The Skeptics Guide to Emergency Medicine

Date: February 17, 2023 Reference: Gettel et al. Rising high-acuity emergency care services independently billed by advanced practice providers, 2013 to 2019. AEM Feb 2023 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and Assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Case: You are an administrator responsible for staffing emergency departments (EDs) in a health care system comprising both urban and rural locales. The hiring pool includes emergency medicine trained physicians, non-emergency trained physicians, and advanced practice providers (physician assistants and nurse practitioners). Prior to your hiring search, you wonder how many patient encounters are being seen by each type of physician or advanced practice provider. You also wonder the breakdown of visit acuity being seen by the different provider types. Background: Advanced practice providers (APPs), primarily physician assistants (PAs) and nurse practitioners (NPs), make up more of the emergency medicine (EM) workforce each year (1-4). While APPs have traditionally focused on low-acuity patient encounters, as ED visit volumes and physician shortages increase, APPs are seeing more complex, high-acuity patients (5-6). In the United States, policies have been implemented to permit more independent APP practice, with or without direct physician support. This increase in independent service provision by APPs and change in practice pattern to more high-acuity patients has not been formally assessed (7-8). There is concern regarding the expanding practice pattern of APPs, and a March 2022 Guideline by the American College of Emergency Physicians (ACEP) stated that PAs and NPs should not perform independent, unsupervised care in the ED setting (9). Given current workforce limitations, it is not feasible to continue current 24/7 staffing models in certain EDs and communities without APPs (1,3). Similarly, many rural Canadian emergency departments have reduced their open hours or closed over recent years due to inadequate staffing (MacLean's Magazine - Dr. Alan Drummond) There are both NPs and PAs working in Canadian EDs currently and we could see their role increase in the future should staffing shortages increase. The SGEM has done two previous podcasts on APPs in the ED. These focused on productivity, safety and diagnostic testing differences between emergency physicians and APPs (SGEM#308 and SGEM#316). Clinical Question: How has the role of APPs in the provision of emergency care changed in recent years? Reference: Gettel et al. Rising high-acuity emergency care services independently billed by advanced practice providers, 2013 to 2019. AEM Feb 2023 Population: Emergency care providers including emergency physicians, non-EM physicians and APPs (Physician assistants, nurse practitioners, certified nurse midwives, certified registered nurse anesthetists) who provided fee-for-service Medicare in the United States emergency departments from 2013 to 2019. Exclusion Criteria: Providers who received less than 50 total reimbursements within a study year for evaluation services reflecting typical emergency critical care codes. Exposure: Patient encounters by APPs Comparison: Patient encounters by Physicians Outcome: Primary Outcome: Proportion of high acuity encounters independently billed by different emergency clinician types over time. Secondary Outcomes: Variation in clinicians seeing high acuity encounters based on geography (urban vs. rural). Proportion of Evaluation Management services provided by each clinician that were high, moderate or low acuity in comparison to the total number of cases seen. Type of Study: Observational study using a repeated cross-sectional analysis of emergency clinicians using the Centers for Medicare & Medicaid Services (CMS) Provider Utilization and Payment Data ...

Dr. Sean Moore, an emergency physician and Chief of Staff at Lake of the Woods District Hospital, shares insights into tackling refractory ventricular fibrillation during cardiac arrests. He discusses a case involving a health professional who suffered an out-of-hospital cardiac arrest and the innovative defibrillation techniques being tested, including double-sequential defibrillation. The conversation also delves into the complexities of research in emergency medicine, particularly in rural settings, and emphasizes the importance of adaptability in critical care practices.

