The Skeptics Guide to Emergency Medicine

Reference: Snelling et al. Ultrasonography or radiography for suspected pediatric distal forearm fractures. New England Journal of Medicine June 2023 Date: July 19, 2023 Guest Skeptic: Dr. Casey Parker is a Rural Generalist that includes in his practice emergency medicine, anesthesia, and critical care. He is also a fully-fledged ultrasonographer. Casey currently splits his time between Broome, a small rural hospital in the remote Kimberley region of Western Australia, and a large tertiary ED in sunny Perth. He has been a guest skeptic on the SGEM multiple times. He is also the creator of the amazing #FOAMed website, Broome Docs. Dr. Casey Parker Case: It is a steady Saturday afternoon in your rural emergency department (ED). The triage nurse calls you to have a look at a child who has arrived with his parents in ED after falling from a bouncy castle at a birthday party.  He is six years old and appears to be in pain with his left wrist swaddled in an ice pack.  He tells you that he was attempting “a double backflip like Spiderman” when he landed heavily on the outstretched hand - this happened about an hour ago. Clinically there is some swelling and tenderness over the distal radius but no deformity.  He has good perfusion and no neurological symptoms in the hand. Because it is a small, rural ED there is no radiographer on site but they can be called in if we would like to get an X-ray…. or there is a portable bedside ultrasound machine in the next room ready to go. The child’s mother tells you that the X-ray tech was also at the party having a great time with her children. So, the question is: should we call in our x-ray tech in and disrupt her party fun or just use the ultrasound machine to diagnose this possible fracture? Background: We have covered pediatric wrist fractures a few times on the SGEM. This includes SGEM#19 way back in 2013 reporting a bandage wrap is a safe alternative to traditional casting for children with greenstick fractures. More recently, the amazing Dr. Tessa Davis covered the FORCE trial on SGEM #372 which looked at buckle fractures and compared immobilization in a cast or splint vs. a soft bandage and they found no difference in pain scores or functional outcomes. The use of bedside ultrasound to diagnose uncomplicated wrist injuries in children has been studied in several diagnostic prospective, observational trials to compare its accuracy to traditional plain film X-rays [1-5].  Most of these trials have shown diagnostic sensitivity and specificity above 90% when compared to X-ray as a gold standard.  This same research team from Queensland in Australia have also published a paper describing the learning curve for novices in detection of forearm fractures in kids [6].  In 2022 Mobasseri et al published a review of 9 such diagnostic studies and concluded that from an orthopedic perspective that the accuracy was not acceptable, the lack of a randomized controlled trial meant that there was not enough data to support the use of ultrasound over X-ray as an initial diagnostic test [7]. There have been no randomized trials that have compared the patient-centered, functional outcomes after a wrist injury based upon the choice of initial diagnostic test modality. Clinical Question: In children with non-deformed distal forearm injuries, does the use of ultrasound as an initial diagnostic test result in inferior functional outcomes? Reference: Snelling et al. Ultrasonography or radiography for suspected pediatric distal forearm fractures. New England Journal of Medicine June 2023 Population: Children between 5 and 15 years of age who presented to the ED with an isolated, acute, clinically non-deformed, distal forearm injury for which imaging for a suspected fracture was indicated Excluded: obvious angulation/deformity (soft tissue swelling allowed), injury >48hr prior, external X-rays obtained, known bone disease, concern for non-accidental trauma, additional injuries requiring X-rays, congenital forearm abnormality, no credentialed clinician available, developmental delay or behavior prohibiting clinical assessment Intervention: Bedside ultrasound carried out and interpreted by a trained clinician (doctors, nurse practitioners and physiotherapists) Comparison: X-ray Outcome:  Primary Outcome: Functional outcome at four weeks (± 3 days) post injury as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) score Secondary Outcomes: PROMIS scores at 1 week and 8 weeks post injury.   