The Skeptics Guide to Emergency Medicine

Date: April 26, 2023 Reference: Han et al. The effect of telemental versus in-person mental health consults in the emergency department on 30-day utilization and processes of care. AEM April 2023 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 moonlighting at the Veterans Administration emergency department (ED) and are caring for an Iraq veteran complaining of post-traumatic stress disorder (PTSD) and severe anxiety. You desire a psychiatric consult and learn that you don’t have in-person consult availability at this facility, but instead use telehealth services. You wonder about how this compares to an in-person consult. Background: Mental health and behavioral complaints are common in the ED, but a shortage of mental health providers results in high numbers of patients requiring transfer, some of whom may have been appropriate for discharge. Telemental health (TMH) has been shown in settings outside the Veterans Administration (VA) to increase access to mental health providers, increase the proportion of patients discharged home, and decrease the number of patients transferred. However, what’s not well studied is the effect of TMH on post-evaluation utilization and processes of care such as medication changes, disposition, length of stay, involuntary holds, and use of chemical or physical restraints. Clinical Question: What is the effect of TMH, versus in-person consult, on 30-day outcomes and processes of care during the visit? Reference: Han et al. The effect of telemental versus in-person mental health consults in the emergency department on 30-day utilization and processes of care. AEM April 2023 Population: Veterans presenting to VA medical center (VAMC) EDs and urgent care centers (UCC) Intervention: Telemental health consult administered via iPad and Apple FaceTime software Comparison: In-person mental health consultation Outcome: Primary Outcome: Composite of 30- day return ED visits, 30-day return hospitalization after the index ED visit, and death from any cause. Secondary Outcomes: Number of medications changed, disposition, length of stay, involuntary hold, use of parenteral benzodiazepines or haloperidol, and use of physical restraints or seclusion Type of Study: Exploratory retrospective cohort study Dr. Jin Han This is an SGEMHOP episode which means we have the lead author on the show.  Dr. Jin Han is an emergency physician with Vanderbilt University Medical Center in Nashville TN, and a researcher with the Geriatric Research, Education, and Clinical Center at the Tennessee Valley VA Healthcare System. Authors’ Conclusions: “TMH was not significantly associated with the 30-day composite outcome of return ED/UCC visits, rehospitalizations, and death compared with traditional in-person mental health evaluations. TMH was significantly associated with increased ED/UCC length of stay and decreased odds of placing an involuntary psychiatric hold. Future studies are required to confirm these findings and, if confirmed, explore the potential mechanisms for these associations.” 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/is the estimate of risk? Fairly narrow CIs Do you believe the results? Yes Can the results be applied to the local population? No Do the results of this study fit with other available evidence? Yes Funding/COI: Grant from the Office of Rural Health of the V...

Dr. Michael Falk, a Pediatric Emergency Medicine expert from Mount Sinai, dives into the nuances of oxygen therapy for kids with respiratory failure. He discusses a clinical trial comparing high-flow nasal cannula to standard oxygen, revealing that high-flow didn’t significantly reduce hospital stays. Insights on potential biases in treatment decisions and challenges with pulse oximetry readings are also highlighted. Falk emphasizes the need for evidence-based practices and tailored approaches to improve outcomes in pediatric care.

Dr. Susanne DeMeester, an Emergency Physician and cardiovascular section editor, delves into the critical issues surrounding women's heart health in sports. She discusses the alarming incidence of sudden cardiac arrest among female athletes and highlights gaps in research and representation. The conversation emphasizes unique risk factors like estrogen influence and the prevalence of conditions like Takotsubo syndrome. Dr. DeMeester calls for targeted cardiovascular screening and enhanced awareness to better protect women in high-intensity sports.