Date: February 1, 2023 Reference: Wolfrum et al. Temperature Control After In-Hospital Cardiac Arrest: A Randomized Clinical Trial. Circulation. September 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com Case: You are working an overnight shift at a small rural hospital. You are tidying your things in anticipation of the arrival of the dayshift when a code blue is called. A 50-year-old man who was admitted to the hospital with a non-ST elevated myocardial infarction (NSTEMI) overnight was found unconscious and without a pulse. The nurses started CPR immediately and place pads before you even arrived. The patient is in ventricular fibrillation, and you achieve return of spontaneous circulation (ROSC) on the second shock. The patient is still unconscious. A post-arrest ECG doesn’t show any signs of STEMI. At this point, the dayshift doc walks into the room and asks, “I can’t keep up with all the evidence. Are we supposed to be starting hypothermia?” Background: “Therapeutic” hypothermia took the critical care world by storm in 2002, with the simultaneous publication of two randomized control trials (RCTs) in the same issue of the New England Journal of Medicine – the Hypothermia after Cardiac Arrest (HACA) study and the Bernard study. As a very brief recap, the HACA study randomized 275 comatose adult patients with ROSC after a witnessed cardiac arrest with a shockable rhythm, a presumed cardiac origin of arrest, and a short downtime. The hypothermia group was cooled using an external device to a target temperature between 32 and 34 degrees Celsius and maintained there for 24 hours. The primary outcome was a good neurologic outcome within six months and occurred in 55% of the hypothermia group and 39% of the normothermia group (p=0.009, RR 1.40, 95% CI 1.08-1.81). This translated into an impressive NNT of 6. The six-month mortality was also improved in the hypothermia group (41% vs 55%, p=0.02) NNT 7. Key issues with this study were possible selection bias, early stopping without a clear endpoint, and a subjective outcome in a trial that was only partially blinded. The Bernard study included 77 patients with an initial cardiac rhythm of ventricular fibrillation who had achieved ROSC but were persistently comatose. It was not randomized to individual patients, but rather based on the day of the week. It was also not blinded. The primary outcome, patients with neurologic function good enough to be sent home or to a rehabilitation facility, occurred in 49% of the hypothermia group and 26% of the normothermia group (p=0.046, although when you plug the numbers into a fragility index calculator, you get a fragility index of 0 and a p value of 0.06). This give a very impressive NNT of 4. There was an NNT of 6 for mortality (51% vs 68%, p=0.16) but it was not statistically significant. For more information on the fragility index (FI) click on this LINK. Therefore, therapeutic hypothermia was introduced into clinical practice based on two small trials with multiple sources of bias. Since 2002, we have seen several larger trials that have raised questions about the value of hypothermia. We have covered the issue of cooling patients post OHCA sever times on the SGEM including the original Targeted Temperature Management (TTM) trial (SGEM#82). TTM was a multicentre RCT from 36 intensive care units (ICUs) in Europe and Australia, which enrolled 950 comatose adult patients on arrival to hospital after out of hospital cardiac arrest, regardless of the presenting rhythm. Patients all had their temperatures controlled, but they were randomized to a target of either 33 or 36 degrees Celsius. There were no statistical differences between the groups in mortality, Cerebral Performance Category (CPC), modified Rankin Score (mRS) or mortality at 180 days. The TTM2 trial was covered on SGEM#336. It was another multicenter RCT,

Date: January 22, 2022 Reference: Samuels-Kalow M et al. Post-Roe Emergency Medicine: Policy, clinical, training, and individual implications for emergency clinicians. AEM Dec 2022 Guest Skeptic: Dr. Michelle Lin is an emergency physician and health services researcher whose goal is to transform acute care delivery to best meet the needs of those who experience the greatest barriers to accessing health care. This is an SGEM Xtra episode. The ruling of the US Supreme Court on June 24, 2022 in Dobbs v Jackson Women’s Health Organization overturned Roe v Wade and allowed individual US states to determine their own restrictions on abortion. There was a recent tweet about allyship and advocacy by an orthopaedic surgeon, Dr. Simon Fleming. He encouraged people to shut up and listen. To amplify other voices and transfer your privilege. I interpreted that to mean, at times, men should talk less and listen more. Dr. Kirsty Challen This is one of those times. Therefore, Dr. Kirsty Challen will be hosting this SGEM Xtra episode. Academic Emergency Medicine published a special contribution in December 2022 exploring the implications of this for providers of emergency healthcare. This episode was recorded one day after the 50th Anniversary of the Roe v Wade on January 22, 1973.  