They also analyzed the children by age cohorts 5 to 9 years and 10 to 15 years old There was also an analysis of the diagnostic accuracy of the ultrasound vs. X-rays. Satisfaction at 4 and 8 weeks (5-point Likert scale with lower scores indicating greater satisfaction) Pain at 1, 4, and 8 weeks using the FACES pain scale Frequency of complications Frequency of radiography Length of stay and treatment time in the ED Trial: Multicenter, open-label, noninferiority, randomized, controlled trial Authors’ Conclusions: “In children and adolescents with a distal forearm injury, the use of ultrasonography as the initial diagnostic imaging method was noninferior to radiography with regard to the outcome of physical function of the arm at 4 weeks.” 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. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. No Follow-up was complete (i.e. at least 80% for both groups). Yes  All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. No Financial conflicts of interest.  No Results: They randomized 270 patients. Primary outcome data at 4 weeks was available for 130 patients in the ultrasonography group and 132 patients in the radiography group. The average age of patients was around 10 years with 90% of them being right hand dominant. There were slightly more male patients in the radiography group (57% vs 50%). Most common mechanism of injury was fall on outstretched hand. Key Results: Ultrasonography was noninferior to radiography as a diagnostic test in terms of functional outcomes at 4-weeks following wrist injury in children. Primary Outcome:  Secondary Outcomes: Functional outcomes were not statistically different at each of the time points. Ultrasound did appear to be better than X-ray in terms of parental satisfaction, length of time in the ED and time away from school. Although the patients randomized to ultrasound initially had about one third as many X-rays on the initial visit, there was a similar number of x-rays performed at follow-up visits Patient Oriented Outcomes: We were pleasantly surprised at all the patient-oriented outcomes in this study: function, pain, satisfaction of both caregivers and patients, missed school days.  We were not quite sure about the satisfaction rating. This was rated on a Likert scale of 1 to 5 and they found that there was greater parent/caregiver satisfaction in the ultrasonography group at follow-up at 4 weeks and 8 weeks. But why? Were they happy because the person performing the ultrasound explained things nicely? Were they happy because ultrasound didn’t expose the child to radiation? Were they happy simply because someone spent more time with them while performing the ultrasound? Selection Bias: One of the exclusion criteria for this study was obvious angulation or deformity on clinical exam. There is a degree of subjectivity in determining deformity. Additionally, soft tissue swelling was allowed. Would we all agree? This study did end up including some patients with angulated fractures. Clinically deformed wrists are in a way easier. We know that they are going to be broken and might need manipulation.  So, by excluding this group the authors are selecting a cohort with more subtle injuries.  However, this is a subjective inclusion criterion.  It may not matter though as all the children got some form of imaging. Clinical Significance of Injuries: Forearm injuries occur on a spectrum from a little bone “bruise”, through a buckle and then the nasty dinner fork fractures.   We have learned from trials like the FORCE trial that there must be a point on this “injury spectrum” where interventions like plaster casts or splints will have no benefit over “do nothing care”.   However, splints are not benign, so applying them to every kid with a tiny cortical breach will almost certainly result in unnecessary immobilization and some degree of temporary loss of function. There’s also the possibility that a poorly applied splint may cause skin breakdown. Or if the child gets the splint wet, it results in them coming back to the ED. It may be that ultrasound is less sensitive than X-ray, but that this does not matter as the injuries we do not see on ultrasound are unlikely to benefit from immobilization. In this trial there were more splints placed on kids in the group who were X-rayed at the initial visit. However, the kids who were found to have a buckle or torus injury did receive a splint in this trial.  And yet there was no difference in functional outcomes. So, maybe it really does not matter what we do in the first instance? The BUCKLED TRIAL and the FORCE trail were recruiting kids at the same time.

