, the unblinded trial design, less relevant composite outcome, and fact that the trial was stopped early limit confidence in the results. That bring us to the PRINCIPLE trial. Clinical Question: Does inhaled budesonide improve clinical outcomes in high-risk outpatients with COVID-19? Reference: Yu et al. Inhaled budesonide for COVID-19 in people at high risk of complications in the community in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial. Lancet 2021 Population: Outpatients with symptomatic COVID-19 within 14 days of symptom onset who were considered high risk for adverse events. This included adults over 65 years of age, or over 50 years of age with co-morbidities. Exclusions: Known allergy or contraindication to inhaled budesonide, were unable to use an inhaler, or already using inhaled or systemic glucocorticoids. Intervention: Inhaled budesonide 800 ug BID for 14 days Comparison: Usual care (there was no placebo) Outcome: Primary Outcome: Composite outcome of COVID-19-related hospital admission or death within 28 days. However, partway through the trial they realized hospitalization was lower than normal, and so they added a second primary outcome: illness duration. Secondary Outcomes: Recovery by 14 days, daily symptoms rating, time to sustained alleviation of symptoms, time to initial reduction of symptoms, contact with health services, oxygen administration, ICU admission, mechanical ventilation and adherence to study medication Trial Design: Multicentre, open-label, multi-arm, randomised, controlled, adaptive platform trial Authors’ Conclusions: “Inhaled budesonide improves time to recovery, with a chance of also reducing hospital admissions or deaths (although our results did not meet the superiority threshold), in people with COVID-19 in the community who are at higher risk of complications.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No The patients were adequately rando

Date: January 16th, 2022 Reference: Matchett, G. et al. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med 2021 Guest Skeptic: Missy Carter, former City of Bremerton Firefighter/Paramedic, currently a professor of Emergency Medical Services at Tacoma Community College’s paramedic program. Missy is currently working in a community emergency department as a physician assistant and recently accepted a critical care position in Tacoma Washington. Case: You respond to a rapid response on the floor for a 58-year-old woman in septic shock who is requiring emergent rapid sequence intubation (RSI). As you prepare to intubate the pharmacist asks if you would prefer ketamine or etomidate for induction in this patient. Background: We have covered the issue of intubation multiple times on the SGEM. This has included looking at supraglottic airways for out-of-hospital cardiac arrests (SGEM#247), video vs. direct laryngoscopy (SGEM#95), tracheal intubation for in-hospital cardiac arrests (SGEM#197), apneic oxygenation (SGEM#186) and confirming intubation with POCUS (SGEM#249). One thing we have not covered is the choice of induction agent for intubation. There has been much debate regarding the use of etomidate verses ketamine for induction in the critically ill [1-4]. A 2009 randomized control trial conducted in French ICUs supported the use of ketamine in this patient population [5]. Both agents are considered hemodynamically stable, but any induction agent may precipitate shock in the critically ill. There is some conflicting evidence as to which agent is preferred for patients who are at high risk of peri intubation complications. Historically there has been concern about adrenal insufficiency caused by etomidate being harmful for patients with sepsis but this has not been shown to cause increased mortality in the literature [6, 7]. Ketamine has emerged as a reasonable alternative but in recent years there has been concern about increased cardiovascular collapse with ketamine especially in those with sepsis or a high shock index [1, 8]. Clinical Question: Which induction agent has a better day 7 survival for critically ill patients requiring emergency endotracheal intubation, ketamine or etomidate? Reference: Matchett, G. et al. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med 2021 Population: Adults 18 years of age and older in need of emergency endotracheal (ET) intubation Exclusions: Children, pregnant patients, patients needing ET intubation without sedation or allergic to one of the agents being used Intervention: Ketamine 1-2mg/kg IV Comparison: Etomidate 0.2-0.3mg/kg IV Outcome: Primary Outcome: 7-day survival Secondary Outcomes: 28-day survival, duration of mechanical ventilation, ICU length of stay, need for vasopressor use, SOFA scores and an assessment of a new diagnosis of adrenal insufficiency by the treating critical care teams. Trial: Prospective, randomized, parallel-assignment, open-label, single-center trial (NCT02643381) Authors’ Conclusions: While the primary outcome of Day 7 survival was greater in patients randomized to ketamine, there was no significant difference in survival by Day 28.” 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. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Unsure The treatment effect was large enough and precise enough to be clinically significant. Unsure Lack of conflicts of interest. No Results: The cohort consisted of 801 critically ill patients that required ET. The mean age was 55 years, 38% female, 69% were in the MICU, and 51% had diagnosis of sepsis. Key Result: Day 7 survival was statistically higher in the ketamine arm compared to the etomidate arm Primary Outcome: 7-day survival favored Ketamine (85.1%) vs etomidate (77.3%), difference − 7.8, (95% CI; − 13 to − 2.4) p = 0.005 Secondary Outcomes: There was no statistical difference in 28-day survival between groups (ketamine 66.8% vs etomidate 64.1%) 1. Selection Bias: These were not consecutive patients. The manuscript says physicians were “encouraged to consider screening and enrolling patients whenever clinical circumstances reasonably permitted but were under no obligation to do so.” When you look at the number of patients excluded due to “clinical circumsta

Date: December 28th, 2021 Reference: Kulvatunyou et al. The small (14 Fr) percutaneous catheter (P-CAT) versus large (28–32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial. J Trauma and Acute Care Surgery. November 2021. Guest Skeptic: Dr. Chris Root is a second-year resident physician in the Department of Emergency Medicine at the University of New Mexico Health Sciences Center in Albuquerque, NM. He is also a resident flight physician with UNM’s aeromedical service, UNM Lifeguard. Prior to earning his MD, he worked as a paramedic in the New York City 911 system. Case: A 43-year-old male presents to your emergency department (ED) the day after being involved in an all-terrain vehicle (ATV) accident. He reports he was riding his ATV along an embankment when it rolled, landing on top of him briefly. He did not seek medical attention at the time of the incident, but he has had persistent chest wall pain and worsening shortness of breath since yesterday evening. He is hemodynamically stable, oxygen saturation is 91% on room air, physical exam reveals ecchymosis and tenderness over the right chest wall with diminished right sided lung sounds. CT scans reveal multiple right sided rib fractures and a hemothorax estimated to measure 500cc with no additional injuries. Background: We have discussed chest tubes a couple of times on the SGEM. This is usually with the master himself, Dr. Richard (Thoracic Rick) Malthaner. The first time was looking at a study about where to put the chest tube in a trauma patient. It turns out location (high or low) does not matter. The most important thing is placing the chest tube in the triangle of safety in the plural space (SGEM#129). The other episode on chest tubes looked at conservative vs interventional treatment for spontaneous pneumothorax (SGEM#300). This randomized controlled trial demonstrated that conservative management was non-inferior to placing a chest tube in a patient with a large first-time spontaneous pneumothorax. Another SGEM episode we did looked at the location of needle decompression for tension pneumothorax (SGEM#339). This was done with our good friend and frequent guest skeptic Dr. Robert Edmonds. This observational study did not support the claim that the second intercostal space-midclavicular line is thicker than the fourth/fifth intercostal space-anterior axillary line. This new SGEM episode looks at the size of chest tubes needed to successfully treat a traumatic hemothorax. Traditionally, these are treated by inserting a large bore chest tube (LBCT). There is increasing evidence supporting the use of smaller, percutaneously inserted chest tubes or pigtail catheter (PC) for the drainage of pleural effusions and pneumothoraces as well as some evidence of their efficacy for hemothorax. Clinical Question: Are small (14fr) pigtail catheters as effective as large (28-32 fr) chest tubes for the treatment of hemodynamcially stable patients with traumatic hemothorax? Reference: Kulvatunyou et al. The small (14 Fr) percutaneous catheter (P-CAT) versus large (28–32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial. J Trauma and Acute Care Surgery. November 2021. Population: Hemodynamically stable adult patients 18 years or older suffering traumatic hemothorax or hemopneumothorax requiring drainage at the discretion of the treating physician. Exclusions: Emergent indication, hemodynamic instability, patient refuses to participate, prisoner or pregnancy Intervention: Placement of small (14 fr PC) chest tube using a percutaneous seldinger technique Comparison: Placement of a large (28-32 fr LBCT) chest tube using a traditional surgical thoracostomy Outcome: Primary Outcome: Failure rate defined as radiographically apparent hemothorax after tube placement requiring an additional intervention such as second tube placement, thrombolysis or video-assisted thorascopic surgery Secondary Outcomes: Insertion complication rate; drainage output (30 minutes, 24-hour, 48-hour, and 72-hour); hospital course outcome up to 30 days (total tube days, ICU LOS, hospital LOS, and ventilator days); and insertion perception experience (IPE) score (1-5 score subjective score,1 - it was okay to 5 - it was the worst experience of my life). Trial: Multicenter, non-inferior, unblinded, randomized, parallel assignment comparison trial Authors’ Conclusions: “Small caliber 14-Fr PCs are equally as effective as 28- to 32-Fr chest tubes in their ability to drain traumatic HTX with no difference in complications. Patients reported better IPE scores with PCs over chest tubes, suggesting that PCs are better tolerated.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes 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 pati

Date: December 21st, 2021 Guest Skeptic: Dr. Howard “Howie” Mell began his career as a firefighter / paramedic in Chicago. He became double board certified in Emergency Medicine (EM) and Emergency Medical Services (EMS). Howie also has a Master of Public Health. Reference: Grotta JC et al. Prospective, multicenter, controlled trial of mobile stroke units. NEJM 2021 Case: The Mayor of your community consults you as an expert in public health, EMS and as an EM physician on whether they should purchase a mobile stroke unit (MSU) ambulance. Background: No one who has listened to the SGEM will be surprised we are covering another paper looking at stroke. We have often discussed the use of thrombolysis for acute ischemic stroke (AIS) with or without endovascular therapy (EVT). However, the SGEM has also looked at secondary stroke prevention on previous episodes (SGEM#24, SGEM#303). The SGEM has looked at pre-hospital stroke care using early administration of nitroglycerin by paramedics to see if it would improve neurologic outcome in patients with a presumed acute stroke (SGEM#269). The results from the RIGHT-2 trial reported no statistical difference in functional outcome as measured by the modified Rankin Scale (mRS) score at 90 days. The SGEM bottom line was that very early application of transdermal nitroglycerin by paramedics in the pre-hospital setting cannot be recommended at this time in patients with a suspected stroke. Mobile Stroke Unit The issue of having a MSU has also been discussed on SGEM#330. A systematic review and meta-analysis which included seven randomized controlled trials and four observational studies including 21,297 patients was critically appraised. The primary outcomes reported better neurologic outcome at seven days but not at one day post treatment by a MSU compared to conventional care (Fatima et al Int J Stroke 2020). The SGEM bottom line from that episode was we cannot recommend the use of MSU based on the available evidence. Clinical Question: Should mobile stroke units be purchased and deployed in your community? Reference: Grotta JC et al. Prospective, multicenter, controlled trial of mobile stroke units. NEJM 2021 Population: Patients calling EMS with a history and physical/neurological examination consistent with acute stroke who is last seen normal (LSN) possibly within 4 hours and 30 minutes and who had no definite tPA exclusions per guidelines, prior to CT scan or baseline labs. Daytime hours and mostly weekdays. Intervention: Care by a mobile stroke unit (MSU) Comparison: Care by traditional EMS referred to as standard management (SM) Outcome: Primary Outcome: Score on the utility-weighted modified Rankin scale (uw-mRS) at 90 days in patients who were adjudicated to be eligible to receive tPA on the basis of subsequent blinded review Secondary Outcomes: There were twelve secondary endpoints in their final protocol listed in hierarchical sequence of importance Agreement between on-board vascular neurologists (VN) and the remote VN Exploratory cost-effectiveness analysis (CEA) Outcomes comparing patients found eligible for tPA on MSU weeks compared to patients on SM weeks Ordinal (shift) analysis of mRS at 90 days, and Proportion of patients achieving 90 day mRS 0,1 vs 2-6 30% improvement from baseline to 24hr NIHSS Outcomes comparing all patients treated with tPA (whether or not adjudicated as tPA eligible) on MSU weeks compared to patients on SM weeks. Uw-mRS at 90 days Ordinal (shift) analysis of mRS at 90 days, and Proportion of patients achieving 90 day mRS 0,1 vs 2-630% Improvement from baseline to 24hr NIHSS Outcomes of those treated within 60 min LSN compared to those treated from 61 to 270 minutes Change in uw-mRS from baseline at 90 days Ordinal shift analysis of MRS at 90 days Proportion of patients achieving 90 day mRS 0,1 vs 2-6 30% improvement from baseline to 24hr NIHSS Outcomes all patients treated with IAT (separate analyses for those adjudicated as tPA eligible, all tPA treated, or all IAT with or without tPA) on MSU weeks compared to patients on SM weeks. Uw-mRS at 90 days Ordinal (shift) analysis of mRS at 90 days, and Proportion of patients achieving 90 day mRS 0,1 vs 2-6 30% improvement from baseline to 24hr NIHSS The time from LSN to tPA treatment on all patients treated within 4.5 hours of LSN on MSU weeks compared to similarly eligible patients on SM weeks Proportion of patients treated within 60 minutes of LSN on MSU weeks vs SM weeks. The time from LSN and from ED arrival to start of endovascular procedure on MSU vs SM weeks Proportion of all tPA-eligible patients having EVT on MSU vs SM weeks The median/mean time from LSN to tPA therapy decision on all patients considered for treatment within 4.5 hours of LSN on MSU weeks compared to SM weeks Time between 911 call and onset of etiology-specific BP management on MSU vs SM weeks. Safety Endpoints: Incidence of symptomatic intracranial hemorrhage (sICH) in enrolled tPA treated patients on MSU weeks

Date: December 21st, 2021 Guest Skeptic: Dr. Spencer Greaves is an Emergency Medicine resident at Florida Atlantic University. He received his Bachelors in Biomedical Engineering from Marquette University and his Masters in Public Health from Dartmouth College. Spencer completed his medical doctorate at the Medical College of Wisconsin. He and his wife live in Boynton Beach, FL where they recently celebrated the birth of their first child. Disclaimer: "While I am proud to be attending this institution, my opinions expressed here are mine alone and do not represent my residency program, hospitals I work at, or any other affiliated organizations." Reference: Vallentin et al. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest - A Randomized Clinical Trial. JAMA 2021 This was an SGEM Journal Club and all the slides from the presentation can be downloaded using this LINK. As a reminder, here are the five rules for SGEM JC. Case: An EMS crew arrives at the home of a 68-year-old suffering from a witnessed out-of-hospital cardiac arrest (OHCA). They have a history of hypertension, elevated cholesterol, and smoked cigarettes for 50+ years. Bystander CPR is being performed. The monitor is hooked up. The paramedics performed high-quality CPR and follow their ACLS protocol. Intraosseous access is quickly obtained, and a dose of epinephrine is provided. CPR is continued while a supraglottic airway is placed successfully. The patient is transported to the emergency department with vital signs absent (VSA). Background: We have covered adult OHCA multiple times on the SGEM. This has included the following issues: Calcium has a theoretical benefit on patients with cardiac arrest as it has inotropic and vasopressor effects. Previous small, randomized control trials (RCTs) have shown no superiority to calcium for return of spontaneous circulation (ROSC). However, the point estimated did favor calcium. Clinical Question: Does administration of calcium during out-of-hospital cardiac arrest improve sustained return of spontaneous circulation? Reference: Vallentin et al. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest - A Randomized Clinical Trial. JAMA 2021 Population: Adults 18 years of age and older with OHCA in the central Denmark region from January 2020 to April 2021 who received at least one dose of epinephrine Exclusions: Traumatic cardiac arrest, known or strongly suspected pregnancy, prior enrollment in the trial, receipt of epinephrine outside the trial, or a clinical indication for calcium administration during the cardiac arrest. Intervention: Calcium chloride 5 mmol given IV or IO immediately after first dose of ACLS epinephrine up to two doses Comparison: Saline placebo given IV or IO immediately after first dose of ACLS epinephrine up to two doses Outcome: Primary Outcome: Sustained ROSC defined as no further need for chest compressions for at least 20 minutes Secondary Outcomes: Survival, favorable neurological outcome, and quality of life assessment at 30 and 90 days Trial: Double-blind, placebo-controlled, parallel group, superiority, randomized clinical trial Authors’ Conclusions: “Among adults with out-of-hospital cardiac arrest, treatment with intravenous or intraosseous calcium compared with saline did not significantly improve sustained return of spontaneous circulation. These results do not support the administration of calcium during out-of-hospital cardiac arrest in adults.” 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). Yes 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. Yes Results: There were 1,221 OHCAs during the trial period. They excluded 824 for a variety of reasons with the most common reason (69%) because they did not receive any epinephrine. The mean age was 68 years, 71% male, more than 80% arrested at home, 85% received bystander CPR and half were in asystole. Key Result: No statistical difference in ROSC Primary Outcome: ROSC 19% in the calcium group vs 27% in the saline group Risk ratio (RR) 0.72 (95% CI; 0.49 to 1.03) Risk Difference, −7.6% (95% CI; −16% to