Although the SGEM is based in Canada and Dr. Challen is British we felt this was an issue of such importance that we wanted to invite the authors to discuss it further with us. TRIGGER WARNING: AS A WARNING TO THOSE LISTENING TO THE PODCAST OR READING THE BLOG POST, THERE MAY BE SOME THINGS DISCUSSED ABOUT ABORTION THAT COULD BE UPSETTING. THE SGEM IS FREE AND OPEN ACCESS 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 ABORTION MATERIAL WE ARE GOING TO BE TALKING ABOUT ON THE SHOW COULD TRIGGER SOME STRONG EMOTIONS. IF YOU ARE FEELING UPSET BY THE CONTENT, THEN PLEASE STOP LISTENING OR READING. THERE WILL BE RESOURCES LISTED AT THE END OF THE BLOG FOR THOSE LOOKING FOR ASSISTANCE. QUESTIONS FOR DR. MICHELLE LIN Dr. Michelle Lin was asked several questions about the implications of the Dobbs v Jackson Women’s Health Organization decision. Please listen to the SGEM Xtra podcast on iTunes to hear her answers and for more details. Dr. Michelle Lin Why does Emergency Medicine need to know? After all, we aren’t abortion providers, or even Obstetrician/Gynaecologists. The paper talks about the unequal implications of this decision – surely the law is the law everywhere? Can you tell us more? What are the legal implications for Emergency Physicians caring for patients who may be miscarrying spontaneously, have an ectopic pregnancy, or present with the complications of an abortion which is illegal in that state? You said something specifically about documentation as well? And what about the pregnant or potentially pregnant Emergency Physician? Is this going to impact on us as a workforce too? You’ve mentioned that one of the policy actions for emergency physicians could be to use EMTALA to pre-empt state restrictions. Can you explain how that would work practically for those of us outside the US who don’t have an EMTALA-like system? Is there anything else you would like to say about this issue? 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 upon the best evidence. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE. Additional Resources: College of Family Physicians of Canada (CFPC) Abortion National Health Services (NHS) Abortions

Dr. Jennifer Harmon, a board-certified pediatric neurologist completing a genetics fellowship at Children’s National Hospital, discusses the complexities of diagnosing and treating Bell palsy in children. She highlights a case involving a nine-year-old girl with facial paralysis, addressing parental concerns about recovery. The conversation tackles the efficacy of prednisolone based on recent clinical trials, critiques on study exclusion criteria, and emphasizes shared decision-making with families during treatment.

Date: January 13, 2023 Reference: Razi et al. Dexamethasone and ketorolac compare with ketorolac alone in acute renal colic: A randomized clinical trial. AJEM 2022 Dr. Kevan Sternberg Guest Skeptic: Dr. Kevan Sternberg is a urologist/endourologist. His focus is on the medical and surgical management of kidney stone disease. Dr. Sternberg did his medical school and residency training at the University of Buffalo (SUNY) and endourology fellowship at the University of Pittsburgh Medical Center. Kevan was on the SGEM Xtra episode three years ago that brought together Emergency Medicine, Radiologists and Urologists to discuss ultrasound vs CT scans for suspected renal colic. You can listen to the SGEM podcast to hear what he thinks the impact of this initiative has been. Case: A 38-year-old female presents to the emergency department (ED) with a five-hour history of acute onset left flank pain.  The pain comes in waves, radiates into her left groin and is associated with nausea and vomiting.  She noticed darkening of her urine, but does not have dysuria, fever, or vaginal discharge. Background: We have looked at many different therapies to treat renal colic on the SGEM. That has included things like fluid bolus or diuretics (SGEM#32), tamsulosin (SGEM#4, #71, #154, #230), acupuncture (SGEM#220) and lidocaine (SGEM#202). The SGEM bottom line to these different treatment options: You don’t need to push fluids (oral/IV) or use diuretics to pass kidney stones. Medical expulsive therapy with tamsulosin is unnecessary for stones < 5mm. If a benefit does exist for Tamsulosin it's with distal ureteral stones > 5 mm. Acupuncture is not superior to morphine for renal colic. The evidence doesn’t support the use of lidocaine for renal colic. Glucocorticoids (steroids) act