Date: April 4th, 2023 Reference: Vaughan and Browne. Reconfiguring emergency and acute services: time to pause and reflect. BMJ Qual Saf. 2023 Apr Guest Skeptics: Dr. Louella Vaugh is an internist practising as a hospitalist physician at an academic centre in London, UK with a special interest in smaller, rural and remote healthcare. Her main job is working for a think tank. John Brown PhD is a Professor of Health Services Research in Ireland who has been studying rural healthcare issues since 2012. This is an SGEM Xtra episode. There have been many “temporary” rural emergency department closures during the past last year. In Ontario alone there have been approximately 160 emergency departments (ED) temporarily closed since the beginning of 2022. This is something that has only happened once since 2006 (Ottawa Citizen March 28, 2023) The study referred to in the editorial looks at the experience in Denmark with a reconfiguration of their emergency healthcare services (Flojstrup et al 2023). The objective of that study was the following: To investigate how the’ natural experiment’ of reconfiguring the emergency healthcare system in Denmark affected in-hospital and 30-day mortality on a national level. The reconfiguration included the centralisation of hospitals and the establishment of emergency departments with specialists present around the clock. It was a stepped-wedge reconfiguration of the entire Danish emergency healthcare system. The main outcome was the adjusted odds ratio for in-hospital mortality and hazard ratio for 30-day mortality with some pre-specified subgroups. They found no statistical difference for in-hospital mortality but slightly increased 30-day mortality. The pre-specified subgroup analyses showed a decrease in in-hospital or 30-day mortality for myocardial infarction, stroke, aortic aneurysm, and major trauma but not for pneumonia, bowel perforation or hip fractures. This was not the only study to come out of the Danish reconfiguration initiative. The dataset also reported increasing admissions, mixed results on length of stay, increasing readmission rates, increasing COPD deaths if transported by ambulance, and expected productivity benefits were not realized. The SGEM advocated for having the evidence to inform/guide our decisions. Here is what the evidence say about the centralization of emergency healthcare services from the Danish study: some possible benefits for small groups of patients (myocardial infarction, stroke, aortic aneurysm, major trauma), there was no overall improvement in the in-hospital mortality trend and a slight worsening of the 30-day mortality trend. Five Assumptions Made about Emergency Healthcare Centralization Listen to the SGEM podcast to hear Louella and John discuss the five assumptions. Listed are the assumptions and some of the points we touched upon. Assumption#1: There is a problem with the quality of EM care that needs to be fixed Boarded patients length of stay (LOS) in the ED increases mortality Canary in the coal mine (fix the mine not the canary) COVID19 and staffing It’s about a system problem not a small hospital problem Assumption#2: Smaller hospitals provide worse care than their larger counterparts Myocardial infarction, stroke, and major trauma account for 1% of ED attendance Other skilled time-sensitive interventions (abdominal, vascular, obstetrical, and intracranial surgeries) still only amount to a total of 5% of ED attendance Little or no evidence that care in small hospitals is worse for 95% of cases Assumption#3: Reconfiguration produces better outcomes While studies of centralisation of care for individual services show better outcomes for specific patient groups, the population-level evidence for whole-scale reconfiguration through changes to ED services tells a different story.

In this discussion, Dr. Justin Morgenstern, an emergency physician and creator of First10EM.com, joins Lauren Fowler, a neuroscience professor focusing on fatigue, and Dr. Emily Hirsh, an associate professor dedicated to faculty wellbeing. They dive into the critical issue of fatigue in emergency medicine, revealing its ties to shift work and how it impairs performance and patient care. Insights into managing burnout, recent research findings on fatigue assessment, and the importance of systemic changes highlight the necessity for a healthier work environment in this demanding field.

Dr. Casey Parker, a Rural Generalist specializing in emergency medicine and ultrasound, shares insights from his work between remote and urban hospitals in Australia. He discusses the effectiveness of point-of-care ultrasound (POCUS) in diagnosing biliary diseases, revealing its advantages over traditional methods. The real clinical case of a woman with abdominal pain highlights the importance of ultrasound training in emergency settings. Casey emphasizes the impact on surgical decision-making and the need for better research methods to enhance diagnostic accuracy.