Date: December 13th, 2021 Reference: Lee et al. Addressing gender inequities: Creation of a multi-institutional consortium of women physicians in academic emergency medicine. AEM December 2021 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com Case: At the completion of her 1-month elective in your rural emergency department (ED), you are discussing career plans with a medical student. She says that she is very interested in emergency medicine, but she isn’t sure if it is the right choice for her. She has worked in five EDs so far, and a man has filled almost every leadership position. She also just got back from an emergency medicine conference, and more than 90% of the speakers were white males. She loves the clinical work in emergency medicine, but she is worried that these apparent gender inequities will limit her career opportunities. Background: Gender equity is something we have spoken about often on the SGEM. Some listeners are happy we cover this topic while others have expressed concern. We recognize this can be an emotional issue. Our position is gender inequity exists in the house of medicine and it should be an issue everyone is interested in addressing. Here are some of the previous SGEM episodes that discussed gender equity: SGEM Xtra: From EBM to FBM – Gender Equity in the House of Medicine SGEM Xtra: Unbreak My Heart – Women and Cardiovascular Disease SGEM#248: She Works Hard for the Money – Time’s Up in Healthcare SGEM Xtra: Money, Money, Money It’s A Rich Man’s World – In the House of Medicine SGEM Xtra: I’m in a FIX State of Mind It is hard to believe some people deny the significant gender inequities that currently exist in medicine. Women are under-represented in leadership positions [1-3]. Women are less likely to be given senior academic promotions [4]. There are fewer women in editor positions in our academic journals [5]. Women receive less grant funding [6-7]. Women are paid less than men, even after accounting for potential confounders [2, 8-10]. Yet a recent twitter poll had more than 1/3 of respondents saying they did not think a physician gender pay gap existed in their emergency department. It is hard to move forward and address a problem when a significant portion of physicians do not even recognize that there is a problem. The literature describes many factors that contribute to gender inequity. Institutional policies related to promotion or advancement may inherently disadvantage women and are likely exacerbated by implicit bias and stereotyping. There are an insufficient number of women in current leadership positions, resulting in fewer mentors and role models for women earlier in their career. Policies around parental leave, emergency child-care, and breast-feeding support affect women disproportionately. Unfortunately, sexual harassment is also still widely documented in emergency medicine and has a major impact on career advancement and attrition [11-13]. The reasons for the gender gap are complex, and likely not completely understood. Existing gender balance within specialties, among other aspects of the "hidden curriculum", likely influence career decisions, with women trainees more likely to enter lower paying specialties. Current leadership positions are dominated by males, who may consciously or not be more supportive of other males for future promotions. Furthermore, there are numerous gender differences, both internal and external, that influence salary expectations and negotiations [14]. Female physicians are more likely to have female patients, and medical pay structures are often inherently biased. For example, in Ontario, where we both work, a biopsy of the penis pays almost 50% more than a biopsy of the vulva. Similarly, incision and drainage of a scrotal abscess pays twice as much as incision and drainage of a vulvar abscess [14]. There is data that suggests that practice patterns vary between women and men. Women in primary care are more likely to address multiple issues during a single appointment. They are more likely to provide emotional support and address psychosocial issues, and less likely to perform procedures. Although these are features most of us would want in a physician, unfortunately they result in lower remuneration in more medical payment models [14]. And of course, all of this occurs in the larger societal context in which women perform far more unpaid labour outside of medicine, resulting in much larger overall workloads, most of which is often overlooked. For a wonderful book on the topic, considering reading Invisible Women by Caroline Criado Perez. Too often, women are blamed for the gender pay gap. It is true that women, on average, work fewer hours, and are more likely to work part time. However, this difference in work is not enough alone to explain the pay gap. For example, one study found that women earned 36% less than their male colleagues, desp

Date: December 10th, 2021 Guest Skeptic: Dr. Carly Eastin is an Associate Professor, Division of Research and Evidence Based Medicine, Department of Emergency Medicine, University of Arkansas for Medical Sciences. She is also the Chair of the SAEM Evidence Based Healthcare and Implementation (EBHI) Interest Group. Carly was a guest skeptic on the SGEM two years ago. That was in the BC Times- (Before Covid). We had the pleasure of recording a live episode of the SGEM at the University of Arkansas. Back in 2019 we were talking about Vitamin C for sepsis (SGEM#268). SGEM Bottom Line: “There is not enough evidence to support the routine use of vitamin C in critically ill patients.” Not much has changed over the last two years. There have been at least two randomized control trials published that do not support the use of Vitamin C in sepsis. Fujii et al (VITAMINS RCT) JAMA 2020: n=216 patients with septic shock. No statistical difference in their primary outcome for duration of time alive and free of vasopressor administration up to day 7 or the secondary outcome of 90-day mortality. Moskowits et al (ACTS RCT) JAMA 2020: n=205 patients with septic shock. no statistical difference in primary outcome of SOFA scores at 72 hours or the secondary outcome of 30-day mortality. It was Dr. Paul Marik who has been a big advocate for Vitamin C sepsis. We did an SGEM episode on his before-after study (SGEM#174: Don’t Believe the Hype) with a dozen skeptics expressing their concern the results were too good to be true. Dr. Marik has also been promoting the use of Vitamin C for COVID19. However, there is insufficient evidence to support the routine use of Vitamin C in the treatment of critically ill or non-critically ill COVID19 patients (NIH COVID19 Treatment Guidelines and Thomas et al JAMA 2021). There is also no high-quality evidence that Vitamin C can prevent COVID19. There is a Phase II interventional randomized placebo-controlled trial testing whether treatment with Vitamin C can prevent symptoms of COVID19 (ClinicalTrials.gov). This SGEM Xtra episode is not to talk about Vitamin C, COVID19 or even do a structured critical appraisal of a recent publication. This is an SGEM Xtra episode to pay tribute to a friend and champion of the EBM community, Dr. Rakesh Engineer. Dr. Rakesh Engineer Rakesh died suddenly in 2019 and the Society of Academic Emergency Medicine (SAEM) reflected upon how best to honour him. SAEM decided to name an award after Rakesh, focusing on his passion for implementation science. Dr. Chris Carpenter knew Rakesh well and was asked to give a brief introduction to those who did not know him. You can listen to his introduction at this LINK. Chris Carpenter: "[Rakesh] was a devoted husband and dedicated father to three sons. He was born in Cleveland, Ohio and attended Ohio State University where he earned both his Bachelors and MD. After his internship at Barnes Jewish Hospital at Washington University St. Louis. He trained in Emergency Medicine at Spectrum Health in Grand Rapid Michigan. After that, he joined the Cleveland Clinic to be with his family, to educate the next generation of emergency physicians and launch his own clinical research career. Rakesh's vision epitomized implementation science, in which knowing is not enough: we must apply. As an emergency medicine clnical researcher, Rakesh thrived at the interface between published evidence and pragmatic application at the bedside. He was a friend and I miss him dearly." Carly: "I did not have the privilege of knowing Rakesh personally very well, but was following him because I was a member of the SAEM Evidence-Based Healthcare and Implementation group when he was active and I was still trying to find my way in the EBM world. He was such a good speaker and was really funny. I also remember that it was Rakesh that gave me my first real understanding of implementation science, and I’ve been hooked ever since." Ken: "I remember running into Rakesh at an SAEM meeting in Indiana. To be more accurate, he almost ran into Chris and me outside the hotel. We were heading out to get something to eat or something and Rakesh pulled up in a big sedan. I want to remember that it was a convertible. We pretended to be almost run over by him. Rakesh quickly jumped out of the car, usual big smile on his face and we had a quick nerdy chat. That is the last memory I have of Rakesh. Chris sent me a goofy picture of Rakesh". Carly: "It’s hard to look at that picture without smiling. I can’t tell you how many stories just like yours I’ve heard about his laughter and fun personality. He was clearly highly respected and loved by many." Rakesh published a lot of peer reviewed articles during his career. This included biomarkers, gun safety and diagnostic imaging studies. Rakesh had just been elected Chair of the Evidence Based Healthcare and Implementation (EBHI) Interest Group for SAEM. He had been an active member of the in

Date: November 16th, 2021 Reference: Hammouda et al. Moving the Needle on Fall Prevention: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement. AEM November 2021 Guest Skeptic: Dr. Kirsty Challen (@KirstyChallen) is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). 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 is also the creator of the wonderful infographics called #PaperinaPic. Case: Mid-shift, you realise that the next patient you are about to see is the third in a row aged over 70 who has fallen at home, and that this is her third attendance for a fall in the last two months. You wonder if any emergency department (ED)-based interventions would help her and people like her be safe. Background: We looked at geriatric falls on an SGEM Xtra in 2015. Back then we found that at one academic site older adults attending ED with falls didn't receive guideline-based assessment, risk stratification or management. Dr. Chris Carpenter In 2014 the SGEM looked at a systematic review by Dr. Chris Carpenter, which concluded that there wasn't a good tool to help us predict which ED patients are at risk of recurrent falls (SGEM #89). Close to three million adults aged 65 and over visit American EDs annually after a fall [1]. Falling is the most common cause of traumatic injury resulting in older adults presenting to the ED [2]. Approximately 20% of falls result in injuries, and falls are the leading cause of traumatic mortality in this age group [3-5]. The SAEM Geriatric Emergency Medicine Task Force recognized fall prevention as a priority over 10 years ago. There is the Geriatric Emergency care Applied Research (GEAR) network, which is trying to improve the emergency care of older adults and those with dementia and other cognitive impairments. GEAR looks to identify research gaps in geriatric emergency care support research and evaluation of these areas. GEAR 2.0 has recently been launched with funding opportunity in conjunction with EMF. There are three other GEAR 1.0 manuscripts which have been published: Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings AEM 2020 Care Transitions and Social Needs AEM 2021 Research Priorities for Elder Abuse Screening and Intervention J Elder Abuse Negl 2021 Clinical Question: In older patients presenting to ED with falls do risk stratification or fall prevention interventions influence patient-centered or operational outcomes? Reference: Hammouda et al. Moving the Needle on Fall Prevention: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement. AEM November 2021 This publication presents two related but different scoping reviews so there are two PICOs. PICO #1 Population: Systematic search that found 32 studies of fall prevention interventions for patients aged 60 or over who presented to ED with a fall. Exclusions: Abstracts repeating data already included in full, not original research. Intervention: Fall prevention interventions including multifactorial risk reduction, medication review, exercise training, models of care like Hospital-at-Home. Comparison: Standard of Care. Outcomes: Quality of care ED metrics, ED operational outcomes like length of stay, patient-centered outcomes like ED returns, further falls, fear of falling, functional decline, institutionalization. PICO #2 Population: Systematic search that found 17 studies of risk stratification and falls care plans in patients aged 60 or over in ED or pre-ED settings. Exclusions: As review 1. Intervention: Risk stratification and falls care plan. Comparison: No risk stratification and falls care plan. Outcomes: ED referral (from pre-ED setting), quality of care ED metrics, ED operational outcomes, patient-centered outcomes. This is an SGEMHOP episode which means we have the honour of having the lead author, Dr. Elizabeth (Liz) Goldberg, on the show. She is an Associate Professor of Emergency Medicine and Health Services, Policy and Practice at Brown University. Her specific areas of interest include improving care for older adults and public health interventions to enhance longevity and healthy aging. Dr. Elizabeth Goldberg Authors’ Conclusions: “Harmonizing definitions, research methods, and outcomes is needed for direct comparison of studies. The need to identify ED-appropriate fall risk assessment tools and role of emergency medical services (EMS) personnel persists. Multifactorial interventions, especially involving exercise, are more efficacious in reducing recurrent falls, but more studies are needed to compare appropriate bundle combinations. GEAR prioritizes five research priorities: (1) EMS role in improving fall-related outcomes, (2) identifying optimal ED fall assessment tools, (3) clarifying p

Date: November 10th, 2021 Reference: Andersen, et al: Effect of Vasopressin and Methylprednisolone vs Placebo on Return of Spontaneous Circulation in Patients With In-Hospital Cardiac Arrest. JAMA Sept 2021. Guest Skeptic: Dr. Neil Dasgupta is an emergency physician and ED intensivist from Long Island, NY, and currently an assistant clinical professor and Director of Emergency Critical Care at Nassau University Medical Center. Case: A code blue is called for a 71-year-old male in-patient that is boarding in the emergency department (ED). He had been admitted the night before for a new diagnosis of rapid atrial fibrillation. He has a history of hypertension, dyslipidemia, and type-2 diabetes. His medications include a beta-blocker, statin, angiotensin converting enzyme inhibitor (ACE-I), metformin, ASA and direct oral anticoagulant (DOAC). You arrive and see that the Advanced Cardiac Life Support (ACLS) algorithm is being followed for adult cardiac arrest patients with pulseless electrical activity (PEA). Cardiopulmonary resuscitation (CPR) is in progress. The monitor shows a non-shockable rhythm. Epinephrine is provided and you quickly place an advanced airway. A second dose of epinephrine is given, and you start to think about reversible causes and your next steps for in-hospital cardiac arrests (IHCA). SGEM#50: Under Pressure Background: We have looked an IHCA a couple of times on the SGEM. The first time we looked at this issue on (SGEM#50). This was also the first SGEM JC done where Dr. William Osler started the Journal Club initiative at McGill University. We reviewed a randomized, double-blind, placebo-controlled, parallel-group trial done in three Greek tertiary hospitals. This trial (n=268) reported increased return of spontaneous circulation (ROSC) and increased survival to hospital discharge with good neurologic function with a vasopressin, steroids, and epinephrine (VSE) protocol compared to epinephrine alone. We felt this was interesting but would need to be validated/replicated before changing our IHCA protocols. Corticosteroids have been suggested as a possible therapy in these cardiac arrest situations. A SRMA published in 2020 on the use of steroids after cardiac arrest reported an increase in ROSC and survival to discharge but was limited by the availability of adequately powered high-quality RCTs (Liu et al JIMR 2020). We covered another SRMA that was published in 2021 looking at the same issue of whether the use of corticosteroids impact neurologic outcomes and mortality in patients with a cardiac arrest (SGEM#329)? These authors reported a statistical increase in good neurologic outcome and survival to hospital discharge with steroids but not survival at one year or longer. This study provided weak evidence in support of using corticosteroids for IHCA as part of a VSE protocol. Answering clinical questions about cardiac arrest with clinical trials has always been fraught with difficulty. However, cardiac arrest is something we regularly treat in the emergency department, and we need more high-quality data to inform our care. Vasopressin had been included as a part of the American Heart Association (AHA) ACLS protocol for quite a while but was removed in favor of a vasopressor monotherapy strategy with epinephrine. The tide now is shifting in resuscitation research to shift our focus from obtaining ROSC to measuring functionality and good neurologic outcomes. In the context of questioning epinephrine’s role in ACLS after Paramedic2, we look at using the VSE protocol in cardiac arrest. Clinical Question: Does adding a combination of vasopressin and methylprednisolone increase the chance of achieving ROSC in cardiac arrest? Reference: Andersen, et al: Effect of Vasopressin and Methylprednisolone vs Placebo on Return of Spontaneous Circulation in Patients With In-Hospital Cardiac Arrest. JAMA Sept 2021. Population: Adult patients 18 years of age and older with an in-hospital cardiac arrest. Excluded: Out-of-hospital cardiac arrest (OHCA), valid do-not-resuscitate order, invasive mechanical circulatory support and known or suspected pregnancy at the time of the cardiac arrest. Intervention: Vasopressin 20 IU and methylprednisolone 40 mg given as soon as possible after first dose of epinephrine, followed by vasopressin 20 IU after each epinephrine up to four doses. Comparison: Placebo of normal saline Outcome: Primary Outcome: ROSC defined as no further need of chest compressions for at least 20 minutes Secondary Outcomes: 30-day survival and 30-day survival with favorable neurologic outcome (defined as a Cerebral Performance Category of 1 or 2) Trial Design: Multicenter, single nation, multicenter, randomized, placebo-controlled, parallel group, double-blind, superiority trial Authors’ Conclusions: “Among patients with in-hospital cardiac arrest, administration of vasopressin and methylprednisolone, compared with placebo, significantly increased the likelihood of return of spontaneous circula