as anti-inflammatories, immunosuppressants, antiproliferative drugs, and have vasoconstrictive effects. It has been hypothesized that adding a long-acting glucocorticoid like dexamethasone may help with pain and vomiting associated with passing a kidney stone and decrease opioid use. Clinical Question: Should we be adding a dexamethasone to NSAIDs for the management of suspected acute renal colic? Reference: Razi et al. Dexamethasone and ketorolac compare with ketorolac alone in acute renal colic: A randomized clinical trial. AJEM 2022 Population: Patients presenting to the ED with flank pain and presumed renal colic Exclusions: Pregnancy (confirmed or possible), analgesic therapy during six hours before admitted to the emergency unit, near history of hemorrhagic diathesis, addiction or recent methadone use, use of warfarin and other anticoagulants, acute abdomen, fever, BP ≥ 180/100 mmHg; any contra- indication for ketorolac including hypersensitivity to aspirin or other NSAIDs, active or history of peptic ulcer disease, a recent history of GI bleeding or perforation or suspected or confirmed cerebrovascular bleeding, advanced hepatic or renal disease, patients at risk for renal failure, hyperkalemia, and uncontrolled severe heart failure; and any contraindications for the use of dexamethasone Intervention: Ketorolac 30mg IV plus dexamethasone 8mg IV Comparison: Ketorolac 30mg IV Outcome: Primary Outcome: Change in pain on a 10-cm visual analog scale (VAS) at 30 minutes and 60 minutes Secondary Outcomes: Grade of vomiting and the need for antiemetics and need for opioids Type of Trial: Single-centered, triple-blind, randomized clinical trial from Iran Authors’ Conclusions: “In comparison with the patients who just received ketorolac, adding dexamethasone provided improved pain control after 30 min of therapy”. 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

Date: January 4th, 2023 Reference: Hasbrouck et al. Acute management of atrial fibrillation in congestive heart failure with reduced ejection fraction in the emergency department. AJEM 2022 Guest Skeptics: Dr. Timlin Glaser currently a fourth-year resident in emergency medicine at Lehigh Valley Health Network and future medical toxicology fellow at the University of Arizona College of Medicine - Phoenix. Dr. Matt Murphy is currently a third-year resident in emergency medicine at Lehigh Valley Health Network.  He has interests in FOAMEd and is currently following the EBM track in his residency. Welcome to the SGEM Matt. This episode is recorded live as an SGEM journal club. There are five rules to journal club 1) You Must Talk/Tweet about SGEM-JC: The SGEM is a knowledge translation project. We know that it can take over ten years for high-quality, clinically relevant information to reach the patient. As Sir Mark Walport famously said: “science is not finished until it’s communicated.” 2) The EBM Answer Is "It All Depends": This rule was learned this from my EBM mentor Dr. Andrew Worster. There are lots of nuances to the application of the literature. It requires critical appraisal skills, clinical judgment and asking the patient about their values and preferences. 3) Don’t Panic – Even Your Faculty Is Not Sure of Some of the Answers: It is hard to stay up on all the relevant medical literature. There is a tsunami of new information being published every day. It can be overwhelming at times. Don’t panic. As Professor Feynman said…It’s ok to say: “I don’t know”. 4) It’s All About the Methods: The method section is the most important section of the paper. We just said there is so much research being published every day. It can be like drinking from a fire hose making it difficult to find the signal in all the noise. As Professor Altman said in the BMJ back in 1994; “we need less research, better research and research done for the right reasons.” This means we need to be asking the right questions that have patient-oriented outcomes and use proper high-quality methods to answer those questions. 5) Be Skeptical of Anything you Learn, Even If You Heard It On the SGEM Journal Club: Skepticism is such an important concept to understand the medical literature and navigate through life. Aristotle advocated for this thousands of years ago and encouraged people to “be a free thinker and don’t accept everything you hear as truth. Be critical and evaluate what you believe in.” Case: A 62-year-old male with a past medical history of heart failure with reduced ejection fraction presents to your emergency department (ED) via ambulance for palpitations and shortness of breath that started earlier that day. He arrives with an irregular heart rate of 142 beats per minute (bpm). The remainder of his vital signs are unremarkable. On physical exam, you notice three plus pitting edema of both lower extremities and bibasilar rales when auscultating his lungs. He takes multiple medications at home, including a beta-blocker, an angiotensin converting enzyme inhibitor (ACEi), and a loop diuretic.  