Suchismita Datta, an Assistant Professor at NYU, and Richard Griffey, a Professor at Washington University, dive into innovations in managing diabetic ketoacidosis (DKA). They discuss the SQuID protocol, which uses fast-acting subcutaneous insulin, potentially improving treatment efficiency and reducing emergency department stays. The conversation also critiques study methodologies and the impact of patient demographics on outcomes, emphasizing the need for diverse representation in research. It's a thrilling look at how new protocols can reshape emergency medicine!

Date: August 20th, 2023 Reference: Milne WK, Challen K, Young T. Skeptics' Guide to Emergency Medicine Season #10 Book Dr. Kirsty Challen Guest Host: Dr. Kirsty Challen is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). She completed undergrad and postgrad training in North West England, acquiring a History of Medicine BSc, a PhD in Health Services Research, an anesthesiologist husband and four children along the way. She is Chair of the Royal College of Emergency Medicine Women in Emergency Medicine group, and involved with the RCEM Public Health and Informatics groups. Kirsty also produces all those wonderful Paper in a Pic Infographics summarizing each SGEM episode. Dr. Tayler Young Guest Skeptic: Dr. Tayler Young is a second year Family Medicine resident at Queen’s University in Kingston, Ontario, Canada. Her interests are quality improvement, Free Open Access Medical Education (FOAMEd) and point of care ultrasound (POCUS). This is an SGEM Xtra to announce that SGEM Season #10 is now available as a FREE pdf book. The SGEM provided the content and Tayler designed the book. She has designed infographics for the Emergency Medicine Ottawa Blog and has summarized SGEM Season #8 and Season #9 with the Avengers and Batman themes. Tayler chose a Harry Potter theme for Season #10 as she is a huge fan of the films and the books. Her favorite character is Norbert the dragon who was secretly hatched by Hagrid in Book 1. Kirsty's favourite character from the Harry Potter series (being a woman in academic EM, still a male-dominated world – see SGEM #352 on the gender pay gap and our Xtra from October 2021 with the wonderful Dr. Suchi Datta about gender inequity) is Hermione Granger. She is the competent skilled witch who faces pushback for knowing the answers and ostracism for not fitting in. She also confesses to having a soft spot for Neville Longbottom, who is quietly ignored and disregarded until trouble really happens and he comes through with the sword of Gryffindor. SEASON #10 Foreword by Dr. Kirsty Challen Harry Potter arrived in our consciousness in 1997 as an unsupported orphan venturing into the magical world for the first time, facing the ever-present but initially under-appreciated threat of Voldemort with Ron and Hermione. The Skeptics Guide to Emergency Medicine was a few years behind, emerging into the #FOAMEd-o-sphere in 2012, but as Harry and his world developed through the books, so has the SGEM. This 10th Edition arrives as advocates of Evidence-Based Medicine continue to tackle the forces of misinformation and pseudoscience. Like Voldemort rising slowly back to power, many in the Ministry of Magic office of academic medicine failed to spot or believe the level of influence social media would have in the world of 2023. Ken Milne was an early adopter of using social media to narrow the knowledge translation gap and reduce the time it takes for quality research to percolate into clinical practice. This isn’t always easy; as Dumbledore says in the Goblet of Fire “there will be a time when we must choose between what is easy and what is right”. As clinicians it might sometimes seem easier to adopt the line of least resistance; blindly and unthinkingly to follow the “rules” of specialty guidelines or the preferences of consultants. But things are not always what they seem; many initially promising treatments fail to translate to benefit in the longer term and it can be tricky to know which is the Scabbers (apparently benign and well received, eventually found to be treacherous and deadly) and which is the Snape (initially unpleasant but at his core hugely valuable). Dr. Dennis Ren As Harry’s group of friends and allies grew wider through the books, so Ken has grown the SGEM faculty; the rotating cast of the SGEM-HOP has been joined by Dennis Ren leading SGEM-PEDS and an ever-increasing number of guest skeptics from many backgrounds (no exclusion of the mudbloods here) ensuring a clinician- and patient-relevant gaze is cast on the medical literature. The structured critical appraisal provides readers and listeners with a Marauder’s Map to see through the complexity and (sometimes) obfuscation of published articles and reach their own, sometimes surprising, conclusions. Like Voldemort (or Harry) some things never seem to die; this 10th edition features the perennial topics of where, if anywhere, thrombolytic agents should feature in the management of ischemic stroke, plus whether the choice of crystalloid for resuscitation really matters at all. New topics with wider relevance also appear, including the strength of the overall evidence base in Emergency Medicine and Orthopedics, and the persistent gender gap in EM remuneration. Even Ron Weasley recognises “when in doubt, go to the library”. Emergency clinicians are well advised “when in doubt, listen to or read the SGEM”. You too can be a skeptic, Harry! SGEM SEASON #10 Each chapter starts with Harry introducing the title, the clinical question the bottom line and the guest skeptic. Then Tayler summarizes in the following sections: Hedwig brings the case presentation and some background information. Phoenix wings surround the PICO question with population, intervention, comparison/control and outcome. The authors’ conclusions and an appropriate quality checklist come from a potions lab. The key results are presented in the Gryffindor common room. Talk Nerdy is examined through Harry’s glasses. To finish, Fawkes the phoenix provides the clinical application, what do I tell the patient and a case resolution, and links to the end notes with other FOAMed resources, twitter poll results and the Paper in a Pic infographic. An important part of the SGEM is the theme music. With the addition of Dr Dennis Ren to the SGEM faculty leading on SGEM-PEDS the theme music has diversified a little from our core loyalty to the 1980s. There is a full list at the end of the book of all the theme music with a QR code directly linked to the SGEM Spotify Season#10 playlist. It’s been another hard year in Emergency Medicine. Where I am in the United Kingdom we have seen ER nurses, residents and even attending physicians striking over conditions and pay.  Canada has seen multiple rural emergency departments have to close due to lack of staff, our colleagues in the United States face the challenges of providing care after the overturning of Roe v Wade. It’s great to have the SGEM family to help us carry on being the best version of ourselves we can be. As Tayler says, find the people that believe in you. All nine previous SGEM seasons are available as PDF books at this LINK. The SGEM will be back soon with 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.

Date: August 14, 2023 Reference: Ma et. al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet 2023 Guest Skeptic: Dr. Mike Pallaci is a Professor of Emergency Medicine (EM) for the Northeast Ohio Medical University, and an Adjunct Clinical Professor of EM for the Ohio University Heritage College of Osteopathic Medicine. He has been program director for two EM residency programs, and is currently a core faculty member for the EM residency at Summa Health System in Akron, OH, where he also serves as the Medical Director of the Virtual Care Simulation Lab. This episode originated because of a thread Mike posted on the social media site formerly known as Twitter.  The tweet said: “I am sick and tired of some non-EM docs/specialists slamming EM when we don’t aggressively lower BP in ICH.” It certainly got a lot of attention. It got a lot of attention both on the positive side (mostly from EM docs who share the frustration) and on the negative side from some neurologists who didn’t seem to particularly care for the premise of the tweet or for the generally positive response. It started out with venting on Twitter about an unpleasant interaction with one of Mike's partners and turned into a week-long discussion that culminated in an invitation to be the guest skeptic on the SGEM to critically appraise INTERACT-3. Mike backed up his position on blood pressure (BP) lowering using evidence. Specifically, he pointed out that the evidence behind the guidelines re BP management in intracranial hemorrhage (ICH) is relatively weak. This received a mixed response on Twitter. Most EM physicians shared the frustration and made positive comments. Some neurologists disagreed with the premise of the tweet and challenged it. I responded by posting the 2013 SGEM episode on INTERACT-2 (SGEM#73) which showed no statistical difference between intensive (<140 mmHg) and guideline directed (<180 mmHg).  