Date: February 27, 2023 Reference: Walsh PS, Schnadower D, Zhang Y, Ramgopal S, Shah SS, Wilson PM. Association of early oseltamivir with improved outcomes in hospitalized children with influenza, 2007-2020. JAMA Pediatr. 2022. Guest Skeptic: Dr. Marisu Rueda-Altez is a pediatric infectious disease fellow at Children’s National Hospital in Washington, DC. She is also the President of the Junior Section of the Society for Pediatric Research. Dr. Marisu Rueda-Altez Case: A 5-year-old child presents to the emergency department in the midst of flu season with three days of fever, upper respiratory symptoms, and malaise. His parents also report that he has lost his appetite and refusing to drink liquids. Nasopharyngeal PCR testing is positive for Influenza A. On physical exam, he is tired appearing and showing signs of respiratory distress with tachypnea and accessory muscle use. His lips look dry and cracked. His oxygen saturation is hovering around 88-90%. His chest radiograph does not demonstrate any focal opacities. After a discussion with his parents, you all agree that it is best for him to be admitted to the for IV hydration and close monitoring. His parents ask you, “A few years ago when we had the flu, we took a medication that helped reduce the length of our symptoms. Would he benefit from that too?” Background: Oseltamivir is recommended by the American Academy of Pediatrics, Infectious Diseases Society of America and Center for Disease Control and Prevention for the treatment of influenza in both adults and children. [1-3] Possible benefits include reduction in duration of symptoms and improvement of outcomes in hospitalized patients. Most of these recommendations are based on data from adult studies during the H1N1 pandemic with limited pediatric data. The SGEM has covered the use of oseltamivir for influenza on SGEM #98 and SGEM #312. Despite the recommendations from these various organizations, there remains some controversy (and skepticism) about the use of oseltamivir due to unpublished trial data, lack of access to the research data by the authors, and ghost-written papers. The BMJ was involved in a long legal battle with the manufacturer that you can read about here. Suffice it to say, that there were more harms than originally reported (including nausea and vomiting, neuropsychiatric events, headaches), and it is possible that the potential benefits were exaggerated.[4] Clinical Question: Will early administration of oseltamivir reduce length of hospitalization and complications of influenza infection? Reference: Walsh PS, Schnadower D, Zhang Y, Ramgopal S, Shah SS, Wilson PM. Association of early oseltamivir with improved outcomes in hospitalized children with influenza, 2007-2020. JAMA Pediatr. 2022. Population: Children <18 year from Pediatric Health Information System (PHIS) database hospitalized with Influenza from 2007-2020. Excluded: Transfers to other hospitals, repeated encounters (if >7 days between encounters, picked one at random; if <7 days, picked the first one), death/ECMO on day 0 or 1 to avoid immortal time bias. Exposure: Early administration of oseltamivir (HD 0 or 1) Comparison: Late administration of oseltamivir (HD 2 or later) or none. Outcome: Primary Outcome: Hospital length of stay (LOS) Secondary Outcomes: 7-day hospital readmission, late ICU transfer (on or after hospital day 2 after being admitted to general ward), composite outcome of in-hospital death or ECMO use. Authors’ Conclusions: "Early use of oseltamivir is associated with shorter hospital stay and lower odds of 7-day readmission, ICU transfer, ECMO use and death." 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? Unsure. Was the cohort recruited in an acceptable way? Unsure Was the exposure accurately measured to minimize bias...

Date: March 8, 2023 Reference: Smida et al. A Retrospective Nationwide Comparison of the iGel and King Laryngeal Tube Supraglottic Airways for Out-of-Hospital Cardiac Arrest Resuscitation. Prehospital Emergency Care 2023 Guest Skeptic: Dr. Chris Root is a third-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 flight physician with UNM’s air medical service, Lifeguard. He is a former New York City paramedic and this summer will be starting fellowship training in EMS medicine at UNM. Case: A paramedic crew responds to a 54-year-old male in cardiac arrest at a private residence. A fire company is on scene providing high-quality cardiopulmonary resuscitation (CPR) and has defibrillated twice with an automated external defibrillator (AED). The fire-based crew has basic life support (BLS) airway supplies including the King Laryngeal Tube, the paramedic crew carries iGel supraglottic airways (SGAs) in addition to their intubation equipment. They plan to use a supraglottic airway as their initial airway strategy during the arrest, but they wonder if either of these two devices is superior. Background: Airway management strategies for out of hospital cardiac arrest (OHCA) have been hotly debated since the dawn of CPR. Two large trials, PART by Wang et al and AIRWAYS-2 by Benger et al recently evaluated the King-LT and the iGel respectively as alternatives to endotracheal intubation (ETI) in cardiac arrest. Given the difficulty associated with intra-arrest endotracheal intubation, use of supraglottic airways in the prehospital setting is becoming more common. This was discussed with paramedic and physician assistant (PA), Missy Carter when critically appraising the AIRWAYS-2 trial regarding the use of the iGel in OHCA on SGEM #247 Clinical Question: Which supraglottic airway is associated with better patient outcomes, the iGel or the King-LT in patients with an out-of-hospital cardiac arrest. Reference: Smida et al. A Retrospective Nationwide Comparison of the iGel and King Laryngeal Tube Supraglottic Airways for Out-of-Hospital Cardiac Arrest Resuscitation. Prehospital Emergency Care 2023 Population: Adult OHCA patients treated by EMS contained within the ESO database from 2018-2021 who received prehospital iGel or King-LT supraglottic airway insertion. Excluded: Patients who were less than 18 years of age, pregnant, had do not resuscitate or other physician orders for life sustaining treatment, achieved ROSC after bystander CPR only, or experienced OHCA due to trauma or hemorrhage were excluded from downstream analyses Exposure: iGel Comparison: King-LT Outcome: Primary Outcome: Survival to hospital discharge home Secondary Outcomes: First-pass success, return of spontaneous circulation (ROSC), prehospital rearrest, Intrarrest ETCO2 values Type of Study: Retrospective observational Authors’ Conclusions: “In this dataset, use of the iGel during adult OHCA resuscitation was associated overall with better outcomes compared to use of the King-LT. Subgroup analyses suggested that use of the iGel was associated with greater odds of achieving the primary outcome than the King-LT when used as a rescue device but not when used as the primary airway management device.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Unsure Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? No How precise are the results? Adequately Precise Do you believe the results? Yes