You order an ECG and confirm the patient has atrial fibrillation (AF) with rapid ventricular response (RVR).  The patient is very symptomatic, and you need to decide which pharmacologic agent you will use to treat his current condition. Background: Atrial fibrillation is a common dysrhythmia seen on a regular basis by emergency physicians. We have covered this topic several times on the SGEM including: SGEM#88: Shock Through the Heart (Ottawa Aggressive Atrial Fibrillation Protocol) SGEM#133: Just Beat It (Atrial Fibrillation) with Diltiazem or Metoprolol? SGEM#222: Rhythm is Gonna Get You – Into an Atrial Fibrillation Pathway SGEM#260: Quit Playing Games with My Heart – Early or Delayed Cardioversion for Recent Onset Atrial Fibrillation? SGEM#267: AFib of the Night – Chemical vs.

Date: Dec 15, 2022 Reference: Mahajan et al. Serious bacterial infections in young febrile infants with positive urinalysis results. Pediatrics. October 2022 Dr. Brian Lee Guest Skeptic: Dr. Brian Lee is a pediatric emergency medicine attending at the Children’s Hospital of Philadelphia and Assistant Professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania. Guest Authors: Dr. Prashant Mahajan Dr. Prashant Mahajan is a Professor of Emergency Medicine and Pediatrics at the University of Michigan Department of Emergency Medicine in Ann Arbor, Michigan. He is the Vice-Chair for the Department of Emergency medicine and Section chief for Pediatric Emergency Medicine in CS Mott Children’s Hospital. Currently, he is the founding chair of Emergency Medicine Education and Research by Global Experts (EMERGE), a global emergency research network across 17 countries and 23 emergency departments. Dr. Nathan Kuppermann is a Distinguished Professor of Emergency Medicine and Pediatrics, and the Bo Tomas Brofeldt Endowed Chair of the Department of Emergency Medicine at UC Davis and Associate Dean for Global Health at UC Davis Health. He chaired the first US research network in Pediatric Emergency Medicine (the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics) then became founding chair of the Pediatric Emergency Care Applied Research Network (PECARN). He also recently completed a term as Chair of the Executive Committee of the global Pediatric Emergency Research Network (PERN). Dr. Nathan Kuppermann Both of our guests have received federal funding for their research and played huge roles in establishing multicenter research networks dedicated to improving the care of children across the world. Case: A 6-week-old girl is brought into the emergency department (ED) for fever of 38.5°C that started four hours prior to presentation. Her parents noted that she has been fussier today and has had feeding a little less than normal, but she’s had no other symptoms. She is otherwise healthy, full-term female who had no pre- or postnatal complications. On exam she is well-appearing, and there are no focal signs of infection. You decide to start by obtaining blood and catheterized urine for testing. The urinalysis shows 15 WBCs, 2+ leukocyte esterase and positive nitrites. While waiting for the results of the blood tests, you tell the family the news that their child likely has a urinary tract infection. The family asks you, “does this mean we found the source of her fever? Our son also had a fever when he was very young, and he had to get a lumbar puncture? Do we need to do a lumbar puncture for her today?” Background: Febrile infants ≤ 60 days are at higher risk for serious bacterial infections (SBI) including urinary tract infections (UTI), bacteremia, and meningitis. While UTIs tend to be the most common, we really do not want to miss those infants with bacteremia and meningitis, termed invasive bacterial infections (IBI). Multiple groups have worked to risk stratify these infants and have listed positive urinalysis as a risk factor for IBI. The SGEM covered the Step-by-Step Approach on SGEM #171 and PECARN Clinical Prediction Rule for Low Risk Febrile Infants on SGEM #296. Recently, the American Academy of Pediatrics (AAP) published guidelines for the management of febrile infants 8-60 days old covered in SGEM #241. In infants 22 days and older, the AAP guidelines state that lumbar puncture may be performed (rather than should) in those with positive urinalysis but normal inflammatory markers. There is wide practice variability in evaluation febrile infants [1-2]. Prior studies have demonstrated low prevalence of meningitis in infants with positive urinalysis [3,4].  Infants between 29-60 days of age are at a comparatively lower risk, with studies estimating their risk to be 0.