In 2017, the SGEM reviewed the ATACH-2 trial (SGEM#172) which showed similar results. A meme was also posted of Charlton Heston from the classic movie the Ten Commandments. It emphasized that GUIDElines are not GODlines. The literature should inform and guide our care, but it should not dictate our care. This is a core principle of evidence-based medicine (EBM). Often the available evidence on a specific medical question is weak. We still need to apply our clinical judgement and ask the patient about their values and preferences. Case: A 67-year-old male presents to the emergency department obtunded with left hemiplegia.  Symptoms began just prior to presentation.  His blood pressure (BP) is 194/110 mmHg.  CT reveals a hemorrhage in the right internal capsule, suggestive of acute hypertensive hemorrhagic stroke.  Should the blood pressure be treated?  If yes, what should the target blood pressure be? How quickly do we want to get there? And are there any other physiologic variables we want to be aggressive about controlling in the early treatment window? Background: We have covered the common issue of elevated BP after ICH on SGEM#73 and SGEM#172. The 2022 AHA/ASA guidelines give several recommendations on this topic. The class (strength) of their recommendation is 2a/2b based upon Level B and Level C quality of evidence.   It is really important to pay attention to the specific language used in the guidelines. First of all, as we’ve already covered, a guideline is something developed by humans giving their best interpretation of the evidence to serve as a guide, not something given to Moses on Mount Sinai. But that point aside, the basis of this discussion was that the strength of the evidence behind these guidelines and the strength of the recommendations in the guidelines themselves are frequently misunderstood and/or misrepresented by our consultants. The specific language used in the guidelines is as follows: “In patients with spontaneous ICH in whom acute BP lowering is considered, initiating treatment within 2 hours and reaching target within 1 hour can be beneficial to reduce the risk of HE and improve functional outcome” They give this a Class 2a recommendation, “Moderate”: is reasonable, can be beneficial; Level of Evidence C-LD (Limited Data). We would say than it would also be reasonable not to acutely lower the BP “In patients with spontaneous ICH of mild to moderate severity presenting with SBP between 150 and 220 mmHg, acute lowering of SBP to a target of 140 mmHg with the goal of maintaining in the range of 130 to 150 mmHg is safe and may be reasonable for improving functional outcomes.” This was a Class 2b recommendation, “Weak”: may be reasonable, may be beneficial, effectiveness not well established; Level of Evidence B-R (Randomized; moderate quality evidence from 1 or more RCTs or meta-analyses of moderate-quality RCTs). Listeners to the SGEM know when the word “may” is used it can be substituted with the phrase “may not” “In patients with spontaneous ICH presenting with large or severe ICH or those requiring surgical decompression, the safety and efficacy of intensive BP lowering are not well established.” Another Class 2b recommendation, “Weak”: may be reasonable, may be beneficial, effectiveness not well established; Level of Evidence C-LD (Limited Data). This does not sound like language describing an intervention that is a “central component of management”. Yet that is what is what many physicians believe the guideline tells us. All you have to do is read the guideline itself to recognize that even the people writing these guidelines, who I would argue are biased toward aggressively treating BP in this scenario, recognize that the answer here is not clear. But when our consultants come to the ED they frequently act as though it is a clear and accepted truth and that this is what we should be doing. Clinical Question: Can the implementation of a goal-directed care bundle incorporating protocols for early intensive blood pressure lowering and management algorithms for hyperglycemia, pyrexia, and abnormal anticoagulation, implemented in a hospital setting, improve outcomes for patients with acute spontaneous intracerebral hemorrhage? Reference: Ma et. al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet 2023 Population: Adults patients 18 years of age and older presenting within 6 hours after the onset of ICH Exclusions: Definite evidence that the ICH is secondary to a structural abnormality in the brain or previous thrombolysis. Also, if the attending clinician felt there was a high likelihood that the patient will not adhere to the study treatment and follow-up regimen. Intervention: A goal-directed intensive care bundle protocol correcting hypertension, hyperglycemia, pyrexia and hypercoagulability, with the goal of achieving treatment targets within one hour of initiating treatment and maintaining them for 7 days (or until discharge or death, whichever came first) Comparison: Usual care at the discretion of the treating physician Outcome: Primary Outcome: Functional recovery measured at 6 months according to the modified Rankin Scale (mRS) score and analyzed as an ordinal outcome (shift across all categories) The authors state that one of the “efforts to improve the success of randomized controlled trials in identifying an effective treatment for ICH have included…to extend the assessment of functional outcome beyond the conventional 90 days, because recovery from ICH takes longer than from acute ischemic stroke.” Secondary Outcomes: Functional recovery according to a shift analysis of scores on the National Institutes of Health Stroke Scale (NIHSS) at seven days. Dichotomous mRS outcomes at 6 months 0-2 vs. 3-6 and 0-2 vs. 3-5 (i.e. – major disability in survivors) Death at 6 months Death or neurological deterioration at seven days Health-related quality of life (HRQoL) using the EuroQoL Group 5-Dimension self-report questionnaire (EQ-5D) Residence at six months (own home vs. other) Time to hospital discharge Safety Outcomes: All-cause and cause-specific serious adverse events were recorded for the duration of follow-up. Type of Study: A pragmatic, international (10 countries), multicenter (121 hospitals), blinded endpoint, stepped wedge cluster randomized controlled trial. Authors’ Conclusions: “Implementation of a care bundle protocol for intensive blood pressure lowering and other management algorithms for physiological control within several hours of the onset of symptoms resulted in improved functional outcome for patients with acute intracerebral haemorrhage. Hospitals should incorporate this approach into clinical practice as part of active management for this serious condition.” 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). 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. Yes The treatment effect was large enough and precise enough to be clinically significant. Unsure

Reference: Easter JS et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Annals of Emergency Medicine 2014. Date: July 10, 2023 Guest Skeptic: Dr. Joe Mullally is a paediatric trainee in the Welsh paediatric training program and interested in Paediatric Emergency Medicine. He is a student in the Paediatric Emergency Medicine Masters Program through Queen Mary University in London in collaboration with the Don’t Forget the Bubbles team. Dr. Joe Mullally Background: Children have big heads proportionally to their body compared to adults which makes them more at risk of traumatic brain injury (TBI). Computerized tomography (CT) is commonly used in the emergency department in the diagnosis of TBI. But we’re always trying to balance the potential harms and potential benefits in medicine. A CT scan does mean radiation to the pediatric brain which can increase the risk of leukemia or brain cancer later [1]. Thankfully, clinically important intracranial injuries are rare in children [2]. So, should we CT scan children with minor head injury? The SGEM covered pediatric concussions and head imaging in SGEM #112 and the NEXUS II Pediatric Head CT Decision Instrument in SGEM #225. Today we’re talking about three other popular clinical decision rules (PECARN, CATCH, and CHALICE). But we also want to know, how do those rules compare to physician judgement? Clinical Question: What is the diagnostic accuracy of clinical decision rules and physician judgment in identifying clinically important traumatic brain injuries (TBI) in children with minor head injury? Reference: Easter JS et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Annals of Emergency Medicine 2014. Population: Children less than 18 years of age presenting with head injury to a level 2 pediatric trauma center in the United States between 2012-2013. These children have to have 1) history of signs of blunt injury to the head 2) GCS scores ≥13, 3) injury within the previous 24 hours prior to presentation, 4) physician concern for potential TBI Excluded: Heightened TBI risk (GCS<13, brain tumors, ventricular shunts, on anticoagulants, or had bleeding disorders), or if they presented >24 hours after injury Intervention: CT vs no CT Comparison: Comparison of PECARN, CHALICE, CATCH, physician judgement, and physician practice Outcomes: Primary Outcome: “Clinically important TBI” defined as death from TBI, need for neurosurgery, need for intubation >24hrs for TBI, or hospital admission >2 nights for TBI. Secondary Outcomes: TBI on scan TBI requiring neurosurgery (craniotomy, elevation of skull fracture, monitoring of intracranial pressure, or intubation for elevated intracranial pressure) Type of Study: Single center prospective cohort study Authors’ Conclusions: “Of the 5 modalities