Date: November 1st, 2021 Reference: Katsanos et al. Utility of Intravenous Alteplase Prior to Endovascular Stroke Treatment: A Systematic Review and Meta-analysis of RCTs. Neurology 2021 Guest Skeptic: Dr. Michal Krawczyk is in his fifth year of neurology residency at Western University in London, Ontario, Canada. He is interested in acute neurological illness, including cerebrovascular disease and epilepsy. Next year he will be beginning a Neurohospitalist fellowship at the University of Texas at Houston. Case: A 70-year-old male with a past medical history of hypertension and peripheral artery disease, last seen normal 1.5 hours ago, presenting with acute onset of aphasia and right sided face and arm weakness. He has a National Institute of Health Stroke Scale (NIHSS) score of 7. At 1am a CT angiogram is obtained that demonstrated a left M2 occlusion, and an Alberta Stroke Program Early CT Score (ASPECTS) of 10. Given the recent publications of trials assessing if mechanical thrombectomy alone is non-inferior to a bridging approach with tPA in addition to mechanical thrombectomy, you wonder whether these trials apply to your patient and what is the best course of action. Background: There are two treatments for acute ischemic stroke, systemic tPA and mechanical thrombectomy (MT). We have covered some studies looking at both treatment modalities on the SGEM. SGEM#29: Stroke Me, Stroke Me SGEM#70: The Secret of NINDS (Thrombolysis for Acute Stroke) SGEM#85: Won’t Get Fooled Again (tPA for AIS) 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? Mechanical thrombectomy is indicated only for patients with large vessel occlusions (LVOs) on imaging. There were a few earlier studies on MT that failed to demonstrate superiority, but it was the study MR CLEAN published in NEJM 2015 that really changed practice. It was a multicenter, randomized, unblinded trial treating 500 patients with an anterior circulation LVO within six hours of symptom onset. The primary outcome was mRS 0-2 at 90 days and it showed an absolute difference of 14% favoring MT. This gives a NNT of 7. Six RCTs have been published since MR CLEAN. All supported MT and all were stopped early (SWIFT PRIME, EXTEND-IA, REVASCAT, ESCAPE, DAWN, and DEFUSE). For patients with LVOs it is unclear whether there is any additional benefit with administering tPA before thrombectomy, also known as a bridging approach, in contrast to skipping tPA and directly proceeding with MT. There are several theoretical advantages of a bridging approach. These potential advantages include thrombus debulking allowing easier clot retrieval, distal emboli lysis, recanalization prior to MT, and it may be beneficial in cases of unsuccessful MT. Conversely, a direct to MT approach may lead to fewer intracerebral hemorrhages (ICH) and quicker initiation of endovascular thrombectomy. Recently, three randomized control non-inferior trials on this topic have been published, two from China (DIRECT-MT, and DEVT) and one from Japan (SKIP). Two trials demonstrated non-inferiority while one trial failed to show that direct MT was non-inferior. Clinical Question: What is the best strategy for treating patients with an acute large vessel occlusion stroke, direct to mechanical thrombectomy or a bridging approach with tPa followed by mechanical thrombectomy? Reference: Katsanos et al. Utility of Intravenous Alteplase Prior to Endovascular Stroke Treatment: A Systematic Review and Meta-analysis of RCTs. Neurology 2021 Population: Randomized controlled trials of patients with acute large vessel occlusion stroke qualifying for MT Exclusions: Observational studies and non-randomized trials Intervention: MT alone Comparison: MT bridged with tPA Outcome: Primary Outcome: mRS score 0-2 at three months Secondary Outcomes: mRS 0-1 and ordinal shift at three months, successful recanalization before MT, successful recanalization after MT, randomization to puncture time, symptomatic intracranial hemorrhage (sICH), any ICH and all-cause mortality Authors’ Conclusions: “We detected no differences in functional outcomes of IV thrombolysis–eligible patients with an acute LVO receiving dEVT compared to BT. Because uncertainty for most endpoints remainslarge and the available data are not able to exclude the possibility of overall benefit or harm, further RCTs are needed.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes The search for studies was detailed and exhaustive. Yes The primary studies were of high methodological quality. No The assessment of studies were reproducible. Yes The outcomes were clinically relevant. Yes There was low statistical heterogeneity for the primary outcomes. Yes The treatment

Date: October 20th, 2021 Reference: Talan et al. Pathway with single-dose long-acting intravenous antibiotic reduces emergency department hospitalizations of patients with skin infections. AEM October 2021 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 research methodology editor for Annals of Emergency Medicine. Lauren also recently won the SAEM FOAMed Excellence in Education Award. Case: A 46-year-old male with a history of diabetes controlled on metformin presents with erythema and warmth to his right lower leg measuring 27 cm by 10 cm for the past four days. The patient is neurovascularly intact and there is no evidence of deep vein thrombosis (DVT) on ultrasound. He has no fever, and his white blood cell count is 12,500. Background: Emergency department visits for skin and soft tissue infections (SSTI) are common and increasing [1]. These types of infections include cellulitis and abscesses. The SGEM has a couple of episodes on the treatment of cellulitis with antibiotics (SGEM#131 and SGEM#209). The treatment of abscesses has been covered a few more times on the SGEM (SGEM#13, SGEM#156, SGEM#164 and SGEM#311). The latest episode looked at the loop technique to drain uncomplicated abscesses. The result was no statistical difference in failure rates between the loop and standard packing. Our conclusion was to consider using the loop technique on your next uncomplicated abscess. Most patients can be managed as outpatients. However, the average length of stay for inpatient care is one week and costs close to $5 billion dollars a year in the USA [2]. The mortality rate for hospitalized patients with SSTI is <0.05% [3, 4]. The only reason for in-patient management in 40% of patients was to provide parenteral antibiotics [5]. This has led to greater interest in long-acting parenteral antibiotics as a possible alternative to admission. Clinical Question: Does the use of a clinical pathway, including a dose of intravenous dalbavancin, in emergency department patients with skin and soft tissue infections reduce hospitalizations? Reference: Talan et al. Pathway with single-dose long-acting intravenous antibiotic reduces emergency department hospitalizations of patients with skin infections. AEM October 2021 Population: Patients ≥18 years old with abscess, cellulitis, or wound infection believed or confirmed to be due to gram-positive bacteria and an area of infection of at least 75 cm2. Excluded: Unstable comorbidity (e.g. severe sepsis), immunosuppression, injection drug use and fever, pregnancy, breastfeeding, bilateral lower extremity involvement, severe neurologic disorder, allergy to glycopeptide antibiotics, suspected gram negative infection or infection likely to need more intensive care or broad spectrum antibiotics, suspected osteomyelitis, septic arthritis, or endocarditis. Intervention: Clinical pathway included a single dose of intravenous (IV) dalbavancin 1500 mg (creatinine clearance ≥30 mL/min) or 1,125 mg for creatinine clearance <30 mL/min not on dialysis Telephone follow up call 24 hours after the visit and a follow up appointment 48-72 hours after discharge Comparison: Usual care pre-implementation of the new clinical pathway Outcome: Primary Outcome: Hospitalization rate at the time of initial care in the population that received at least one antibiotic dose Secondary Outcomes: Hospitalizations through 44 days, health resource utilization (length of stay, level of care, major surgical interventions, ICU admissions), adverse events, and patient-related outcomes (satisfaction, work productivity, and quality of life surveys at 14 days) Trial Design: Before-and-after observational study at eleven US academic affiliated emergency departments (EDs). Dr. David Talan This is an SGEMHOP episode which means we have the lead author on the show. Dr. Talan is considered an authority in acute infections that result in severe morbidity and death. He is currently on the faculty of the Department of Emergency Medicine, and Department of Medicine, Division of Infectious Diseases at UCLA Medical Center. Dr. Talan also serves on the editorial board of the Annals of Emergency Medicine. Authors’ Conclusions: “Implementation of an ED SSTI clinical pathway for patient selection and follow-up that included use of a single-dose, long-acting IV antibiotic was associated with a significant reduction in hospitalization rate for stable patients with moderately severe infections.” 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 o

Date: October 7th, 2021 This is an SGEM Xtra episode. I had the honour of co-presenting at the Renaissance School of Medicine, Stony Brook University, Department of Emergency Medicine Grand Rounds. The title of the talk "From EBM to FBM - Gender Equity in the House of Medicine. You may be wondering: why is a middle aged, white, heterosexual, cis gender, male, atheist, nerd co-presenting on gender equity in the house of medicine? "And isn’t it ironic, don't you think? A little too ironic. And, yeah, I really do think". According to Sir Patrick Steward (Captain Jean-Luc Picard from Star Trek), “People won’t listen to you or take you seriously unless you’re an old white man, and since I’m an old white man I’m going to use that to help the people who need it” My co-presenter was Dr. Suchismita Datta. She is an Assistant Professor in the Department of Emergency Medicine and GME Diversity Leader for the NYU Long Island School of Medicine. The presentation is available to listen to on iTunes and GooglePlay and all the slides can be downloaded using this LINK. Three Objectives Recognize gender inequity in medicine Identify gender inequities in each of the three pillars of of evidence-based medicine (EBM) Understand how gender inequities can impact the cardiovascular care of women Dr. Datta's Journey Dr. Datta Dr. Datta shares her personal journey from medical school to attending physician and discusses the challenges she faced along the way. She and her husband Neil met at medical school. They both matched to the same emergency medicine (EM) program. After graduation they began working at a high-volume, high-acuity critical access hospital. After a few years they moved back to New York. Dr. Datta describes her unpaid and paid maternity leave, difficulties in pumping breast milk while on shift and the pay gap she experienced. Gender Inequities Using the EBM Model There are three pillars of EBM. The literature should inform care, guide care but it should not dictate care. Clinicians must also use their good clinical judgment in applying the literature. We also need to ask patients about what they value and prefer. This can be summarized into a Venn diagram capturing the Dr. Sackett's definition of EBM. The Medical Literature: Who gets most of the grant money in medicine? Men Who rises to the top academic positions at universities? Men Who rises to the top academic positions in medicine? Men Who rises to the top academic positions in Emergency Medicine? Men Who is most likely to be the first author on a medical publication? Men Who is most likely the first author on a emergency medicine publication? Men Who is most likely to be the first author on a Pediatric Emergency Medicine (PEM) Paper? Men Who are often excluded from being subjects in medical research? Women The Clinicians: Who historically has been the clinician in the room? Men Who is most likely to rises to top leadership positions within the hospital structure? Men Who gets paid more in medicine? Men Who gets paid more in academic medicine? Men Who gets paid more in academic Emergency medicine? Men Who is more likely to be introduced with their professional title at grand rounds? Men Who get's paid more in Ontario, Canada? Men What can be done about the gender pay gap? CMAJ 2020 The Patients: Who traditionally was more likely to access health care? Women Who is typically responsible for most family health care needs? Women Who has been systemically under-treated when it comes to painful conditions? Women Who are provided less care for life threatening illnesses like STEMIs? Women Cardiovascular Disease in Women Gender biases and inequities can seriously impact our clinical management. Cardiovascular disease in women is understudied, women are underrepresented in clinical trials, CVD is under recognized in women, they are being under diagnosed and under treated. This is associated with women having worse outcomes compared to men for this clinical situation. Women presenting with without the classic chest pain during coronary syndrome were less likely to receive timely therapies. This included less fibrinolytics and less primary percutaneous intervention (Canto et al JAMA 2012 and Rogers et al Circulation 2012) Women get the same benefit from PCI but have been shown to have more experience periprocedural complications (Alexander et al Circulation 2006, Regitz-Zagrosek et al Our Heart J 2011 and Dey et al Heart 2009) Women with atypical presentations were also less likely to receive aspirin, other antiplatelet agents, heparin, and beta-blocker therapies during their hospitalization (Canto et al JAMA 2012 and Rogers et al Circulation 2012) Women had a 4% absolute higher in-hospital mortality after presentation with ACS when compared to men (Canto et al JAMA 2012) Women and cardiovascular disease Commission: reducing the global burden by 2030 (Vogel et al Lancet 2021) Conclusion We hope that Dr. Datta's personal journey help

Date: September 28th, 2021 Reference: Zampieri et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA 2021 Guest Skeptic: Dr. Aaron Skolnik is an Assistant Professor of Emergency Medicine at the Mayo Clinic Alix School of Medicine and Consultant in the Department of Critical Care Medicine at Mayo Clinic Arizona. Board certified in Emergency Medicine, Medical Toxicology, Addiction Medicine, Internal Medicine-Critical Care, and Neurocritical Care, Aaron practices full time as a multidisciplinary intensivist. He is the Medical Director of Respiratory Care for Mayo Clinic Arizona and serves proudly as the medical student clerkship director for critical care medicine. Case: A 66-year-old woman is brought in by EMS from home with lethargy and hypotension. Chest x-ray is clear, labs are remarkable for a leukocytosis of 16,000 with left shift; exam is notable for left flank pain and costovertebral tenderness. Straight catheter urinalysis is grossly cloudy, and pyuria is present on microscopy. Blood pressure is 85/50 mm Hg. You wonder which intravenous (IV) fluid should you order? Background: In ten seasons of the SGEM we have not covered the issue of which IV solution is the best in critical ill patients. That includes both trauma patients and septic patients. The controversy has been long standing with the standard joke being that there is nothing “normal” about normal saline. Saline is a hypertonic acidotic fluid. Many critically ill patients receive intravenous crystalloids for volume expansion as part of their resuscitation. Some bench work, observational studies, and now two large, unblinded, cluster-randomized single-center trials (SMART and SALT-ED) suggested a benefit to using balanced crystalloids (i.e. Lactated Ringer’s or Plasmalyte 148) over 0.9% saline. In the two large trials, this benefit was seen as a reduction in a composite outcome of major adverse kidney events within 30 days (MAKE-30). In the non-blinded SMART trial, there was no statistical difference in the individual components of the composite outcome (in-hospital death before 30 days, new renal replacement therapy or in creatinine >200% of baseline). The SALT-ED trial was also a single-centre unblinded trial, but the primary outcome was hospital free days. They reported no statistical difference between the two groups. Their secondary composite outcome of death, new renal-replacement therapy, or final serum creatinine >200% of baseline, was statistically better with balanced crystalloid vs saline. However, there was not a statistical difference in any of the individual components of the composite outcome. The BaSICS trial attempts to answer whether balanced solutions are superior to saline using a large, double-blind, factorial, multi-center randomized trial. Clinical Question: Does administration of a balanced solution (Plasma-Lyte 148) during intensive care unit (ICU) stay, compared with saline solution, result in improved 90-day survival in critically ill patients? Reference: Zampieri et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA 2021 Population: Adult patients admitted the ICU for more than 24 hours, needing at least one fluid expansion and with at least one risk factor for acute kidney injury (age over 65, hypotension, sepsis, required mechanical ventilation or non-invasive ventilation, oliguria or increased serum creatinine level, cirrhosis or acute liver failure) Exclusions: Required or expected to require renal replacement therapy within 6 hours of admission, severe electrolyte disturbances (sodium < 120 mmol/L or > 160 mmol/L), death considered imminent within 24 hours, suspected or confirmed brain death, palliative or comfort care only or patients previously enrolled in the trial. During the study, hyperkalemia (K+ > 5.5 mEq/L) was removed as an exclusion criteria, after the second interim analysis. Intervention: Plasmalyte 148 solution at either slow (333 mL/hr) or fast (999 mL/hr) infusion rate. Comparison: 0.9% sodium chloride solution at either slow (333 mL/hr) or fast (999 mL/hr) infusion rate. Outcomes: Primary Outcome: 90-day survival Secondary Outcomes: Need for renal replacement therapy up to 90 days after enrollment, occurrence of acute kidney injury, for patients without acute kidney injury at enrollment, SOFA score and, number of days not requiring mechanical ventilation within 28 days Trial Design: Double-blind, factorial, randomized clinical trial conducted at 75 ICUs in Brazil. Authors’ Conclusions: “Among critically ill patients requiring fluid challenges, use of a balanced solution compared with 0.9% saline solution did not significantly reduce 90-day mortality. The findings do not support the use of this balanced solution.” Quality Checklist for Ra

Date: September 20th, 2021 Reference: Litell et al. Most emergency department patients meeting sepsis criteria are not diagnosed with sepsis at discharge. AEM 2021. Guest Skeptic: Dr. Jess Monas is a Consultant in the Department of Emergency Medicine at the Mayo Clinic Hospital, Phoenix, Arizona. She is also an Assistant Professor, Department of Emergency Medicine Mayo Clinic Alix School of Medicine in Scottsdale, Arizona. Jess also does the ultra summaries for EMRAP. Case: A 60-year-old man presents to the emergency department with a non-productive cough and increasing shortness of breath. He has a history of chronic obstructive pulmonary disease (COPD), hypertension (HTN), congestive heart failure (CHF), and benign prostatic hypertrophy (BPH). He’s afebrile. He has a heart rate of 93 beats per minute, a blood pressure of 145/90 mm Hg, respiratory rate of 24 breaths per minute, and an oxygen saturation of 92% on room air. Initial labs come back with a slightly decreased platelet count (149) and a minimally elevated creatinine (1.21 mg/dl or 107 umol/L). He triggers a sepsis alert, and you get a pop-up suggesting IV antibiotics and 30cc/kg of IV fluids. So, you ask yourself, is this guy really septic and should we bypass those fluids? Background: We have covered sepsis many times on the SGEM since 2012. This has included the three large RCTs published in 2014-15 comparing early goal-directed therapy (EGDT) to usual care. All three showed no statistical difference between the two treatments for their primary outcome (SGEM#69, SGEM#92 and SGEM#113). There was also SGEM#174 which said don’t believe the hype around a Vitamin C Cocktail that was being promoted as a cure for sepsis and SGEM#207 which showed prehospital administration of IV antibiotics did improve time to get them in patients with suspected sepsis, but did not improve all-cause mortality. The SGEM was part of a group of clinicians who were concerned about the updated 2018 Surviving Sepsis Campaign (SSC) guidelines. Specifically, the fluid, antibiotics, and pressor requirements within the first hour of being triaged in the emergency department. Despite the lack of high-quality evidence to support these sepsis bundles, many hospitals incorporated them into their electronic medical record (EMR). They created these sepsis alerts with the intention of identifying septic patients, so they can be treated accordingly. Most physicians agree that antibiotics should be given early in septic patients. However, the jury is still out for other interventions with potential for harm, particularly, the infusion of 30cc/kg of IV fluids. Worldwide sepsis contributes to the death of 5.3 million hospitalized people annually. It is the leading cause of death in the intensive care unit (ICU) in the US and the most expensive diagnosis. Since 2015, the Centers for Medicare & Medicaid Services (CMS) have indexed the quality of hospital care for sepsis to the SEP-1 core measure. Interventions, particularly early antibiotics, have been associated with improved mortality. Diagnosing sepsis can be challenging. To adequately capture patients, specificity has been sacrificed for better sensitivity. We care more about catching all the true positives and worry less if a few true negatives get mixed up in there. Using vital signs and lab abnormalities certainly captures more patients, but it also identifies those without an infection. Patients with cirrhosis, toxicities, those on dialysis. It is possible that some of these patients can be at risk for harm from one of these interventions. Clinical Question: What proportions of patients meeting sepsis criteria were actually diagnosed with sepsis, and how many non-septic patients had risk factors for harm from aggressive fluid resuscitation? Reference: Litell et al. Most emergency department patients meeting sepsis criteria are not diagnosed with sepsis at discharge. AEM 2021. Population: These were adult ED patients presenting to a tertiary academic medical center who met criteria for Sepsis-3 or Sepsis-3 plus shock. Sepsis-3 was defined as patients with a SOFA score ≥ 2 (Sequential Organ Failure Assessment score) and a suspected infection (which they counted if patients were given IV antibiotics within 24 hours of admission). Sepsis-3 plus shock was defined as Sepsis-3 with an initial lactate level > 2 and any systolic blood pressure < 90. Excluded: Trauma patients and those with missing ICD-9 codes. This is because prophylactic antibiotics often administered in traumatic or orthopaedic injuries. Intervention: N/A Comparison: They compared those with a sepsis diagnosis at discharge to those without a sepsis diagnosis at discharge. Outcome: Primary Outcome: The primary outcome was proportion of ED patients with suspected sepsis based on consensus criteria who were not diagnosed with sepsis at discharge. Basically, they were initially flagged as potentially septic, but didn’t turn out to be. Secondary Outcomes: Proportion of