Date: March 3, 2023 Reference: Hosseinialhashemi et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial. Ann Emerg Med. 2022 Guest Skeptic: Dr. Dominique Trudel is a CCFP-EM resident in Ottawa, Ontario. Her interest is serving French minority communities delivering care at the Montfort Hospital in Ottawa. Case: Jim is a 50-year-old male who presents to the emergency department with anterior epistaxis. He reported it started last night in his bedroom where he used a space heater. He denies nose picking. He tried applying pressure, but it didn’t work. Vitals are stable and he is not on any anticoagulants. Background: We have covered the topic of epistaxis several times on the SGEM. The first episode was SGEM#53: Sunday Bloody Sunday. This trial looked at 216 adult patients with anterior epistaxis and randomized them to topical TXA (500mg in 5ml) compared to anterior nasal packing. The results were impressive for stopping bleeding in <10min, discharge <2hrs, rebleeding <24hrs, and patient satisfaction.  TXA is a synthetic derivative of lysine that inhibits fibrinolysis and thus stabilizes clots that are formed. It has been tried in several medical conditions and been reviewed on the SGEM. There is also a short YouTube video discussing the evidence for TXA. Trauma (CRASH-2): 1.5% absolute mortality benefit (SGEM#80) Isolated TBI (CRASH-3): No statistical difference in mortality (SGEM#270) Post-Partum Hemorrhage (WOMAN): No statistical difference in primary outcome (SGEM#214) Gastrointestinal Bleeding (HALT-It): No statistical difference in primary outcome (SGEM#301) Intracranial Hemorrhage (TICH-2 & ULTRA): No superiority for good neuro outcome (SGEM#236 and SGEM#322) That first SGEM episode on using TXA for epistaxis showing favorable results also discussed eleven questions concerning epistaxis. It’s a good overview on the management of epistaxis. The episode included the Dundee protocol for adult epistaxis management from 2012. A second RCT from the same group looked at TXA for adults with anterior epistaxis who were also taking antiplatelet medications. This too showed impressive results claiming superiority of TXA(SGEM#210). When the NoPAC trial was published, it curbed some of the enthusiasm for TXA in epistaxis (SGEM#321). It was the largest double-blinded RCT (N=496), and found no reduction in the need for anterior packing with the use of intranasal TXA. However, this trial included patients who had already failed 10 min of pressure and 10 min of packing with a topical vasoconstrictor. They also used a lower dose of TXA in the noPAC study. Another issue was that 65% of the patients were taking anticoagulants. Lastly, the primary outcome was different than the previous two RCTs claiming efficacy. These conflicting results have led to uncertainty regarding the use of TXA in patients with epistaxis. Hosseinialhashemi et al sought to provide some clarity with their trial looking at TXA in uncomplicated anterior epistaxis. Clinical Question: Should we use TXA for uncomplicated anterior epistaxis? Reference: Hosseinialhashemi et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial. Ann Emerg Med. 2022 Population: 18-year-old and older, stable patients with atraumatic anterior epistaxis, without bleeding disorders or anticoagulation. Excluded: Posterior bleeds, hemodynamically unstable, allergic to TXA; known nasopharyngeal, nasal cavity, or paranasal malignancy; pregnancy; the experience of out-of-hospital nasal packing; and epistaxis caused by trauma, known bleeding disorders, recent use of anticoagulation drugs or clopidogrel and patients who were prisoners. Intervention: Cotton pledgets soaked in TXA 500mg, phenylephrine 0.05g and lidocaine 10% x five sprays.