described (PECARN, CATCH, CHALICE, physician judgment and physician practice), only physician practice and PECARN identified all clinically important TBIs, with PECARN being slightly more specific. CHALICE was incompletely sensitive but the most specific of all rules. CATCH was incompletely sensitive and had the poorest specificity of all modalities.” Quality Checklist for Observational Study:   Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Unsure  Was the outcome accurately measured to minimize bias? Unsure  Have the authors identified all-important confounding factors? Yes Was the follow up of subjects complete enough? Yes How precise are the results? Fairly precise Do you believe the results? Yes Can the results be applied to the local population? Unsure  Do the results of this study fit with other available evidence? Yes Funding of the Study. No financial conflicts of interest. Results: During the study period, 1,526 children with head injury presented to the ED, and they enrolled 1,062 (70%). The enrolled group had a median age of 6.1 years and 64% were male with 95% presenting with GCS of 15. In comparison the non-enrolled group had a median age of 5 years, 58% male, and 99% had GCS of 15. In summary, the enrolled group was a little bit older, with slightly higher proportion being male, and a bit fewer having GCS of 15. They ended up excluded another 53 mostly because they presented >24 hours from time of injury ending up with a total of 1,009 children included in the study. Key Results: Only PECARN clinical decision rule and physician practice had 100% sensitivity for detecting clinically important TBI. Fifty-two (5%) had injuries seen on CT scan. The most common were skull fractures but there were a few subarachnoid and subdural hemorrhages as well. Twenty-one (2%) had clinically important TBI. Only four (0.4%) required neurosurgical intervention. Selection Bias: This study had some inclusion criteria that may have led to selection bias. Specifically, the physician concern for potential TBI is very subjective. They also excluded anyone who was not seen within 24 hours with the reasoning that risk of clinically important TBI decreases with time. Although this may appear appropriate, we have probably encountered a child in the ED who presented greater than 24 hours from head injury. Maybe these families tried to wait it out after initial injury to avoid the ED visit, but the child continued to have persistent symptoms. What do you do if there may be physician concern for TBI in those circumstances? It’s unclear how these exclusion criteria impacted the study. Verification Bias: Verification bias occurs when only a proportion of the study participants receive confirmation of the diagnosis by the reference standard test (CT scan). Approximately half of patients were discharged after initial evaluation. A third of patients were observed for a median of three hours. The remainder underwent CT scan. Practically, we’re not arguing that every single patient in the study should have received a CT scan. The authors resorted to other methods to follow up with patients. It’s also important to realize that just because something may be radiologically significant, does not necessarily mean it is clinically significant. In this study, they noted 52 (5%) of patients who had injuries present on CT but only 21 (2%) had clinically significant TBI. Follow up obtained for 87% of patients who did not undergo CT. 57% of those were evaluated by physician and 43% were evaluated by phone. The team also looked at trauma registries and quality improvement reports to see if any patients had died. This is imperfect. Maybe the patient sought care at an institution outside of the health system they originally presented to. For more information on understanding the direction of bias in diagnostic studies we suggest you read the classic paper by Kohn et al 2013. There is also the new book by Dr. Jesse Pines on clinical decision rules and he was interviewed on an SGEM Xtra in June.  