Date: September 16th, 2021 Reference: Sippola et al. Effect of Oral Moxifloxacin vs Intravenous Ertapenem Plus Oral Levofloxacin for Treatment of Uncomplicated Acute Appendicitis. The APPAC II Randomized Clinical Trial. JAMA 2021 Guest Skeptic: Dr. Rob Leeper is an assistant professor of surgery at Western University and the London Health Sciences Center. His practice is in trauma, emergency general surgery, and critical care with an academic interest in ultrasound and medical simulation. Rules of SGEM Journal Club Case: A 23-year-old man with CT confirmed uncomplicated appendicitis, mild abdominal pain, stable clinical signs, and essentially normal laboratory investigations has just concluded his bedside consultation with the on-call general surgery team. The patient and surgeons have had an evidence-informed discussion and have arrived at a mutually agreed upon decision to proceed with non-operative treatment of his appendicitis. The patient is recommended to undergo admission to hospital for serial observation and intravenous antibiotics. The patient asks; “gosh doc, if this disease is so mild why can’t I just go home and take antibiotics by mouth?”. Dr. Eric Walser Background: The appendix is a structure about as long as your pinkie finger that hangs off the beginning of the colon, in the right lower quadrant of your abdomen. There are lots of theories about subtle functions of the appendix, but its most prominent role is to become inflamed or infected in approximately 7% of people. Usually appendicitis occurs because the lumen, or inside, of the appendix is obstructed by something. Often that is a piece of stool called a fecalith, but other times it can be lymph tissue or another process we may never actually identify. This causes the pressure in the appendix to increase eventually obstructing venous outflow and then arterial inflow. We used to assume that this was an ordered progression that always leads to appendiceal rupture in a stepwise fashion, but we now think that there is more of a spectrum of severity based on individual anatomic and other factors. While the presentation of appendicitis can vary from patient to patient, as our emergency medicine colleagues know well, most patients are not diffusely peritonitic or systemically unwell. Before we had things like surgery or antibiotics, appendicitis carried up to a 50% case fatality rate. Luckily now, with these treatments the mortality rate is almost zero. For the last 135 years we have treated appendicitis with an appendectomy, which is now almost always performed in laparoscopic fashion. A laparoscopic appendectomy involves a general anesthetic, making three small incisions between 1 and 2 cm in length; and the operation usually takes somewhere between 30 to 60 minutes. Most patients go home the same day or the next morning, either with a short course of antibiotics or with none after surgery. Most patients who have this surgery are back to work and their usual routine at around the two-week mark. The chance of requiring additional procedures is quite low unless we find that the appendix has already perforated. It is a good, and generally very safe operation, with a high rate of patient satisfaction. Omar et al published a study in 2008 showing just how safe laparoscopic appendectomies have become. They found in over 230,000 UK patients the death rate was less than half compared to the open procedure (0.64% vs 0.29%; p<0.001). Patrick Roy Nonoperative treatment of appendicitis (NOTA) was first described in the 1940s and moved into the public consciousness when Patrick Roy was treated with antibiotics alone during the 1994 Stanley Cup playoffs. In 2014, tennis star Rafael Nadal was diagnosed with acute appendicitis. He was participating in the Shanghai Masters Tennis Tournament at the time. Nadal opted to be treated with antibiotics and had his appendix removed via laparoscopic one month later. There have been several randomized trials like the APPAC trial and the CODA trial demonstrating that, in general, nonoperative management is safe, but that 25-60% of patients would go on to require an appendectomy during follow-up, which was usually around one year. The recent Eastern Association for the Surgery of Trauma (EAST) guidelines from 2019 on appendicitis could not provide a recommendation on the use of NOTA as first line treatment. Despite this, we know from database studies that appendectomy remains far more common in North America, with nonoperative management reserved for remote areas or extenuating circumstances. We have covered adult uncomplicated NOTA a couple of times on the SGEM. The first time was on SGEM#115 and we reviewed two SRMAs on the topic that came to opposite conclusions. The other time we looked at this issue was with Dr. Leeper on SGEM#256. We reviewed an observational study on NOTA. SGEM Bottom Line: Nonoperative management of acute uncomplicated appendicitis may be better than we thought in selected patients but comes

Date: September 8th, 2021 Reference: Desch et al. The TOMAHAWK Investigators. Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation. NEJM 2021. Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. He heads curriculum and conference for the academic year and is passionate about resident education on- and off-shift, from procedural to evidence-analytical. Dr. Kaushal Khambhati is also a fourth-year resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. He is interested and experienced in healthcare informatics, previously worked with ED-directed EMR design, and is involved in the New York City Health and Hospitals Healthcare Administration Scholars Program (HASP). Five Rules of the SGEM Journal Club Case: A 70-year-old woman is found unresponsive and apneic at home by her partner. EMS arrives and finds the patient in monomorphic ventricular tachycardic (VT) cardiac arrest. She has a history of hypertension and non-insulin dependent diabetes mellitus. The paramedics achieve return of spontaneous circulation (ROSC) after CPR, advanced cardiac life support (ALCS), and Intubation. She arrives in the emergency department (ED) with decreased level of consciousness and shock. The EKG shows sinus tachycardia with nonspecific changes and no ST segment elevations, Q waves, or hyperacute T waves. Her point-of-care ultrasound (POCUS) shows appropriate-appearing global ejection fraction and no marked wall motion abnormalities. Cardiology has been consulted and asks for a neurology consultation given her mental status. Background: The American Heart Association estimates there are approximately 350,000 EMS-assessed out-of-hospital cardiac arrests (OHCAs) in the United States per year. Half of these arrests are witnessed with the other half being un-witnessed. Many of these OHCAs are due to ventricular fibrillation or pulseless VT. Defibrillation is the treatment of choice in these cases but does not often result in sustained ROSC (Kudenchuk et al 2006). Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients. There is evidence that taking those patients with ROSC and EKG showing STEMI directly for angiography +/- angioplasty is associated with positive patient-oriented outcomes. The AHA has a statement with recommendations based on the available data. They suggest to perform catheterization and reperfusion for post-arrest patients with ST-segment elevation, even if the patient is comatose However, there is no consensus if this strategy should be employed in patients without ST-segment elevation (Yannopoulos et al, Circulation 2019). The 2015 AHA Guidelines make the following recommendations: Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG (Class I, LOE B-NR). Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG (Class IIa, LOE B-NR). Lemke et al 2019 published a multicentre RCT done in the Netherlands looking at patients without ST segment elevation in OHCA with ROSC. Patients were randomized to receive immediate coronary angiography or delayed coronary angiography performed after neurologic recovery. They found no superiority to the immediate strategy for their primary outcome of survival at 90 days. One of the limitations of the COACT trial is they only included patients who had an intra-arrest shockable rhythm which only accounts for 60% of OHCA patients. Clinical Question: Does early coronary artery angiography following resuscitation of Out-of-Hospital Cardiac Arrest benefit patient outcomes in patients without ST Segment elevation patterns on their post-ROSC EKG? Reference: Desch et al the TOMAHAWK Investigators. Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation. NEJM 2021. Population: Adults aged 30 years and older with shockable or non-shockable OHCA, ROSC and no ST segment elevation EKG pattern. Exclusions: ST-segment elevation or left bundle branch block, no ROSC, severe hemodynamic or electrical instability requiring immediate coronary angiography/intervention (delay clinically not acceptable), life-threatening arrhythmia possibly caused by acute myocardial ischemia, cardiogenic shock (defined by clinical and hemodynamic criteria), obvious extra-cardiac etiology such as traumatic brain injury, primary metabolic or electrolyte disorders, intoxication, overt hemorrhage, respiratory failure due to known lung disease, suffocation, drowning, IHCA and known or likely pregnancy Intervention: Immediate angiography as soon as possible after hospital admission Comparison: Delayed or selective angiography after b

Date: August 31st, 2021 Reference: McLean et al. Interphysician weight bias: A cross-sectional observational survey study to guide implicit bias training in the medical workplace. AEM Sept 2021 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: You are working in the emergency department (ED) with the new resident, one of whom is overweight. You overhear his colleagues wonder where he went, chuckling, and one of them comments that “he probably went for second breakfast.” Realizing that these residents are making fun of their colleague’s weight, you decide to address the issue. Background: We have talked about biases many times on the SGEM. Usually when we use the term bias it is in the context of something that systematically moves us away from the “truth”. Science does not make truth claims and the term is used as a shorthand for the best point estimate of an observed effect size. An example in the medical literature would be selection bias. This is when subjects for a research study are not randomly selected. This can skew the results and impact the conclusions. Another example would be publication bias. Studies with “positive” results are more likely to be published while those with “negative” results are more likely to end up in the bottom of the file drawer. There are many other types of bias in the practice of medicine. Some of my favourite ones are anchoring bias, base-rate neglect, and hindsight bias. For a description of these and many more check out Dr. Pat Croskerry list of 50 cognitive biases in medicine. You can also click on the codex for an extensive list of different biases. This SGEM episode focuses on a kind of bias as defined by the common English language as “a particular tendency, trend, inclination, feeling, or opinion, especially one that is preconceived or unreasoned”. It is a sense of prejudice or stereotyping and the formation of a foregone conclusion independent of current evidence. There are many biases in the house of medicine. We have discussed some of them on the SGEM. They include things like age, gender, socioeconomic status, race, and other factors. The gender pay gap is one of the topics that has been spoken about most on the SGEM. A paper by Wiler et al AEM 2019 showed females in academic emergency medicine were paid ~$12,000/year less than their male colleagues (SGEM#248). The September 2021 issue of AEM is a special issue focusing on biases in emergency medicine. It includes articles on racial, ethnic and gender disparities. One specific topic jumped out as something that has not received much attention, weight bias. There is literature on physicians’ weight biases towards patients and patients’ weight bias towards physicians. However, there is limited information on physician-to-physician weight bias. Clinical Question: What is the prevalence of interphysician implicit, explicit, and professional weight bias? Reference: McLean et al. Interphysician weight bias: A cross-sectional observational survey study to guide implicit bias training in the medical workplace. AEM Sept 2021 Population: Practicing physicians and physicians-in-training in North America Excluded: Those who did not consent; did not identify as physicians or physicians-in-training; or were not currently residing in North America. Intervention: Survey instruments measuring implicit weight bias (IWB), explicit weight bias (EWB), and professional weight bias (PWB) Comparison: None Outcome: Descriptive analyses along with correlative models Dr. Mary McLean This is an SGEMHOP episode which means we have the lead author on the show. Dr. Mary McLean is an Assistant Program Director at St. John’s Riverside Hospital Emergency Medicine Residency in Yonkers, New York. She is the New York ACEP liaison for the Research and Education Committee and is a past ALL NYC EM Resident Education Fellow. Dr. McLean was the guest skeptic on the SGEM#310 reviewing an article showing EM physicians are not great at performing the HINTS exam. Implicit Bias: Implicit bias is unconscious and often subtle type of bias that is hard to pinpoint in ourselves and notoriously hard to measure. Implicit weight bias (IWB) was measured using the Implicit Association Test (IAT) based on work from Project Implicit which is a Harvard-based research organization. The weight bias IAT has been previously validated for the general population. This was adapted by adding the theme of physicians in the medical workplace. Project Implicit’s silhouette images of people with obesity was modified to add stethoscopes and clipboards, and adjust clothing to look like scrubs, white coats, or professional clothing. The good and bad layperson descriptor words were also replaced with words used to describe good and bad doctors, based on Stern's medical professionalism framework Explicit Bias: Explicit bias is a more outward bias expressed in words or actions, that’s eas

Date: August 27th, 2021 Reference: Gagnon et al. Direct-access physiotherapy to help manage patients with musculoskeletal disorders in an emergency department: Results of a randomized controlled trial. AEM 2021 Dagny Haas Guest Skeptic: Dagny Kane-Haas is a physiotherapist who also has a master’s degree in Clinical Science in Manipulative Therapy. Case: A forty-year-old woman presents to the emergency department (ED) with a sore lower back after moving some boxes at home over the weekend. She tried acetaminophen with limited relief. Her pain is eight out of ten on the zero-to-ten-point numeric pain rating scale (NPRS). She has no red flags (TUNA FISH) and is diagnosed as having mechanical back pain without imaging as per ACEP Choosing Wisely. You know mechanical low back pain is difficult to treat effectively and are trying to set expectations. While preparing her for discharge you wonder if seeing a physiotherapist before going home from the ED would improve her outcome. Background: Acute and chronic back pain has been covered many times on the SGEM. There is no high-quality evidence that acetaminophen, NSAIDS, steroids, diazepam, muscle relaxants or combinations of pharmacologic modalities provide much relief. 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 We do know that opioids are very effective at reducing many types of pain including muscular skeletal pain. However, opioids have many side effects and concerns about substance misused. The ACEP 2020 clinical policy on the use of opioids states: “Preferentially prescribe nonopioid analgesic therapies (nonpharmacologic and pharmacologic) rather than opioids as the initial treatment of acute pain in patients discharged from the emergency department. For cases in which opioid medications are deemed necessary, prescribe the lowest effective dose of a short-acting opioid for the shortest time indicated.” (Level C Recommendation) There are several non-pharmaceutical treatments that have also been tried to treat low back pain. They include: Cognitive Behavioural Therapy and mindfulness (Cherkin et al JAMA 2016), chiropractic (Paige et al JAMA 2017), physical therapy (Paolucci et al J Pain Research 2018) and acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013). None of these other treatments has high-quality evidence supporting their use. We have covered a randomized control trial looking at acupuncture to treat painful conditions presenting to the ED, including acute back pain, on SGEM#187. That trial reported no difference in clinical or statistical relevant reduction of pain at one hour between groups (acupuncture only, acupuncture plus pharmacotherapy or pharmacotherapy alone). However, we have not done a structured critical appraisal of an RCT looking at physiotherapy for this clinical condition. Clinical Question: Does access to a physiotherapist in ED help patients who present with minor musculoskeletal disorders (MSKD)? Reference: Gagnon et al. Direct-access physiotherapy to help manage patients with musculoskeletal disorders in an emergency department: Results of a randomized controlled trial. AEM 2021 Population: Adult patients 18-80 years of age presenting to the ED with suspected minor MSKD, traumatic or not. Minor was defined using the Canadian Triage and Acuity Scale (CTAS) score of 3, 4 or 5. Excluded: Non-minor MSKD (ex: open fractures or open wounds), red flags, clinically unstable, hospitalized patients, or those in long-term care facilities. Intervention: Physiotherapist evaluated the patient post triage in the ED. They would recommend interventions based on their clinical assessment. This could include advice, technical aids, imaging, prescribed or over-the-counter medication, and consults with other health care professionals. However, there was no follow-up by the physiotherapist. Comparison: Usual care Outcome: Primary Outcome: Pain and function at one and three months. Pain was assessed using a NPRS. Function was evaluated using the Pain inventory subscale of the short version of the Brief Pain Inventory (BPI). The BPI scores ten activities of daily living (e.g., general activity, mood, walking, work, sleep) on a zero-to-ten-point scale (0 - no interference with function and 10- completely interferes with function) Secondary Outcomes: Utilization of resources at ED discharge, interventions utilized, medications, healthcare professionals consulted, return ED visits and imaging received. Authors’ Conclusions: “Patients presenting with a MSKD to the ED with direct access to a PT had better clinical outcomes and used less services and resources than those in the usual care group after ED discharge and up to 3 months after discharge.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those i