Date: December 11th, 2022 Dr. Dennis Ren Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine physician at Children’s National in Washington, DC. You may also know him as the host of this season’s SGEM Peds. This is an SGEM Xtra for the holidays. We have done previous shows on what we have learned from Star Trek and Top Gun. It is hard to believe that we have not done an SGEM Xtra about what Batman has taught us about medicine and life. The release of Season#9 of the SGEM as a PDF book seemed like an excellent opportunity to discuss Batman. This is because the book has a DC comic theme.  Some people might find that a bit dark. However, this edition arrives at a time of uncertainty. We have been navigating our way through a pandemic, understaffing, emergency department closures, boarding crises, astronomical wait times sometimes barely keep our heads above water and struggling to do everything we can to care for the patients who depend on us. Despite the challenges we face, I hope the SGEM has been a beacon in the darkness, a bat signal, to remind us that the application of the principles of evidence-based medicine is more important than ever. We discussed this early in the pandemic with Dr. Simon Carley from St. Emlyn’s. Before we start talking nerdy about Batman, I think it is important we give a shout out to Dr. Tayler Young. She is a first year Family Medicine resident at Queen’s University. Her interests are quality improvement and Free Open Access to Medical Education (FOAMed). Tayler did Season#8 book with an Avengers theme. SGEM Season#9 contains the an introduction by Dr. Chris Carpenter. He takes us back to 1934 and the start of DC comics. Batman first appears in 1939. The first page for each chapter has the clinical question, the SGEM bottom line and introduces the guest skeptic. Next comes the case presentation and some background material. This is followed by the PICO with each letter looking like the superman symbol. Each episode has the authors’ conclusions and the appropriate quality checklist to probe the study for its validity. The key results are listed. The Talk Nerdy To Me section has a Green Lantern theme. This is followed by the clinical application, what do I tell the patients and a case resolution section. Each chapter ends with any other FOAMed resources, twitter poll results and the Paper in a Picture infographic by  Kirsty Challen You can listen to the SGEM podcast and hear Tayler discuss the layout of SGEM Season#9.  You can also download all the previous SGEM books clicking on this LINK. Batman and How it Relates to Medicine and Life We discuss eleven ways that Batman relates to emergency medicine and life. You can listen to the entire discussion on the SGEM podcast available on iTunes. 1. Emergency Medicine is Batman If I were to pick one superhero that embodies the practice of emergency medicine, it must be Batman. He is a detective, a tactician, strategist. He is truly a jack of all trades. He has knowledge of criminal justice, psychology, forensics, chemistry, just to name a few. Sounds very similar to emergency medicine where we act as primary care providers, pediatricians, intensivists, cardiologists, neurologists, psychiatrists, often during one shift. Batman also has a lot of cool gadgets just like we have many tools in our arsenal when practicing emergency medicine. I think some of us might even carry a fanny pack (utility belt) on shift. 2. Vulnerability One of the things that sets Batman apart from other superheroes is that ultimately, he is human. He can get fatigued. He can be hurt. This quality makes me appreciate him more. Dr. Tim Graham shared his powerful story of burnout on SGEM Xtra: Everybody Hurts, Sometimes. We have witnessed people working in emergency medicine perform heroic acts every day, but it’s important take a moment to check in on each other. The pressure and stress can build up and it is ok not to be ok,