Inter-Rater Reliability: The authors looked at agreement amongst physicians on the study variables. They considered a kappa value of >0.5 to be acceptable. There are other sources that suggest a different interpretation: values ≤ 0 as indicating no agreement and 0.01–0.20 as none to slight, 0.21–0.40 as fair, 0.41– 0.60 as moderate, 0.61–0.80 as substantial, and 0.81–1.00 as almost perfect agreement [3]. Most of these variables and their associated kappa values are presented in Appendix 2. They looked at 180 observations total and most variables have good agreement. Worsening headache and intoxication have the lowest kappa’s of 0.49 and 0.43 respectively but there is no further discussion. GCS only had a kappa of 0.65. Previous studies show that agreement among physicians on GCS scores is quite variable [4]. In children, there are modifications to the GCS scoring based on age which poses additional challenges. This also potentially impacts the patients who were included in this study. Were there patients inappropriately excluded or inappropriately included if there was variation in how GCS was determined amongst physicians? Clinician Judgment: The authors report that physicians were trained on the data collection instrument. After assessing the patient but before obtaining results of testing, they recorded the presence of predictor variables. Is it possible that completing the data collection instrument with all the predictor variables influenced their decision because it reminded or cued them to what the predictor variable were significant? There was also discrepancy between physician estimate versus physician practice. Physicians’ estimate had sensitivity at 95% but physician practice had a sensitivity of 100% meaning they CT scanned more children compared to their estimate. We’re not sure why that is. It is also interesting to note that the specificity of physician estimate was better than physician practice. Clinical Decision “Rules”: I don’t really like the saying "clinical decision rule.” The “rule” part just feels so strict to me. We know that evidence-based medicine has three pillars, clinical judgment, scientific literature, and patient/family value and preferences. There is a lot of room for shared decision making here. How about we call these “tools” instead. They are there to help guide decision making but should not be taken as dogma. Our friend Justin Morgenstern from First10EM takes a stronger position in his blog post called: Clinical decision rules are ruining medicine  Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion. However,

Join emergency medicine physician Dr. Chris Bond and paramedic Neil MacDonald as they dissect the evolving practices in spinal motion restriction following a workplace injury case. They discuss the shift away from traditional cervical immobilization techniques and the impact of paramedic perceptions on patient care. Delve into the intricacies of statistical methodologies in spinal care research and the debate over cervical collar effectiveness, all while advocating for more personalized and evidence-based approaches in emergency medical protocols.

In this discussion, Dr. Jeff Jarvis, Chief Medical Officer at MedStar and seasoned emergency medicine expert, weighs in on the evolving techniques for intubation, focusing on the debate between video and direct laryngoscopy. He highlights the vital role of first-pass success in emergency settings and shares insights from recent research. The conversation also touches on ethical dilemmas in clinical trials and the challenges of informed consent, particularly in pre-hospital environments. Jarvis's engaging take combines humor with crucial medical insights.

Dr. Samina Ali, a pediatric emergency medicine physician and researcher, dives into the complexities of managing pain in children. She discusses the pressing need for better pain assessment and treatment protocols in emergency settings. The conversation emphasizes a collaborative approach to create comprehensive pain management standards in Canada. Dr. Ali also highlights the significance of family involvement and innovative distraction techniques to ease children's fears during medical procedures, paving the way for more compassionate healthcare.

In a thought-provoking discussion, Dr. Anand Swaminathan, an Assistant Professor of Emergency Medicine, dives into the controversial use of Tamiflu for influenza treatment. He shares insights from a systematic review that questions the drug's efficacy and reveals its side effects, including gastrointestinal issues. The podcast also examines historical safety concerns and emphasizes the need for a shift in clinical practices regarding Tamiflu's routine use, urging practitioners to reconsider treatment strategies for flu patients. It's a must-listen for those navigating influenza care!

Dr. Salim Rezaie, a community emergency physician and founder of the critical appraisal blog REBEL EM, dives deep into the impact of tranexamic acid (TXA) in trauma care. He explores a striking motor vehicle collision case, debating TXA’s effectiveness versus traditional treatments. The discussion highlights key studies like CRASH-2 and scrutinizes research methodologies, showing how they influence patient outcomes. Engagingly, they weigh the survival benefits against potential long-term issues, all while adding a splash of humor to the serious topic of emergency medicine.