Date: August 19th, 2021 Reference: Pantell et al. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics 2021 Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. Case: A 25-day-old, full-term boy presents to the emergency department with fever. His parents report that he felt warm that evening, and they found that he had a rectal temperature of 38.2°C (100.8°F). He has an older sister at home with a cough and rhinorrhea. Overall, he has no symptoms and appears well. He has continued to feed normally and produce wet diapers. The parents ask you, “Do you really think he needs any additional testing? He probably caught something from his sister, right?” Background: Parents often bring their infants to the ED with concerns about fever. They can develop a real “fever fear” or “feverphobia” and often need reassurance that fever alone is not dangerous. We have talked about pediatric fever and fever fear with Dr. Anthony Crocco from Sketchy EBM back on SGEM#95 and made a “Ranthony” video on the topic. The American Academy of Pediatrics says that “…fever, in and of itself, is not known to endanger a generally healthy child. In contrast, fever may actually be of benefit; thus, the real goal of antipyretic therapy is not simply to normalize body temperature but to improve the overall comfort and well-being of the child.” However, fever without source in infants less than three months of age represents a significant diagnostic dilemma for clinicians. Several clinical decision instruments had been developed previously, including the Rochester (Jaskiewicz et al 1994), Boston (Baskin et al 1992) and Philadelphia (Baker et al 1993) criteria to help clinicians stratify the risk of significant bacterial infections. A new clinical decision instrument called the Step-by-Step approach was reviewed on SGEM#171. SGEM#171 Bottom Line: If you have availability of serum procalcitonin measurement in a clinically relevant time frame, the Step-by-Step approach to fever without source in infants 90 days old or younger is better than using the Rochester criteria or Lab-score methods. With the caveat that you should be careful with infants between 22-28 days old or those who present within two hours of fever onset. We have been trying to optimize our approach to evaluating and managing febrile infants for more than four decades. Our goal is to identify the febrile infants with urinary tract infection, bacteremia, and bacterial meningitis (or what was referred to as serious bacterial infections) while simultaneously trying to spare them from invasive and potentially unnecessary procedures like lumbar punctures or the possible iatrogenic consequences of empiric antibiotics or hospitalization. Several risk stratification tools have been published over the years. These clinical decision instruments included subjective clinical criteria along with pre-determined thresholds for lab criteria like white blood cell count (WBC) and immature to total neutrophil ratio. Unfortunately, these criteria may not be appropriate in the current era. In fact, the Modified Boston and Philadelphia Criteria for invasive bacterial infections may misclassify almost one-third of infants with bacterial meningitis. With routine screening of pregnant women, improvements in food safety, and conjugate pneumococcal vaccines, we have seen a decrease in Group B streptococcus, Listeria, and Streptococcus pneumoniae infections in infants. Instead, there has been a shift to Gram-negative organisms being the most common culprits in bacterial infections in infants. Simultaneously, our ability to test for infection has advanced with the use of inflammatory markers (IM) like procalcitonin and C-reactive protein (CRP) as well as polymerase chain reaction (PCR) testing for rapid identification of multiple viruses and bacteria. Clinical Question: What are recommendations for evaluating and managing well-appearing, term infants, 8 to 60 days of age with fever ≥38°C? Reference: Pantell et al. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics 2021 Authors’ Conclusion: “Three algorithms summarize the recommendations for infants 8 to 21 days of age, 22 to 28 days of age, and 29 to 60 days of age. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.” Quality Checklist for A Guideline: The study population included or focused on those in the emergency department? No An explicit and sensible process was used to identify, select and combine evidence? Yes The quality of the evidence was explicitly assessed using a validated instrument? Yes An explicit and sensible process was used to the relative value of different outcomes? Yes The guideline thoughtfully balances desirable and undesirable effects? Yes T

Date: August 12th, 2021 Reference: Daya et al. Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Circulation 2020 Guest Skeptic: Missy Carter is a PA practicing in emergency medicine in the Seattle area and an adjunct faculty member with the Tacoma Community College paramedic program. Missy is also now the director for Difficult Airway EMS course in Washington State Case: An EMS crew arrives to your emergency department (ED) with a 58-year-old female who suffered a witnessed ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA). They performed high-quality CPR and shocked the patient twice before giving amiodarone via intraosseous (IO). After giving hand off the medic tells you she had difficulty finding intravenous (IV) access and went straight to an IO. She wonders if she should have spent more time on scene trying to get the IV versus the tibial IO she has in place. Background: We have covered OHCA multiple times on the SGEM. This has included the classic paper from Legend of EM Dr. Ian Stiell on BLS vs. ACLS (SGEM#64), the use of mechanical CPR (SGEM#136), and pre-hospital hypothermia (SGEM#183). ALPS Trail The issue of amiodarone vs lidocaine has also been covered on SGEM#162. This was the ALPS randomized control trial published in NEJM 2016. The bottom line from that SGEM critical appraisal was that neither amiodarone or lidocaine were likely to provide a clinically important benefit in adult OHCA patients with refractory VF or pulseless ventricular tachycardia. We did do an episode on IO vs IV access for OHCA (SGEM#231). This was a critical appraisal of an observational study published in Annals of EM (Kawano et al 2018). The key result was that significantly fewer patients had a favorable neurologic outcome in the IO group compared to the IV group. However, we must be careful not to over-interpret observational data. There could have been unmeasured confounders that explained the difference between the two groups. In recent years there has been an effort to lower the cognitive load in the pre-hospital setting and focus resources on the interventions that positively effect patient outcomes. There has been a trend to place supraglottic devices over intubation with some evidence to support this move (SGEM#247). Another trend is to use IO access over IV access to free up pre-hospital providers to focus on more meaningful interventions. Clinical Question: Does it matter if you give antiarrhythmic medications via IV or IO route in OHCA? Reference: Daya et al. Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Circulation 2020 Population: Adult patients with non-traumatic out-of-hospital cardiac arrest and shock refractory ventricular fibrillation or pulseless ventricular tachycardia after one or more shocks anytime during resuscitation. Excluded: Patients who had already received open-label intravenous lidocaine or amiodarone during resuscitation or had known hypersensitivity to these drugs Intervention: Amiodarone, Lidocaine or placebo given IO Comparison: Amiodarone, lidocaine or placebo given IV Outcome: Primary Outcome: Survival to hospital discharge Secondary Outcomes: Survival to hospital admission, survival with favorable neurologic outcome (modified Rankin Scale score of 3 or less) Authors’ Conclusions: We found no significant effect modification by drug administration route for amiodarone or lidocaine in comparison with placebo during out-of-hospital cardiac arrest. However, point estimates for the effects of both drugs in comparison with placebo were significantly greater for the intravenous than for the intraosseous route across virtually all outcomes and beneficial only for the intravenous route. Given that the study was underpowered to statistically assess interactions, these findings signal the potential importance of the drug administration route during resuscitation that merits further investigation. 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? There were wide 95% CI around the point estimate of risk ratios Do you believe the results? Yes Can the results be applied to the local population? Yes Do the results of this study fit with other available evidence? Yes Results: In the ALPS publication, there were 37,889 patients with non-traumatic out-of-hospital cardiac arrest of which 7,051 (18.6%) had shock-refractory ventricular fibrillation or pulseless ventricular tachycardia. The inten

Date: August 7th, 2021 Dr. Susanne DeMeester Guest Skeptic: Dr. Susanne (Susy) DeMeester is an Emergency Physician practicing at St. Charles Medical Center in Bend, Oregon. She has been very involved with EMRAP's CorePendium as the cardiovascular section editor and has a chapter coming out soon on women and acute coronary syndrome. Dr. DeMeester was on SGEM#222 as part of the SGEMHOP series. She was the lead author of a study looked at whether an emergency department algorithm for atrial fibrillation management decrease the number of patients admitted to hospital. The SGEM Bottom Line: There are clearly patients with primary atrial fibrillation who can be managed safely as outpatients. There are no evidence-based criteria for identifying high-risk patients who require admission, so for now we will have to rely on clinical judgement. This SGEM Xtra episode is the result of some feedback I received from a listener following SGEM#337 episode on the GRACE-1 guidelines for recurrent low-risk chest pain. The person lamented that it would be nice if a cardiac case scenario was of a female patient. This made me review past SGEM episodes which confirmed there has been a gender bias. While there were a half-dozen episodes that did have female patients, they were the minority. So, I felt a good way to address the issue would be to invite an expert like Dr. DeMeester to discuss this gender bias. There is a difference between gender and sex. Despite having different meanings they are often used interchangeably. Gender refers to social constructs while sex refers to biological attributes. This is not the first SGEM episode that has addressed the gender gap in the house of medicine. I had the honour of presenting at the 2019 FeminEM conference called Female Idea Exchange (FIX19). My FIX19 talk was called from Evidence-Based Medicine to Feminist-Based Medicine. It looked at the three pillars of EBM: relevant scientific literature, clinicians, and patients. I realized that each of the three pillars contained biases against women. In the presentation, multiple references were provided to support the claim that a gender gap does exist. The conclusion from the FIX19 talk was that we should be moving from Evidence-Based Medicine (nerdy and male dominated) to Feminist-Based Medicine (recognizing the inequities in the house of medicine) to Gender-Based Medicine (acknowledging the spectrum of gender and sexuality) and ultimately to Humanist- Based Medicine. The SGEM did a regular critical appraisal of a recent publication with Dr. Ester Choo (SGEM#248). It covered the study published in AEM looking at the continuation of gender disparities among academic emergency physicians (Wiler et al AEM 2019). We also did an entire SGEM Xtra episode with Dr. Michelle Cohen on the broader issue of the gender pay gap (SGEM Xtra: Money, Money, Money It’s A Rich Man’s World – In the House of Medicine). This was based on the Canadian Medical Association Journal article focusing on closing the gender pay gap in Canada (Cohen and Kiren 2020). Five questions about gender disparities when it comes to cardiovascular disease. What is the burden of cardiovascular disease in females and is it the same as males? We know females are often excluded from being subjects in medical research. Are female represented proportionally in cardiovascular disease clinical research? Are there differences between males and females with regards to cardiovascular disease risk factors? Do females who have a cardiovascular event present differently to the emergency department? Have any sex differences been identified in the treatment and outcomes of females with cardiovascular events? Please listen to the SGEM podcast to hear Dr. DeMeester's answers to these five questions. What can be done to address this gender gap? The Lancet gathered a group of international experts to answer this question. The commission published recommendations to reduce the global burden of cardiovascular disease in women by 2030 (Vogel et al). This Includes: Acknowledging the current burden of disease Raising awareness about the differences in presentations and sex-specific and under-recognized risk factors Increasing the number of women included in clinical trials The European Society of Cardiology supported this initiative. They published an article called: Cardiovascular Disease in Women - Reducing the gender gap in prevention, diagnosis and treatment of cardiovascular disease. The Lancet also created a number of infographics to help with the knowledge translation of these recommendations. 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. The ultimate goal of the SGEM is for 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’ G

Date: July 29th, 2021 Reference: Azizi et al. Optimal anatomical location for needle decompression for tension pneumothorax: A multicenter prospective cohort study. Injury 2021 Guest Skeptic: Dr. Robert Edmonds is an emergency physician in the Air Force in Ohio. This is Bob’s 14th episode cohosting the SGEM. DISCLAIMER: THE VIEWS AND OPINIONS OF THIS PODCAST DO NOT REPRESENT THE UNITED STATES GOVERNMENT OR THE US AIR FORCE. Case: You are driving home from a busy shift and see a car collision occur right in front of you. The driver is a restrained self-extricated male who lost control of his vehicle into a light post and the vehicle’s airbags deployed. After safely pulling over and having a bystander call 911, you evaluate the patient. He is speaking in full sentences without confusion, has a strong, rapid pulse, significant pain in his chest and is having a very hard time breathing. As you wait for EMS to arrive, you quickly dash back to your car to retrieve your stethoscope and an angiocatheter you have in your glovebox. You notice a marked difference between breath sounds on the left side and decide the patient needs treatment for a tension pneumothorax. After obtaining consent from the patient, you debate whether to decompress at the second intercostal space in the midclavicular line as you originally learned, or in the fourth/fifth intercostal space midaxillary line as per the current ATLS guidelines. Background: The latest ATLS guidelines were published in 2018. We covered them on the SGEM Xtra with Dr. Neil Parry. There were several changes to the new guidelines but one of them was changing the location for needled decompression for adult patients. Needle thoracostomy is subject to several complications compared to a tube thoracostomy primarily due to the shorter length of the needle as well as the smaller lumen, so site selection has focused on finding a short distance and a site unlikely to kink or get dislodged. Dr. Richard Malthaner We have covered chest tube thorocostomy a couple of times on the SGEM with Dr. Richard (Thoracic) Malthaner. SGEM#129 looked at where to put the chest tube on trauma patients and if a post-procedure chest Xray (CXR) was required. The conclusion from that episode 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 other episode on chest tubes was SGEM#300. The clinical question was does everyone with a large first-time spontaneous pneumothorax need a chest tube? The answer from that episode was It is reasonable to provide conservative management (no chest tube) in a patient with large first-time spontaneous pneumothoraxes if you can ensure close follow-up. The changes in the ATLS guidelines were based in part on a small study (n=20) utilizing cadavers [1]. There were also studies using CT scans showing a preference for the fourth/fifth ICS AAL [2,3]. These studies were limited by heterogeneity (I2 83%-98%), possible publication bias, and not being randomized trials. These authors are adding to the literature by utilizing ultrasound on live patients. This could reduce some of the potential confounders in prior studies that were exclusively cadavers which may have differences in CWT due to post-mortem changes. The previous studies also focused on homogenous populations like military members and are therefore less generalizable to the general population. Additionally, by using ultrasound instead of CT, some of the confounders from arm placement during CT were reduced. Clinical Question: Is the chest wall thickness at the second intercostal space in the midclavicular line not thicker than the fourth/fifth intercostal space anterior axillary line? Reference: Azizi et al. Optimal anatomical location for needle decompression for tension pneumothorax: A multicenter prospective cohort study. Injury 2021 Population: A convenience sample of all adults presenting to one of the eight participating hospitals over a two-week period. (June 11-23, 2019) Excluded: Patients with pre-existing thoracic deformities, patients who were seriously ill requiring continuous urgent care, and patients who were unable to provide consent Intervention: Chest wall thickness at the second intercostal space in the midclavicular line Comparison: Chest wall thickness at the fourth/fifth intercostal space anterior axillary line Outcome: Primary Outcome: Median CWT in ICS2-MCL and ICS 4/5 AAL Secondary Outcomes: BMI 25-30 CWT, BMI 30+ CWT, hypothetical failure rates of needle decompression Authors’ Conclusions: “In overweight- and obese subjects, the chest wall is thicker in ICS 4/5-AAL than in ICS2-MCL and theoretical chances of successful needle decompression of a tension pneumothorax are significantly higher in ICS2-MCL compared to ICS 4/5-AAL.” Quality Checklist for Observational Study: D

Date: July 24th, 2021 Guest Skeptic: Dr. Brain Goldman is an Emergency Medicine physician who works at Mount Sinai hospital in Toronto. He is the host of CBC radio show White Coat Black Art and the podcast The Dose. He is also the author of the bestselling books The Night Shift, Secret language of Doctors, and the Power of Kindness. This is a SGEM Xtra. Brain and I went on an away mission by shuttle craft to Ticonderoga, NY for the weekend. This was to join Mr. William Shatner to celebrate his 90th birthday. We took the opportunity during part of the road trip to record an SGEM episode about how Star Trek made us better physicians. Some of you may love this episode while others may not. William Shatner 90th Birthday Party Celebration Away Mission 2021 There were a number of challenges that needed to be overcome to make this epic trip happen. First, it was difficult to get VIP tickets to this sold out event hosted by James Cowley. James created the Star Trek: Original Series Set Tour. This is an amazing recreation of the sets from the original series. James is also an executive film producer, actor and famous Elvis impersonator. He graced us with a performance as Elvis as part of the birthday celebration weekend (link to video). After obtaining a couple of VIP tickets to the event, the next concern was: what colour of shirt to wear? There is the gold command tunic worn by Captain James T. Kirk, the blue science/medical tunic worn by Mr. Spock and Dr. McCoy, or the infamous red shirt. Please note that the red shirt characters were not statistically more likely die. Another challenge was traveling to the USA. The border restrictions were supposed to have been eased on July 21st to allow crossing by ground. However, it was announced on July 20th that the restrictions would remain in place until August 9th. People were allowed to cross by air if fully vaccinated and had negative COVID19 test within three days of departure. This allowed us to fly over the border, rent a car and drive to Ticonderoga. The final challenge was what to get Mr. Shatner for his 90th birthday. I called the Stratford Festival a few months before the event and asked for their assistance. They kindly searched their archives for the three seasons he was part of the company (1954-1956). There were no pictures that featured him on stage because he was not a famous actor at the time. They did find two photos of Mr. Shatner receiving the Festival’s Guthrie Award from Governor General Vincent Massey in 1956. There were also some newspaper clippings describing how Mr. Christopher Plummer was admitted to hospital for a kidney stone and his understudy, William Shatner, took over the lead role in Henry the V. The Stratford Festival Archivist did find one amazing photo of Mr. Shanter from 1954. It is a picture of him sitting in a chair surrounded by a few other individuals checking out the masks for the 1954 production of Oedipus Rex. It looked like he was getting ready to sit in the captain's chair aboard the USS Enterprise NCC 1701. It's this photo that I had printed, framed and presented to him as a birthday present. He was very gracious and appreciative of receiving this special birthday gift. For those of you not familiar with Star Trek it started with a TV series that had 79 episodes and was broadcasted over three seasons from 1966-1969. It is a science fiction franchise created by Gene Roddenberry. Star Trek The Original Series (TOS) launched many other TV series and movies. This SGEM Xtra will discuss some of the lessons learned from Star Trek and how it has applied to our practice of emergency medicine. Brian and I had a wonderful away mission. Some of the highlights included the private tour of the Enterprise by Mr. Shatner. I had the chutzpah to ask a question of during the bridge chat about what Mr. Shatner learned from his time at the Stratford festival that he applied to his career in TV and movies. His answer was he learned excellence from the best directors and actors in the world. It was also wonderful to go on a couple of hikes with Brian around Ticonderoga and see the natural beauty of this historic town. It is located in New York state on the north end of Lake George and a southern portion of Lake Champlain. There is also fort in Ticonderoga build by the French in the 18th century that played an important role during the American revolution. Mr. Daren Dochterman Another super experience was meeting the talented Mr. Daren Dochterman. He is a set designer who has worked on many movies. Daren won an award for his work on the visual effects for the movie Star Trek: The Motion Picture Director's Cut. He informed us that the Director's Cut is being remastered for 4K release and he is part of the team. Daren also co-hosts the best Star Trek podcast called the Inglorious Treksperts with Mark A. Altman. After Brian and I met him and discussed our love of Star Trek TOS he made us honorary treksperts. Our private tour of t