Reference: Cashen K, Reeder RW, Ahmed T, et al. Sodium bicarbonate use during pediatric cardiopulmonary resuscitation: a secondary analysis of the icu-resuscitation project trial. Pediatric Crit Care Med. 2022 Date: February 15, 2023 Guest Skeptic: Dr. Carlie Myers is Pediatric Critical Care Attending at Cincinnati Children’s Hospital Medical Center. Dr. Carlie Myers Case: A 6-month-old boy presents to the emergency department (ED) with three days of worsening cough, cold symptoms, and fever. Parents note that he has been progressively more tired and difficult to arouse. He is found to be in hypoxic respiratory failure and septic shock. Intravenous (IV) access is obtained. He is quickly intubated. Despite multiple fluid boluses, he remains hypotensive and is started on vasoactive support. His blood gas reveals a mixed respiratory and metabolic acidosis with a lactate of 5.0. Despite your best efforts, he has an episode of agitation leading to hypoxia and subsequent cardiac arrest. Your team begins high quality cardiopulmonary resuscitation (CPR). An arterial blood gas is obtained demonstrates a pH of 7.0, PaCO2 of 70, PaO2 of 28, HCO3- of 7, Base Deficit of -10, and Lactate 10.0. A team member asks if you want to administer some sodium bicarbonate (1mEq/kg). Background: We often manage patients in cardiac arrest in the ED or the intensive care unit (ICU). Apart from high-quality CPR and early defibrillation, many other interventions we try lack a strong evidence base. But that does not stop us from trying to save the patient’s life and may represent some intervention bias.[1] The SGEM has covered the use of epinephrine, vasopressin, methylprednisolone, and calcium for cardiac arrest in SGEM#238, SGEM#350, and SGEM#353. Today we are focusing on sodium bicarbonate. Sodium bicarbonate has historically been used during CPR with the goal of alkalizing blood pH and treating metabolic acidosis. There are a few key assumptions about the use of sodium bicarbonate.  Low pH decreases cardiac function and responsiveness to catecholamines. Sodium bicarbonate administration will increase the pH. The increase in pH will lead to improved responsiveness to catecholamines and cardiac function. But it’s not that straightforward. Many of the studies supporting these claims were conducted on animal models or in vitro. [2] It is unclear if we see the same effects of acidosis and sodium bicarbonate in vivo. HCO3- + H+ ↔ H2O + CO2 Rapid bicarbonate infusion can cause an imbalance in CO2 across the cell membrane. HCO3- + H+ converts to H2CO3 and then to CO2 +H20. Extracellular CO2 rises rapidly, it diffuses across cell membranes and the reverse reaction occurs H2O + CO2→ HCO3- + H+; therefore, creating intracellular acidosis. There was a lack of evidence about the benefits and potential harm from using sodium bicarbonate in cardiac arrest [3], so it was removed from the American Heart Association’s (AHA) guidelines. The latest guidelines from the AHA in 2020 state, “clinical trials and observational studies since the 2010 guidelines have yielded no new evidence that routine administration of sodium bicarbonate improves outcomes from undifferentiated cardiac arrest and evidence suggests that it may worsen survival and neurological recovery.” [4] This association seems to hold true in the pediatric literature as well. [5-6] Clinical Question: What is the association between sodium bicarbonate use and pediatric in-hospital cardiac arrest mortality and morbidity? Reference: Cashen K, Reeder RW, Ahmed T, et al. Sodium bicarbonate use during pediatric cardiopulmonary resuscitation: a secondary analysis of the icu-resuscitation project trial. Pediatric Crit Care Med. 2022 Population: Pediatric patients 37 weeks to 18 years of age who received chest compressions across 18 pediatric intensive care units (PICU) or pediatric cardiac intensive care units (PCICU) from Oct 2016 to March 2021.