Date: December 16th, 2022 Reference: Hohle et al. Massive Blood Transfusion Following Older Adult Trauma: the Effect of Blood Ratios on Mortality. AEM December 2022 Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals. She is also the wonderful educator that creates the Paper in a Pic infographics summarizing each SGEM episode. Case: A 71-year-old man is brought to your emergency department (ED) by emergency medical serviced (EMS) having fallen two steps at home. EMS have already splinted an obvious mid-shaft femoral fracture, but he continues to be tachycardic and hypotensive. After a bedside ultrasound shows fluid in the right hemithorax, you insert an intercostal drain which immediately fills with one litre of blood. Noting with some relief that at least he isn’t anticoagulated, you activate the hospital massive transfusion protocol. The transfusion tech calls to remind you that your protocol is currently under review, and asks if would you like the 1:1 or the 1:3 version of fresh-frozen plasma (FFP) to packed red blood cells (pRBC)? Background: Major trauma in older patients is increasing in frequency (1), with the median age of major trauma patients in the UK from 2012-2017 being 63.6 years (2). Falling is the most common cause of traumatic injury resulting in older adults presenting to the ED [4]. Approximately 20% of falls result in injuries, and falls are the leading cause of traumatic mortality in this age group [5,6,7]. Over the last few years there has been increasing concern that the practice of transfusing only PRBC might worsen traumatic coagulopathy. Although a number of trials have attempted to find optimal ratios for transfusion components and the Eastern Association for the Surgery of Trauma practice guidelines suggest a “high” ratio, little of the literature has addressed how this might be applied in an older population. We looked at the PROPPR trial on SGEM#109 when it came out in 2015 and concluded then that a 1:1:1 transfusion strategy was a reasonable approach to massive transfusion and that it seemed to achieve more hemostasis and less death from exsanguination at 24 hours. We’ve also looked at trauma in older patients in SGEM#324 (we don’t yet want to use spirometry to aid discharge decisions in patients with rib fractures), SGEM#212 (increasing age, more rib fractures, more underlying disease and poor oxygenation are risk factors for poor outcome in older patients with chest trauma) and in SGEM#89 in 2014 when we first concluded that identifying older patients at risk of falls is really tricky. CLINICAL QUESTION: DOES FFP:PRBC RATIO IN MASSIVE TRANSFUSION FOR TRAUMA AFFECT SURVIVAL IN OLDER ADULTS? Reference: Hohle et al. Massive Blood Transfusion Following Older Adult Trauma: the Effect of Blood Ratios on Mortality. AEM December 2022 Population: Patients aged 65 or older receiving massive blood transfusion from American College of Surgeons Trauma Quality Improvement Programme National Trauma Data Bank 2013-2017. Massive transfusion was defined as >=10 units of pRBCs in 24 hours or >=5 units within 4 hours of ED admission. Excluded: Patients who were dead on arrival at ED, patients who received no plasma, and those who received more plasma than red cells. Intervention: 1:1 ratio of FFP to pRBC Comparison: 1:2 or lower ratio of FFP to pRBC Outcomes: Primary Outcome(s): 24-hour and 30-day mortality Secondary Outcomes: Hospital and ICU length of stay, ventilator days, complications and need for emergency surgery for haemorrhage control. Type of Study: Observational cohort study Dr. Rae Hohle This is an SGEM HOP and we are pleased to have the lead author on the show. Dr. Rae Hohle is a PGY1 in Emergency Medicine at Regions Hospital in St. Paul, MN. She has a background in computer science and with the support of her program has been able to continue to work on research projects in re...