Date: July 14th, 2021 Reference: Pernica et al. Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial. JAMA Pediatr. 2021. Guest Skeptic: Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder of website lead of Don’t Forget the Bubbles (DFTB). When not drinking coffee and reading Batman comics he is playing with his children. Case: Six-year-old Morten comes into your emergency department (ED) with what looks like pneumonia. He has been febrile with a temp of 39 degrees Celsius, he is mildly tachypneic but shows no real signs of respiratory distress and you can hear some crackles in the right mid-zone. His chest X-ray (CXR) confirms your findings, but he is well enough to be treated as an outpatient. Background: It is hard to believe we have not covered the common condition of pediatric community acquired pneumonia (CAP) on the SGEM. Perhaps it is because there is limited evidence on this common condition. However, we have covered other pediatric infectious issues like: Honey for Cough SGEM#26 Fever Fear SGEM#95 Lumbar Punctures SGEM#296 Bronchiolitis SGEM#228 Invasive Bacterial Infection SGEM#334 We do have high-quality evidence that a CXR is not necessary to confirm the diagnosis of CAP in patients who are well enough to be managed as outpatients. There is also high-quality evidence that pre-school children do not routinely need antibiotics. This is because most pneumonias in this age-group are caused by viral pathogens (Bradley et al 2011). Antibiotics are recommended for school age children diagnosed with CAP. However, how long should they be treated is an open question. The IDSA guidelines provide a strong recommendations based on moderate quality of evidence to guide our care. (Bradley et al 2011). Treatment courses of 10 days have been best studied, although shorter courses may be just as effective, particularly for more mild disease managed on an outpatient basis. (strong recommendation; moderate-quality evidence) There is an RCT reporting five days of amoxicillin (80mg/kg divided TID) was non-inferior to ten days for CAP in children six months to 59 months of age (Greenberg et al 2014). This was a relatively small study (n=115) from Israel. A short course (five days) has also been recommended by the American Thoracic Society and the IDSA for adults with CAP under certain conditions (Metlay et al 2019). We recommend that the duration of antibiotic therapy should be guided by a validated measure of clinical stability (resolution of vital sign abnormalities [heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature], ability to eat, and normal mentation), and antibiotic therapy should be continued until the patient achieves stability and for no less than a total of 5 days (strong recommendation, moderate quality of evidence). Clinical Question: Is a five day course of antibiotic therapy non-inferior to a ten day course to achieve clinical cure for paediatric community-acquired pneumonia? Reference: Pernica et al. Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial. JAMA Pediatr. 2021 Population: Children aged six months to ten years of age diagnosed with community acquired pneumonia (CAP) who are well enough to be treated as an outpatient. CAP was defined as fever (rectal, oral or axillary in 48 hours before presentation), tachypnea (based on age, accessory muscle use or auscultation findings), CXR, or primary diagnosis by the ED physician. Exclusions: Empyema or necrotizing pneumonia, preexisting pulmonary disease, congenital heart disease, history of aspiration, malignant neoplasm, immunodeficiency, kidney disfunction, on beta-lactam antibiotics for >24hrs at presentation, 5-days of beta-lactam <72hours before presentation, IV cephalosporin or azithromycin in the ED, suspected mononucleosis, prolonged admission in the previous two months, CAP diagnosed in the previous month, lung abscess in the previous six months or an allergy to penicillin allergy. Intervention: Five days of high-dose amoxicillin (90mg/kg/d divided TID) followed by five days of placebo Comparison: Ten days of high-dose amoxicillin (90mg/kg/d divided TID) Outcome: Primary Outcome: Clinical cure at 14-21 days Secondary Outcomes: Days off school/childcare, missed work days for carers, adverse reactions and adherence Authors’ Conclusions: “Short-course antibiotic therapy appeared to be comparable to standard care for the treatment of previously healthy children with CAP not requiring hospitalization. Clinical practice guidelines should consider recommending 5 days of amoxicillin for pediatric pneumonia management in accordance with antimicrobial stewardship principles.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patien

Date: July 1st, 2021 Guest Skeptic #1: Dr. Chris Carpenter is Professor of Emergency Medicine at Washington University in St. Louis and a member of their Emergency Medicine Research Core. He is a member of the SAEM Board of Directors and the former Chair of the SAEM EBM Interest Group and ACEP Geriatric Section. He is Deputy Editor-in-Chief of Academic Emergency Medicine. He is also Associate Editor of Annals of Internal Medicine’s ACP Journal Club and the Journal of the American Geriatrics Society, and he serves on the American College of Emergency Physician’s (ACEP) Clinical Policy Committee. Dr. Carpenter also wrote the book on diagnostic testing and clinical decision rules. Reference: Musey et al. Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department. AEM July 2021 This is an extra special SGEM. It is a combo of an SGEM Xtra and an SGEMHOP. The Society of Academic Emergency Medicine (SAEM) has decided to publish its own clinical practice guidelines (CPGs). They are called Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE). This episode will review the GRACE-1 guideline looking at low-risk recurrent chest pain. Because this is a new initiative by SAEM, I interviewed Dr. Chris Carpenter about these new GRACE guidelines. Dr. Chris Carpenter Listen to the SGEM podcast to hear him answer five background questions about these new CPGs. Who came up with the idea of doing CPGs? Why do we need more guidelines? Walk us through the GRACE process? Why pick recurrent, low-risk chest pain to be the first CPG? What do you hope to achieve with these CPGs Guest Skeptic #2: Dr. Suneel Upadhye is an Associate Professor of Emergency Medicine & Clinical Epidemiology at McMaster University. He is a founding member of the Best Evidence in Emergency Medicine (BEEM) program. Suneel is also the inaugural Research Lead for the EM Researchers of Niagara, which is a novel community-based EM research group within Niagara region, Canada. He is also a Guidelines Methodologist within CAEP and the SAEM GRACE groups. Case: You are seeing a patient who has returned to the emergency department (ED) with recurrent chest pain. It is their fourth visit in the last twelve months. He has had his chest pain for approximately three to four hours now and is not classic for ischemic symptomatology. His initial high-sensitivity (hs) troponin is negative, and his ECG is unremarkable. In reviewing his records, you note that he has undergone significant cardiac testing in the recent past, which was unremarkable. This included a normal exercise stress test and CCTA 18 months ago. You also note that he has an underlying anxiety disorder, which is being treated and followed by his family physician. Background: This new SAEM GRACE initiative is committed to using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system, GRADE was pioneered at McMaster University, in creating rigorous, transparent, and trustworthy guidelines on common clinical problems for emergency medicine (EM) physicians that are not always directly studied in EM research activities. The steering group/panelists explored many different potential questions, and voted on the top eight, that were then reviewed in systematic fashion; evidence was rated using GRADE methods, and then final recommendations were made using the GRADE Evidence-to-Decision framework (Upadhye et al CJEM 2021 and Courtney and Lang AEM 2021). The Methods team sought initial GRADE training, then shared that learned expertise with the question groups, many of whom were relative novices in guideline methodology. After two years, a comprehensive document is being published that answers the key diagnostic dilemmas in recurrent chest pain patients who have had recent normal cardiac investigations, to streamline testing and ED length of stay without risk of major adverse coronary events (MACE) at 30 days. Clinical Question: What are the recommendations for managing patients with recurrent, low-risk chest pain in the ED? Recurrent Chest Pain: Patients who have had a previous visit to an ED with chest pain that led to a diagnostic protocol for its evaluation that did not demonstrate evidence of acute coronary syndrome (ACS) or flow-limiting coronary stenosis. This included two or more ED visits for chest pain in a 12-month period. Low-Risk: This was defined by HEART score <4 points (and other scores validated in the ED setting such as the HEART pathway or TIMI score) for disease-related poor outcomes within 30 days all of which require an electrocardiogram (ECG) for risk stratification. Expedited: This was considered a period of three to five days. There is no 100% guaranteed safety outcome for patients with low-risk chest pain with respect to 30-day MACE, but the “warranty” on negative high-sensitivity troponin test results (assay- and institution-dependent), either sing

Date: July 1st, 2021 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com. Reference: Dankiewicz et al: TTM2 Trial Investigators. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest. NEJM 2021 Case: A 58-year-old man collapsed in front of his family. When paramedics arrived, they found him to be in cardiac arrest, with ventricular fibrillation on the monitor. Paramedics managed to get return of spontaneous circulation after a single defibrillation, but the patient is still comatose on arrival. The charge nurse turns to you and asks: should I grab the ice packs? Background: Hypothermia has been a mainstay of post-arrest care after the publication of two trials in 2002 that both suggested a benefit. This trial by Bernard and colleagues randomized 77 patients with an initial cardiac rhythm of ventricular fibrillation who had achieved return of spontaneous circulation (ROSC) but were persistently comatose. The trial was not truly randomized, as the groups were based on the day of the month, and they also weren’t blinded. The results of this Australian trial seemed too good to be true. Hypothermia resulted in a large improvement in neurologic outcomes, defined as well enough to be sent home or to a rehab facility. It was 49% of the hypothermia group versus only 26% of the normothermia group. This gives a NNT of 4. The reported p value was borderline at 0.046, and when I re-calculate, it comes out as 0.06 (not statistically significant). The other trial was the Hypothermia After Cardiac Arrest (HACA), also published in NEJM 2002. They randomized 273 comatose adult patients out of 3,551 screened patients. These were witnessed OHCA who had a shockable rhythm, achieved ROSC, and had a short downtime. This trial used an air mattress to cool patients and was also not blinded. This second trial done in Europe also showed impressive results for favorable neurologic outcome. It was 55% in the hypothermia group vs 39% in the normothermia group (NNT 6). They also reported a 14% absolute decrease in mortality with therapeutic hypothermia post-OHCA. As a result of these two-small trials, hypothermia was widely adopted. However, there were many voices in the evidence-based medicine world that reminded us of the significant uncertainty that remained, and the weaknesses of these two trials. The SGEM covered a few trials looking at therapeutic hypothermia for OCHA in the pre-hospital setting. The bottom line is there is not good evidence that therapeutic hypothermia is superior to usual care and cannot be recommended. SGEM#21: Ice, Ice, Baby (Hypothermia post Cardiac Arrest) SGEM#54: Baby It’s Cold Outside (Pre-Hospital Therapeutic Hypothermia in Out of Hospital Cardiac Arrest) SGEM#183: Don’t RINSE, Don’t Repeat Because of that uncertainty, a much larger, multi-center trial was run. This is the original Target Temperature Management (TTM) trial by Nielson et al NEJM 2013. As almost everyone knows, they compared two difference hypothermia targets, 33C and 36C. The result was no benefit for their primary outcome of mortality at the end of the trial and no benefit Cerebral Performance Category (CPC), modified Rankin Score (mRS) or mortality at 180 days. We did a structured critical appraisal of the TTM trial on SGEM#82. The bottom line was that the trial did not demonstrate a benefit of a targeted temperature of 33C vs. 36C for survival of OHCAs. But both groups in the TTM trial were hypothermic, so although it was the highest quality evidence available, it didn’t tell us whether hypothermia was any better than normothermia. Which is why the TTM2 trial was performed. Clinical Question: Does hypothermia result in improved survival after cardiac arrest as compared to controlled normothermia? Reference: Dankiewicz et al: TTM2 Trial Investigators. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest. NEJM 2021 Population: Comatose adult patients admitted to hospital after an OHCA, irrespective of initial rhythm. Intervention: Hypothermia with a target temperature of 33 degrees Celsius, maintained for 28 hours, and then slowly rewarmed by one degree every three hours. Comparison: Normothermia with an aim to maintain a temperature of 37.5C or less. Outcome: Primary Outcome: Death from any cause at six months Secondary Outcome: The main secondary outcome was a poor functional outcome at six months, defined as a score of four to six on the modified Rankin scale (mRS) Authors’ Conclusions: “In patients with coma after out-of-hospital cardiac arrest, targeted hypothermia did not lead to a lower incidence of death by 6 months than targeted normothermia.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomi

Date: June 25th, 2021 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. Reference: Chinnock et al. Self-obtained vaginal swabs are not inferior to provider-performed endocervical sampling for emergency department diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis. AEM June 2021 Case: A 31-year-old female presents to the emergency department with pelvic pain and vaginal discharge for the past 24 hours. She is afebrile, vital signs are normal and she is having a significant amount of pain. She says the pain is so severe that she cannot even imagine having a pelvic exam done right now for STI testing. Background: Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) are the two most common sexually transmitted infections (STI) reported in the United States. Emergency departments (EDs) now diagnose an increasing percentage of NG/CT cases compared to STI clinics. (1,2) The standard of care for NG/CT diagnosis is nucleic acid amplification testing (NAAT), with the collection method being provider-performed endocervical sampling (PPES). PPES is uncomfortable for patients and has numerous other limitations, including the need for exam rooms, an available provider and often a female chaperone. These limitations can delay sample collection and can also add significant delay in a busy ED. The need for universal pelvic examination in the ED to perform STI testing has also come under increasing scrutiny. (3) Vaginal sample collection with self-obtained vaginal swabs (SOVS) was first developed and researched in non-ED settings based on these reasons and others. These studies demonstrated comparable sensitivity for NG/CT diagnosis when comparing SOVS to PPES, and high patient acceptability. (4-8) However, those studies were performed in a wide range of non-ED settings and were mostly asymptomatic screening rather than STI testing in an acute care environment. This study compares PPES with SOVS in an ED setting and explores patient’s acceptability or preference of SOVS versus PPES. Clinical Question: Do self-obtained swabs have noninferior sensitivity for the diagnosis of NG/CT compared to provider performed swabs in an ED setting using a rapid NAAT. Reference: Chinnock et al. Self-obtained vaginal swabs are not inferior to provider-performed endocervical sampling for emergency department diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis. AEM June 2021 Population: Female patients 18 years of age or older who were judged by the treating practitioner to need NG/CT testing Exclusions: Incarcerated any acute psychiatric condition precluded understanding instructions or giving informed consent, not English or Spanish proficient, or treated for NG/CT within the previous four weeks. Intervention: Self-obtained vaginal swab (SOVS) for NG/CT Comparison: Provider performed endocervical sampling swab for NG/CT Outcome: Primary Outcome: Noninferiority of SOVS sensitivity for NG/CT, with noninferiority being demonstrated if sensitivity was 90% or above. Secondary Outcomes: Kappa measurement of the SOVS and PPES, SOVS organism-specific sensitivity for NG and CT, acceptance rate of SOVS, rate of patients worried about doing SOVS correctly, and SOVS refusal rate. Dr. Brian Chinnock This is an SGEMHOP episode which means we have the lead author on the show. Dr Brian Chinnock is Professor in Department of Emergency Medicine at the UCSF-Fresno Medical Education Program, and Research Director. Authors’ Conclusions: “SOVS are noninferior to PPES in NG/CT diagnosis using a rapid NAAT in ED patients and surveys indicate high patient acceptability.” Quality Checklist for Observational Trials: 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/is the estimate of risk? The results are precise with narrow confidence intervals Do you believe the results? Yes Can the results be applied to the local population? Yes Do the results of this study fit with other available evidence? Yes Results: The researchers found 750 patients eligible for inclusion in the study. The final cohort consisted of 515 patents with completed PPES and the SOVS results. The mean age was 30.7 years of age with 52% Hispanic ethnicity. The overall prevalence for either NG or CT or both was 17% (86/515). Of these patients with STIs, 34% (29/86) had infection with NG, 54% (47/86)) with CT, and 12% (10/87) with coinfection. Key Result: SOVS was non-inferior to PPES Primary Outcome: Noninferiority of SOVS sensitivity for NG

Date: June 11th, 2021 Guest Skeptic: Dr. Dennis Ren is a paediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. Reference: McLaren SH, et al. Invasive bacterial infections in afebrile infants diagnosed with acute otitis media. Pediatrics 2021 Case: You are working with a medical student at the emergency department when a 2-month-old boy is brought in by his parents for fussiness. They note that he has had upper respiratory symptoms for the past few days and fussier than usual. He has still continued to feed well and make wet diapers. He has not had any fever. Yesterday, they noticed that he seemed to be pulling at his right ear. On exam, he is afebrile, active, and alert. He cries and moves vigorously when you look into his ear. You see a bulging, red tympanic membrane. His left tympanic membrane is clear. The rest of his exam is unremarkable. You turn to the medical student and ask her what she would like to do for this patient. She replies that she thinks the patient has an acute otitis media (AOM) but given his age, she is also thinking about the possibility of an invasive bacterial infection (IBI) and would like to obtain some blood for labs and even consider a lumbar puncture for cerebral spinal fluid. How do you reply? Background: Acute Otitis media is the second most diagnosed illness in children and the most common indication for antibiotic prescription [1-2]. We have covered the of AOM twice on the SGEM: SGEM#132: One Balloon for Otitis Media with Effusion with Dr. Richard Lubell SGEM#278: Seen Your Video for Acute Otitis Media Discharge Instructions SGEMHOP with lead author Dr. Naveen Poonai? In 2013, the American Academy of Pediatrics (AAP) updated recommendations for the diagnosis and management of acute otitis media (AOM) for children older than 6 months. Unfortunately, there is limited guidance for patients younger than 6 months. The diagnosis of AOM becomes more complicated by the concern for concurrent invasive bacterial infections (IBI) in infants less than 3 months of age. Previous studies have demonstrated low prevalence of concurrent IBI in infants with AOM, but sample size has been small and included a mix of afebrile and febrile infants [3-4]. Additionally, the microbiology of pathogens causing AOM has shifted after the implementation of the pneumococcal conjugate vaccine with a higher proportion of patients having culture negative AOM [5]. This uncertainty has led to wide practice variation and controversy surrounding diagnostic testing (blood and cerebrospinal fluid testing), antibiotic administration (IV vs oral), and disposition (discharge vs admission) in infants with AOM. Clinical Question: What is the prevalence of invasive bacterial infections and adverse events in afebrile infants ≤ 90 days of age with acute otitis media? Reference: McLaren SH, et al. Invasive bacterial infections in afebrile infants diagnosed with acute otitis media. Pediatrics 2021 Population: Afebrile infants ≤ 90 days of age with clinically diagnosed acute otitis media across 33 pediatric emergency departments (29 USA, 2 Canadian and 2 Spanish EDs) from 2007 to 2017 Excluded: Temperature ≥38°C and <36°C in the ED or within 48 hours, antibiotic use (other than topical) within 48 hours of presentation, concurrent mastoiditis, evidence of focal bacterial infection, transferred to ED with previous diagnostic testing/antibiotics Intervention: Evaluation of invasive bacterial infections in blood or cerebrospinal fluid (CSF) Comparison: None Outcomes: Primary Outcome: Prevalence of IBI (bacterial meningitis and bacteremia) Secondary Outcomes: Variability in diagnostic testing for IBIincluding blood or cerebrospinal fluid (CSF), parenteral antibiotic administration, and hospitalization. Safety Outcome: AOM-associated adverse events Authors’ Conclusions: “Afebrile infants with clinician-diagnosed acute otitis media have a low prevalence of invasive bacterial infections and adverse events; therefore outpatient management without diagnostic testing may be reasonable.” 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 (diagnostic testing) accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Unsure 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 Results: They screened 5,270 infants from 33 sites to establish a cohort of 1,637 who met inclusion/exclusion criteria. The median age was 68 days and 89% met the simplified American Academy of Pediatrics diagnostic criteria for AOM. Key Result: No infan

Date: May 25th, 2021 Guest Skeptic: Dr. Garreth Debiegun is an emergency physician at Maine Medical Center in Portland, ME and clinical assistant professor with Tufts University School of Medicine. He also works at an urgent care and a rural critical access hospital. Garreth is interested in wilderness medicine and is the co-director of the wilderness medicine clerkship at Maine Med, and the medical director for Saddleback Ski Patrol and for Maine Region NSP. At work Garreth imagines himself as a student of evidence-based medicine trying to provide the best care based on the best evidence. References: Suzuki et al. Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial. JAMA 2021 Zi et al. Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke: The DEVT Randomized Clinical Trial. JAMA 2021 Case: A 74-year-old woman presents to your emergency department with 1.5 hours of right-sided weakness, aphasia, and neglect. On rapid bedside assessment you calculate the National Institute of Health Stroke Score/Scale (NIHSS) of 11 and a Field Assessment for Stroke Triage for Emergency Destination (FAST-ED) score of 7; you suspect a large vessel occlusion (LVO) based on the high NIHSS and FAST-ED score >3. A non-contrast CT shows no evidence of intracranial hemorrhage. A CT angiogram plus CT perfusion demonstrate a clot in the left proximal middle cerebral artery (MCA) with a small infarcted area and a large penumbra. Based on your institution’s current guidelines, the patient is a candidate for endovascular therapy, but they are also within the current window for the administration of thrombolytics. You wonder if you gotta be starting something? Specifically, you wonder if you should give the thrombolytics while waiting for your neurointerventional/endovascular team? Background: Management of acute ischemic stroke has been discussed on the SGEM ever since this knowledge translation project was launched in 2012. My position remains that there is uncertainty as to whether tPA provides a patient-oriented outcome and this was summarized in the downgrading of the NNT recommendation to “yellow” with Dr. Justin Morgenstern from First10EM. The world of stroke management has changed in the last few years the more robust evidence to support endovascular therapy (EVT) for large vessel occlusion (LVO) strokes. The tipping point came with the publication of MR. CLEAN in 2015. It was a multicenter, randomized, unblinded trial of patients with an LVO stroke in the anterior circulation treated in less than six hours after onset of symptoms. The primary outcome was good neurologic function defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days. The trial included 500 patients and reported an absolute risk reduction of 14% (33% EVT vs 19% control) with a NNT of 7. Four other RCTs were stopped early due to the publication of MR. CLEAN. All of these were published in the NEJM in the following six months. SWIFT PRIME (n=196) NNT of 4 EXTEND-IA (n=70) NNT of 2-5 depending on which outcome you picked REVASCAT (n=206) extended the window to eight hours NNT 6.5 ESCAPE (n=316) extended to 12 hours NNT 4 There are dangers with stopping trials early. Dr. Gordon Guyatt wrote in the BMJ that it can introduce bias towards efficacy. He said you should have a high level of skepticism regarding the findings of trials stopped early for benefit, particularly when those trials are relatively small, and replication is limited or absent. A systematic review and meta-analysis (SRMA) was published by Badhiwala, JH et al in JAMA 2015 looking at EVT for stroke. The first three RCTs reported no superiority. Then came MR. CLEAN and those four additional studies that were stopped early. The forest plot shows a point estimate that favors EVT and the 95% confidence interval does not cross the line of no statistical difference. We do need to be careful in not over interpreting this data because the bias of stopping trials early could have been compounded in the SRMA process. A couple more RCTs were published since the 2015 SRMA: DAWN 2018 (n=206) NNT 3 between 6-24 hours, stopped early DEFUSE 2018 (n=182) NNT 4 between 6-16 hours, stopped early Here is a lists all the studies and the number of patients enrolled/center/year put together by friend of the SGEM, Dr. Salim Rezaie (REBEL EM). The average was 4.6 patients/year from these stroke centres. While the NNT for EVT looks very impressive, it is suffering from denominator neglect. Once the patient is getting the intervention the NNT is in the single digits. However, how many possible stroke patients were screened, and code strokes were called to get the impressive NNTs of the EVT trials? Most of these trials didn’t tell us how many patients they screened to get the patients they regis

Date: May 28th, 2021 Guest Skeptics: Heather Logan is the executive Strategy lead for the Canadian Agency for Drug and Technologies in Health (CADTH). Dr. Wendy Levinson is the Chair of Choosing Wisely Canada (CWC) and a Professor of Medicine, University of Toronto This SGEM Xtra is based on document created by CADTH and presented at Choosing Wisely Canada National annual meeting May 13, 2021. The title of the report is Using Health Care Resources Wisely After the COVID-19 Pandemic: Recommendations to Reduce Low-Value Care. We have discussed Choosing Wisely before on SGEM Episodes: SGEM#15: Choosing Wisely SGEM Xtra: CAEP Choosing Wisely SGEM Xtra: Right, You’re Bloody Well Right, You’ve got the Bloody Right to Care Choosing Wisely Canada (CWC): Dr. Wendy Levinson It is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices. Choosing Wisely Canada is led by a team of clinicians and staff based at St. Michael’s Hospital (Toronto), the University of Toronto, and in collaboration with the Canadian Medical Association. Choosing Wisely Canada mobilizes and supports clinicians and organizations committed to embedding campaign recommendations into practice. There are close to 350 documented quality improvement projects across the country that are building capacity for the spread and scale of Choosing Wisely. These efforts are underway in hospitals, long-term care homes, and primary care clinics. Many of these innovative projects, including their evidence-based tools and methods, have been packaged into easy to follow toolkits that are broadly circulated in order to encourage widespread adoption. This has allowed Choosing Wisely Canada to foster a network for those looking to implement campaign recommendations into practice. Canadian Agency for Drug and Technologies in Health (CADTH): Heather Logan It is an independent, not-for-profit agency funded by Canadian federal, provincial, and territorial governments (except Quebec) to provide credible, impartial advice and evidence-based information about the effectiveness of drugs and other health technologies to Canadian health care decision-makers. CADTH believes that credible, objective evidence should inform every important health care decision. When you want to know what the evidence says, ask CADTH. Created in 1989 by Canada’s federal, provincial, and territorial governments, CADTH was born from the idea that Canada needs a coordinated approach to assessing health technologies. The result was an organization that harnesses Canadian expertise from every region and produces evidence-informed solutions that benefit patients in jurisdictions across the country. South Huron Hospital Association (SHHA) is known as the "Little Hospital that Does". SHHA has been choosing wisely since 2012 selecting five items every three years. SHHA Choosing Wisely 2012 Influenza shots for staff with privileges SGEM#20 Use Ottawa ankle and knee rules SGEM#3 and SGEM#5 No routine use of antivirals for Bell’s Palsy SGEM#14 No routine use of antibiotics for simple cutaneous abscesses SGEM#13 No routine use of proton pump inhibitors for upper GI bleeds SGEM#16 SHHA Choosing Wisely 2015 Utilize Canadian CT head rules to guide our decisions on getting CT heads SGEM#106 Utilize Canadian C-Spine rules to guide our decisions on obtaining plain film c-spine imaging SGEM#232 Do not do annual physical exams on asymptomatic adults with no significant risk factors Do not screen women with Pap smears if under 21 years of age or over 69 years of age Do not order echo cardiograms routinely SHHA Choosing Wisely 2018 Only use supplemental Oxygen for STEMI patients that are hypoxic (saturations < 90%) SGEM#193 Use appropriate antibiotic selection for uncomplicated COPD exacerbation ie. Amoxicillin, Septra and Doxycycline Do not start IV unless you are 80% sure that you are actually going to use the IV SGEM#204 Treat Chronic Pain utilizing non-pharmacological means before prescribing an opioid medication Don’t place or leave in place a urinary catheter without reassessment Low-Value Care, Challenges of COVID19, High-Value Care and the Purpose of the CADTH Report Slides from the Choosing Wisely Presentation - May 13th, 2021 CADTH Four Step Approach Recommendations in Six Key Clinical Areas Primary care: Seven recommendations span primary care, including avoiding unnecessary rural transfers, annual exams, and screening and imaging tests Specialty care: Four recommendations address low-value procedures, including chronic dialysis, colonoscopy for constipation, cardiac imaging without high-risk markers, and knee MRIs End-of-life care: Three recommendations emphasize the importance of advance care planning conversations for patients with serious illness and access to palliative care Hospital care: Two recommendations address low-value routine i

Date: May 20th, 2021 Guest Skeptic: Dr. Robert Edmonds is an emergency medicine physician in the Air Force in Dayton, Ohio, and a University of Missouri-Kansas City residency alumni from 2016. Reference: Jhunjhunwala et al. Reassessing the cardiac box: A comprehensive evaluation of the relationship between thoracic gunshot wounds and cardiac injury. Journal of Trauma and Acute Care Surgery. September 2017 DISCLAIMER: THE VIEWS AND OPINIONS OF THIS PODCAST DO NOT REPRESENT THE UNITED STATES GOVERNMENT OR THE US AIR FORCE. This SGEM episode was recored live for the Truman Medical Centers Multidisciplinary Trauma Conference. We did the session over zoom as an SGEM Journal Club. If you would like a copy of the slides from the presentation you can download them free open access at this LINK. Case: You receive a call on the Biocom for an incoming Type A trauma, three minutes out. The patient is an adult male with a gunshot wound to the chest, and they’re combative with emergency medical services (EMS). Upon arrival in the emergency department (ED), the patient is incoherently speaking, has a pulse of 135 beats per minute, blood pressure of 85/50 mm Hg, and an obvious open wound in their left mid-axillary line at the level of the nipple. Background: Penetrating trauma is a major disease burden in the United States, and gunshot wounds cause 30,000 deaths annually [1] . As a country, penetrating trauma accounts for about 10% of all trauma cases [2] , but at some trauma centers it can reach much higher numbers. Here at the Truman Medical Center the average penetrating trauma for gunshot wounds alone represents ~19% of all traumas. Naturally, patients with a direct cardiac injury from a gunshot wound (GSW) require prompt identification and management, so tools have sprung into existence to attempt to risk stratify patients at a higher risk of an underlying cardiac injury. One of the more common tools is the “cardiac box”. This three-dimensional area is at the highest risk of cardiac injury. The anatomical area is defined anteriorly as between the clavicle and xyphoid, and between the bilateral midclavicular lines. Per the authors, “The dogma of the cardiac box is largely based on small studies with primarily stab wounds. The underlying issue is that stab wounds are low kinetic energy and result from instruments with a fixed length. Thus, most stab wounds usually only result in a cardiac injury if the entrance is in very close proximity to the heart or there is a long weapon. Because these studies did include gunshots, the concept of the “box” was ultimately uniformly applied to all mechanisms. Injuries from high kinetic energy projectiles, however, can cause cardiac injury from entrance wounds to any area of the torso, especially the thorax.” Although it may be obvious to some that injury outside the cardiac box doesn’t rule out injury to the heart, the existence of such a tool colors our language and shifts the perceived risk in the clinician’s head. According to a recent study in the Journal of Surgical Research [3] , 44% of all penetrating thoracic trauma patients presented to a non-trauma center (not a level 1 or level 2 ACS defined trauma center). For clinicians in these settings, use of the “cardiac box” nomenclature can have a significant impact on the perceived injuries when communicating with an on-call surgeon or when transferring the patient to another facility. If the injury is outside the cardiac box, it can be perceived as less concerning and may give the treating team a false sense of security. Clinical Question: Are the anatomic borders of the cardiac box adequate to predict cardiac injury from gunshot wounds? Reference: Jhunjhunwala et al. Reassessing the cardiac box: A comprehensive evaluation of the relationship between thoracic gunshot wounds and cardiac injury. Journal of Trauma and Acute Care Surgery. September 2017 Population: All patients in the Fulton County (Georgia) Medical Examiner’s autopsy registry who sustained a penetrating torso gunshot wound from January 2011 to December 2013. Excluded: Injuries above the clavicles and below the xyphoid Exposure: Wounds that were in the cardiac box- “defined as the two-dimensional plane covering the anterior surface of the thorax from the level of the clavicle to the tip of the xiphoid… and between the midclavicular lines (laterally).” The authors also included this same region projected onto the posterior thorax as well. Comparison: Patients with wounds outside the “cardiac box” Outcome: Primary Outcome: Cardiac injury Safety Outcome: None (this data all came from autopsy reports) Authors’ Conclusions: “For GSWs, the current cardiac box is inadequate to discriminate whether a gunshot wound will cause a cardiac injury. As expected, entrance wounds nearest to the heart are the most likely to result in cardiac injury, but, from a clinical standpoint, it is best to think outside the “box” for GSWs to the thorax.” Quality Checklist for Observational Study

Date: May 21st, 2021 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 and an Associate Editor for the NEJM Journal Watch Emergency Medicine. Reference: Varner et al. A randomized trial comparing prescribed light exercise to standard management for emergency department patients with acute mild traumatic brain injury. AEM May 2021 Case: A 32-year-old female presents with headache after a low-speed motor vehicle collision as a restrained driver. She was ambulatory on scene. The patient is not anticoagulated, has no midline neck pain, and no evidence of other injuries. She is generally well appearing without any deficients on neurological examination, given her minor mechanism, and normal examination no imaging or further testing is required. You tell her you believe she has a concussion. Background: Concussions or mild traumatic brain injury (mTBI) are commonly diagnosed in the Emergency Department (ED). Most patients recover within the first week; however, 15-30% of patients develop persistent post-concussive symptoms. Historically, cognitive and physical rest have been recommended following the diagnosis of mTBI and patients have been advised to resume exercise only once symptoms have abated. Recent studies have challenged this dogma of "rest is best" with one multicenter study finding that early return to physical activity within a week of injury was associated with an improvement in time to symptom reduction. One of the issues that comes up with minor head injuries is do we need to get advanced imaging. We looked at the Canadian CT Head Rule (CCHR) published by Dr. Ian Stiell in the Lancet 2001 on SGEM#106. You can find this clinical decision instrument on MDCalc. The SGEM has also covered the issue of getting CT scans in pediatric patients with minor head injuries. That used the PECARN data which has a protocol for children less than two years of age and those older than two years of age. That SGEM#112 episode on pediatric concussions was covering a study that asked if there is a benefit to recommending strict rest after a child has a concussion. The bottom line from that episode was that in children with concussion, two days of rest followed by a gradual return to activity is preferred over five days of rest followed by a gradual return to activity. The longer strict rest period appears to cause more post-concussive symptoms. We have also looked at the diagnostic accuracy if the CCHR in patients 65 years of age or older in predicting clinically important brain injuries (SGEM#266). The published study opened the door for reducing the number of unnecessary head CTs in this cohort of patients, but further high-quality prospective studies are required prior to clinical application. There is limited information on the best strategy for preventing post-concussion syndrome (PCS). Clinical Question: Are patients presenting to the ED with mild concussion who are prescribed light exercise less likely to develop post-concussive syndrome at 30 days compared with those given standard discharge instructions? Reference: Varner et al. A randomized trial comparing prescribed light exercise to standard management for emergency department patients with acute mild traumatic brain injury. AEM May 2021 Population: Adults 18-64 years old presenting to the ED with a mild TBI. This was defined as a direct blow to body with force transmitted to the head resulting in somatic, cognitive, emotional, or behavioral or sleep symptoms within the prior 48 hours. Exclusions: Patients with acute intracranial injury, multisystem injuries preventing light exercise, GCS <15 at time of discharge, intoxication at time of discharge, or inability for telephone follow up Intervention: Standardized discharge instructions that included 48 hours of rest and then gradual return to usual activity with a prescription for 30 minutes of light exercise daily (ex walking) Comparison: 48 hours of rest and then gradual return to usual activity but instructed not to exercise until symptoms had resolved or advised to do so by a medical provider Outcomes: Primary Outcome: Proportion of patients with post-concussive syndrome at 30 days, defined as the presence of three or more symptoms on the Rivermead Post-concussion Symptoms Questionnaire (RPQ) at 30 days Secondary Outcomes: Change in RPQ from baseline to 7, 14, and 30 days after the initial ED visit; number of missed days of school or work; and repeat visits to a health care provider. Dr. Catherine Varner This is an SGEMHOP episode which means we have the lead author on the show. Dr. Catherine Varner is an emergency physician and clinician scientist at the Schwartz / Reisman Emerge

Date: May 6th, 2021 Guest Skeptic: Dr. Daniel Schwerin is employed with Prisma Health-Upstate as a clinical assistant professor, emergency medicine GME director for emergency medical services and medical director for several local EMS agencies and has lectured on prehospital stroke management. Reference: Fatima et al. Mobile stroke unit versus standard medical care in the management of patients with acute stroke: A systematic review and meta-analysis. International Journal of Stroke 2020 Case: A 70-year-old man develops sudden right-sided weakness beginning shortly after breakfast and his partner appropriately calls emergency medical services (EMS). Their local EMS service arrives quickly with a conventional ambulance. He has heard about these special ambulances with CT Scanners and wonders if that will make an important difference for his partner. Background: We have discussed stroke so many times on the SGEM. It is one of the five most popular topics like TXA, PE, POCUS and ketamine. Justin Morgenstern from First10EM and I recently downgraded the NNT website recommendation for tPA in acute ischemic stroke to “yellow”. A yellow recommendation means the benefits and harms are unclear due to the uncertainty in data. But something that often comes up when discussing stroke treatment is we need to go fast because time is brain. The term “time is brain” was coined by Dr. Camilo Gomez back in 1993. He modified his position in 2018 and said: “It is no longer reasonable to believe that the effect of time on the ischaemic process represents an absolute paradigm. It is increasingly evident that the volume of injured tissue within a given interval after the estimated time of onset shows considerable variability in large part due to the beneficial effect of a robust collateral circulation.” We never did have high-quality evidence to support the position that treating stroke patients earlier was better. All we had was an association because there were no RCTs that randomized stroke patients into getting thrombolytics early or late. This means there could have been unmeasured confounders responsible for the observed effect. The largest placebo controlled RCT looking at tPA for acute ischemic stroke was IST-3 which was covered on SGEM#29. There were several serious problems with that trial including: Largely unblinded trial (91%) Stopped early Self-reported outcome by telephone or mailed questionnaire No superiority for primary outcome 4% absolute increase in early mortality Another interesting point about IST-3 is the subgroup analysis did not support the claim that time was brain. There was no statistical difference between the <3hrs, 3-4.5hrs and >4.5hrs. However, the point estimate favored tPA in <3hrs, then placebo between 3-4.5hrs and then back to tPA in >4.5hrs? You also need to look very carefully at the figure to see they used the 99% confidence interval instead of the standard 95% confidence intervals. If calculating the Odds Ratio for the 3-4.5hr group you find it is statistically significant favouring the placebo group. Clinical Question: Does a mobile stroke unit (MSU) with earlier imaging and delivery of tPA improve outcomes, or is the downstream effect of improved resources at a comprehensive stroke center that improves outcomes for patients with strokes? Reference: Fatima et al. Mobile stroke unit versus standard medical care in the management of patients with acute stroke: A systematic review and meta-analysis. International Journal of Stroke 2020 Population: This was a systematic search that found 11 articles that were either randomized controlled trials (RCTs), retrospective or prospective studies that compared the clinical outcomes among patients treated in either a mobile stroke unit or through conventional care/standard medical care for the acute stroke. Exclusions: Case–control studies, case series, and case reports Intervention: MSU that is a specialized ambulance equipped with a CT-scanner, point-of-care laboratory, and thrombolysis is started immediately within the MSU vehicle. Comparison: Conventional care that consists of transferring to the patient the emergency department or specialized stroke centres and given thrombolysis in-hospital according to the imaging report. Outcome: Primary Outcomes: Neurologic outcome as defined by modified Rankin scale (mRS) score at day 7 and day 1 post treatment. Good neurologic outcome was an mRS of 0-2 while a poor neurologic outcome was an mRS of 3-6 Secondary Outcomes: All-cause mortality, stroke related-neurological death, other adverse events, and mean time gains Authors’ Conclusions: “Our results corroborate that patients treated in mobile stroke unit lead to short-term recovery following acute stroke without influencing the mortality rate. Further prospective studies are needed to validate our results.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Unsure The search for studies was d

Date: May 7th, 2021 Guest Skeptic: Dr. Ryan Stanton is a community emergency physician with Central Emergency Physicians in Lexington, KY. He is on the Board of Directors for the American College of Emergency Physicians and host of the ACEP Frontline Podcast. He is an EMS medical director with Lexington Fire/EMS as well as the AMR/NASCAR Safety Team. Reference: Shah and Mitra. Use of Corticosteroids in Cardiac Arrest - A Systematic Review and Meta-Analysis. Crit Care Med Feb 2021 Case: A 58-year-old male has a witnessed cardiac arrest while admitted to the observation unit for a chest pain evaluation. CPR is initiated and a hospital rapid response team is called. The resuscitation team arrives and ACLS protocols are continued. The issue of whether corticosteroids should be administered is brought up during the code. Background: Cardiac arrests have high morbidity and mortality rates both in-hospital cardiac arrests (IHCAs) and out of hospital cardiac arrests (OHCAs). It is estimated that the survival to discharge for an IHCA is approximately 18% with only 10% for OHCAs. This contrasts with what the public sees watching CPR being done on TV. Survival on screen is four to five times higher than reality, according to one study (see graphic). Improving outcomes for patients with cardiac arrests has been an ongoing challenge in pre-hospital and in hospital medicine. We have discussed many aspects of such care on the SGEM including: Therapeutic hypothermia (SGEM#54, SGEM#82, SGEM#183 and SGEM#275) Epinephrine (SGEM#64 and SGEM#238) IV vs IO Access (SGEM#231) Supraglottic Airways (SGEM#247) Crowd Sourcing CPR (SGEM#143 and SGEM#306) Mechanical CPR (SGEM#136) We understand more physiologic changes that take place following cardiac arrest and there have been several studies looking at the potential role of corticosteroids in the intra-arrest timeframe. SGEM#50 looked at a RCT published in JAMA 2013 looking to see if a vasopressin, steroids, and epinephrine (VSE) protocol for IHCAs could improve survival with favorable neurologic outcome compared to epinephrine alone. That RCT had 268 patients and demonstrated a better odds ratio for ROSC and survival to discharge with good neurologic outcome. The SGEM bottom line at the time was that the results were very interesting, but a validation study should be done to try and replicate the results. I have not seen a validation study published. We know that epinephrine can increase ROSC, survival to hospital, and even survival to hospital discharge based on the Paramedic 2 Trial. Unfortunately, epinephrine was not superior to placebo for the patient-oriented outcome of survival with good neurologic outcome. Corticosteroids have been suggested as a possible therapy in these clinical situations. However, there is an old RCT that looked at dexamethasone in OHCA and it failed to demonstrate an improvement in survival to hospital discharge (Paris et al AEM 1984). A SRMA published in 2020 on the use of steroids after cardiac arrest reported an increase in ROSC and survival to discharge but was limited by the availability of adequately powered high-quality RCTs (Liu et al JIMR 2020). Clinical Question: Does the use of corticosteroids impact neurologic outcomes and mortality in patients with a cardiac arrest? Reference: Shah and Mitra. Use of Corticosteroids in Cardiac Arrest - A Systematic Review and Meta-Analysis. Crit Care Med Feb 2021 Population: Randomized controlled trials and comparative observational studies of patients with in or out of hospital cardiac arrests Exclusions: Any single arm studies, case reports/ series, narrative reviews, and studies irrelevant to the focus of this article. Intervention: Corticosteroids as adjunct therapy in cardiac arrest Comparison: Patients that did not receive corticosteroids in cardiac arrest Outcome: Primary Outcomes: Good neurologic outcome (measured using the Glasgow-Pittsburgh Cerebral Performance Category score), survival to hospital discharge, and survival at greater than or equal to 1 year Secondary Outcomes: Return of spontaneous circulation (ROSC), Intensive Care Unit (ICU) and hospital length of stay (LOS), duration of vasopressor and inotropic treatment, and blood pressure (systolic blood pressure, diastolic blood pressure, and mean arterial pressure [MAP]) during CPR and after ROSC. Authors’ Conclusions: “The study found that there are limited high-quality data to analyze the association between corticosteroids and reducing mortality in cardiac arrest, but the available data do support future randomized controlled trials. They did find that corticosteroids given as part of a vasopressin, steroids, and epinephrine regimen in in-hospital cardiac arrest patients and for post resuscitation shock did improve neurologic outcomes, survival to hospital discharge, and surrogate outcomes that include return of spontaneous circulation and hemodynamics. They found no benefit in in-hospital cardiac arrest or out-of-hospital cardiac arrest p

Date: April 30th, 2021 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com. He is also one of the SGEM Hot Off the Press Faculty. Reference: Donaldson et al. Review article: Why is there still a debate regarding the safety and efficacy of intravenous thrombolysis in the management of presumed acute ischaemic stroke? A systematic review and meta-analysis. Emerg Med Australas 2016. This SGEM Xtra is based on the new recommendation on TheNNT website for tPA in acute ischemic stroke. This is the third time there has been a recommendation on this topic. The first review gave thrombolytics a "red color recommendation: no benefit." The second review gave alteplase, a single agent, a "green color recommendation: benefit>harm." Since no relevant trials were published between the two and both author groups examined essentially the same data and arrived at opposing conclusions, we wanted to understand and try to explain the conflicting interpretations. Our interpretation of the available literature was to give it a “yellow colour recommendation: net benefits and harms unclear due to uncertainty in data”. This resulted in the summary statistic of the benefit NNT (not reported: Uncertain) and Harms in NNT (not reported: Uncertain). More details on the NNT Rating System are available. It would be hubris to presume that our summary would arrive at the one true answer. But our goal wasn’t to provide an answer. Our goal was simply to explain the science as well as we could, so people could understand why there is a debate – and the uncertainty that underlies that debate. The Donaldson et al SRMA included 10,431 patients in 26 randomized trials comparing intravenous thrombolysis with placebo or standard care in acute ischemic stroke [1]. Their efficacy endpoint was good functional outcome, defined as a modified Rankin Score (mRS) of 3 or less. This is defined as some residual disability requiring assistance but able to walk and care for personal needs independently. The harm endpoints were symptomatic intracranial hemorrhage (as defined by individual trials) and overall mortality The authors report a 3.2% improvement in good neurologic outcome, a 5.4% increase in symptomatic intracranial hemorrhage, and a 2.5% increase in mortality. However, we question the certainty implied by these summary numbers. Emberson and colleagues reported only on alteplase (a problem we will discuss further) and found a 5% improvement in neurologic outcomes, a 5.5% increase in intracranial hemorrhage, and a 1.4% increase in 90-day mortality that was not statistically significant [2]. A 2014 Cochrane review by Wardlaw et al and arrived at similar conclusions with significant improvement in neurologic outcomes, increased intracranial hemorrhage, and increased mortality [3]. Thus, our conclusions and discussion are unchanged by choice of review and reflect our belief that pooling data on this topic is overly simplistic and masks profound uncertainty. We both really like TheNNT website, and the NNT as a concept. But there are problems with the NNT if used in isolation. One of the great conceptual difficulties of summary statistics like the number-needed-to-treat (NNT) is the implication of certainty. A major strength of the NNT is its simplicity, making complex research easier to understand. A weakness, however, is also its simplicity, because it can hide the complexity of research, ignore confidence intervals, and obscure biases. For most topics, these details are far more important than any individual number. There is an SGEM Xtra on some of the limitations of the NNT/NNH summary statistics called the NNT - WET or DRI? It was based on an article published Dec 2019 in AEM by Reeves and Reynolds. There are multiple sources or uncertainty around thrombolytics and stroke which we discussed in TheNNT recommendation. Conflicting Individual Trial Results The first source of uncertainty we highlighted was conflicting individual trial results. Among 26 trials in this systematic review by Donaldson et al, 24 research groups found no benefit in their selected primary outcome [1]. And the two that claim a benefit (NINDS part 2 and ECASS III) both had baseline imbalances that may explain the difference [4,5]. In fact, there are re-analyses that adjust for those imbalances in both trials, and the benefits disappear [6,7]. However, in some re-analyses of NINDS-2 the benefit is maintained, which adds to the uncertainty here [8,9]. We reviewed the NINDS trial with Dr. Swaminathan back on SGEM#70. More recently Prof Fatovich and I reviewed the reanalysis of ECASS-3 by Dr. Brian Alper on SGEM#297. Clinical Heterogeneity of Individual Trials Another source of uncertainty is the clinical heterogeneity of individual trials. The 26 trials are clinically heterogeneous, enrolling stroke patients of differing demographics, treatment times, stroke severities, anatomic terr

Date: April 19th, 2021 Guest Skeptic: Dr. Kirsty Challen (@KirstyChallen) is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). 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 is also the creator of the wonderful infographics called #PaperinaPic. Reference: Martel et al. Randomized Double-blind Trial Intramuscular Droperidol, Ziprasidone and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department. AEM April 2021 Case: You are sitting minding your own business charting on shift when you become aware of shouting and banging from your ambulance bay. On investigating you find a collection of nursing, EMS and hospital security personnel surrounding an obviously agitated patient with blood on his head who is attempting to punch them. The nurse wants to know what medications he can get to chemically restrain the patient. Background: We have covered the issue of excited delirium back in SGEM#218 with a systematic review which found that the evidence base for most pharmacological treatments at that point was poor. Way back in 2013 we looked at haloperidol for agitation due to psychosis (SGEM#45) and concluded that it was an effective treatment but had common side effects. Droperidol has been used widely, particularly in Australasia, for acute severe agitation. Unfortunately, an FDA Black Box warning and supply issues meant that droperidol effectively vanished from the US armamentarium from 2013-2019 and other agents were used and investigated. Clinical Question: In patients needing parenteral sedation for acute agitation, is droperidol, ziprasidone or lorazepam intramuscularly most effective and safe? Reference: Martel et al. Randomized Double-blind Trial Intramuscular Droperidol, Ziprasidone and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department. AEM April 2021 Population: Emergency department (ED) patients 18 years or old where the treating physician determined the need for parenteral sedation for acute agitation (it needed a patient or staff safety concern, not purely a high agitation score). Exclusions: Prisoners or those in police custody, pregnant or breast-feeding, or with documented allergy to any study medications. Intervention: Droperidol 5mg IM, Ziprasidone 10mg IM or Ziprasidone 20mg IM Comparison: Lorazepam 2mg IM Outcome: Primary Outcome: Adequate sedation at 15 minutes was defined as an Altered Mental Status Scale (AMSS) of zero Secondary Outcomes: Need for additional sedation, ED length of stay, respiratory depression (SpO2<90% requiring supplemental O2, EtCO2 falling by 10mmHg or rising by 15mmHg). Dr. Marc Martel This is an SGEMHOP episode, which means we have the lead author on the show. Dr. Martel is a practicing emergency physician at Hennepin County medical center in Minneapolis, Minnesota since 2000. He has been a nocturnist for essentially his entire career. Dr. Martel’s research focuses on finding the safest way to care for patients with acute agitation while respecting patient's dignity, limiting restraint use, and efficiently getting them care they need. Authors’ Conclusions: “Droperidol was more effective for sedation and was associated with fewer episodes of respiratory depression than lorazepam or either dose of ziprasidone.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Unsure 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. Yes 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. No The treatment effect was large enough and precise enough to be clinically significant. Yes Results: They recruited 115 participants into the trial, 87 of whom were men. The mean age was around 40 years, and the underlying diagnosis was primarily alcohol intoxication, with other diagnoses being drug intoxication, head injury, and psychiatric conditions. Key Result: Droperidol was more effective than ziprasidone or lorazepam in treating E.D. patients with acute agitation. Primary Outcome: Adequate sedation at 15 minutes 64% of the droperidol group vs 35% and 25% of the ziprasidone groups and 29% of the lorazepam group. Droperidol: 16/25: 64% (95% CI; 45%-80%) Ziprasidone 10mg: 7/28: 25% (95% CI; 13%-43%) Ziprasidone 20mg: 11/31: 35% (95% CI; 21%-53%) Lorazepam 9/31: 29% (95% CI; 16%-47%) Secondary O