The Skeptics Guide to Emergency Medicine

Date: September 28th, 2022 Reference: Hartford et al. Disparities in the emergency department management of pediatric migraine by race, ethnicity, and language preference. AEM September 2022. Guest Skeptic: Dr. Lauren Westafer is an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the cofounder of FOAMcast and is a pulmonary embolism and implementation science researcher. Case: A 15-year-old patient presents to the Emergency Department with a unilateral pounding headache. The headache is similar to prior migraine headaches. They have photophobia but no vision changes, weakness, numbness, tingling, or neurologic deficits. They took 400 mg ibuprofen at home without relief. The patient and their mother ask what the next steps will be and what type of medication will be administered. Background: We have looked at migraine treatment a few times on the SGEM. That includes an episode on steroids to prevent bounce back visits to the ED (SGEM#28), ketorolac for acute treatment (SGEM#66), acupuncture for prophylaxis (SGEM#211) and a calcitonin gene-related peptide antagonist (SGEM#279). Patients with migraines often present to the ED looking for pain relief. There are many therapeutic options available to clinicians to address their pain. Unfortunately, poor pain control persists despite the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) making pain “the fifth vital sign” in 2001 to raise the awareness of oligoanalgesia in the ED. Despite the limitation of having a subjective measure as a vital sign, the problem of oligoanalgesia (poor pain management) persists (Motov and Khan). Some groups of patients who are at greater risk than others (elderly, women, mentally ill, certain ethnic groups, and insurance status). Children represent one group that is less likely to receive adequate analgesia. (Brown et al, Selbst and Clark). It is not well documented, whether gaps in pain assessment and treatment exist in conditions in which opioids are not indicated, such as migraine headaches. It is hypothesized that race, ethnicity and language (REaL) could also be independently associated with pain control. Clinical Question: Is there an association between patient demographics (race, ethnicity, and language) and pain management among pediatric ED patients presenting with migraine headaches? Reference: Hartford et al. Disparities in the emergency department management of pediatric migraine by race, ethnicity, and language preference. AEM September 2022. Population: All patients treated in a single pediatric ED with at least one migraine-relevant medication using an ED migraine pathway from pathway inception (October 14, 2016) through February 28, 2020. Excluded: Repeat encounters Intervention: Intravenous (IV) medications +/- oral (PO)/intranasal (IN) Comparison: Oral or intranasal medications only Outcome: Primary Outcome: Treatment group assignment according to race, ethnicity and language (REaL) categories. Secondary Outcomes: Pain intensity scores using the age-appropriate scale (FACES or 0-10 pain scale), ED length of stay, ED charges (billing data) Dr. Emily Hartford This is an SGEMHOP episode which means we have the lead author on the show. Dr. Emily Hartford is as assistant professor in Pediatric Emergency Medicine at the University of Washington and Seattle Children’s Hospital.  She works to improve equity for patients of diverse backgrounds in the ED as well as in global partnerships to improve pediatric emergency education. This study was part of a quality improvement project that involved a migraine protocol (see below). Authors’ Conclusions: “In this retrospective analysis of pediatric migraine patients in the ED, we found that race/ethnicity and language for care were significantly associated with odds of receiving intravenous therapies compared to oral or intrana...

Date: September 20th, 2022 Reference: Menon et al. Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial. The Lancet 2022 Guest Skeptic: Professor Daniel Fatovich is an emergency physician and clinical researcher based at Royal Perth Hospital, Western Australia. He is Head of the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research; Professor of Emergency Medicine, University of Western Australia; and Director of Research for East Metropolitan Health Service. Case: A 74-year-old man arrives from home by private vehicle complaining of right-sided weakness and dysarthria beginning two hours prior to arrival. Advance neuroimaging demonstrates no bleed and no large vessel occlusion. His NIHSS score is calculated to be 10 and he has no absolute contra-indications for systemic thrombolysis. Background: A lot has happened since you were on the SGEM last time discussing stroke (SGEM#325). This includes the CADTH report on thrombolysis by Alteplase for acute ischemic stroke in less than 4.5 hours with a letter to the editor from some neurologists representing CSC expressing their serious concerns about the report. Neurologist Dr. Ravi Garg was on an SGEM Xtra discussing his publication analysing the 1995 NINDS study. He showed the study had a high risk of selection bias. Dr. Garg concluded that the baseline imbalances observed in the NINDS study were more likely due to randomization errors than random chance. His advice was treatment decisions and guideline recommendations based on the original treatment effect reported in the NINDS tPA study should be done cautiously. We also had stroke neurologist Dr. Jeff Saver on an SGEM Xtra discussing his SRMA using the fragility index. He holds a much different interpretation of the stroke literature than Dr. Garg. The conclusion to Dr. Saver’s publication was that intravenous alteplase given within three hours of symptom onset for acute ischemic stroke is one of the most robustly proven therapies in medicine. Besides the disagreement about the strength of the evidence for tPA, there are challenges with administering this medication. It involves giving an infusion of 0.9mg/kg IV to a maximum dose of 90mg. The infusion starts with 10% of the total dose given as a bolus administered in one minute. The remaining amount is infused over 60 minutes.  Tenecteplase (TNK) is a genetically modified variant of alteplase with greater fibrin specificity (15-fold higher) and longer plasma half-life (22 min vs 3.5 min). Because of its ease of use as a single bolus and more favourable benefit-to-risk profile, it is preferred over alteplase as the fibrinolytic agent of choice for acute myocardial infarction. Clinical Question: Is tenecteplase non-inferior to alteplase in treating acute ischemic stroke? Reference: Menon et al. Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial. The Lancet 2022 Population: Adult patients aged 18 years and older with ischemic stroke who met eligibility criteria for alteplase (ischemic stroke causing disabling neurologic deficit, within 4.5 hours of onset). Patients eligible for endovascular thrombectomy in addition to intravenous thrombolysis were eligible for enrolment. Exclusions: Standard contraindications to IV thrombolysis Intervention: Tenecteplase (0.25 mg/kg) bolus Comparison: Alteplase (0.09 mg/kg bolus + 60 min infusion total 0.9 mg/kg to maximum of 90mg) Outcome: Primary Outcome: Proportion mRS 0-1 at 90 days, up to 120 days Secondary Outcomes: mRS 0-2 at 90-120 days; 90-120 day EQ-VAS & EQ-5D-5L, door to needle time, proportion given endovascular therapy,

Date: September 16th, 2022 Reference: Gerlier C, et al.  Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING and ABCD2 tests: A diagnostic cohort study. AEM 2021 Guest Skeptic: Dr. Peter Johns has been practicing emergency medicine since 1985 and has been passionate about vertigo education for the last two decades.  He co-authored the Vertigo chapter in the current edition of Tintinalli’s emergency medicine textbook and has a YouTube channel about vertigo with over 16,000 subscribers and five million views. Case: This is a real case seen by Peter and you can see the actual exam findings in a video on his YouTube channel. A 70-year-old woman wakes up with dizziness and presents to the emergency department (ED) later that day.  She’s vomited twice, and describes her dizziness as a constant spinning sensation, which gets worse when she moves her head.  She has some unsteadiness but can walk unaided.  She has no other neurologic symptoms.  In particular, she denies any new significant headache or neck pain, or focal weakness or paresthesia, dysarthria, diplopia, dysmetria, dysphagia or dysphonia, (the so-called Dangerous D’s).  When you examine her, and she is looking straight ahead, you observe that she has horizontal and slight torsional nystagmus beating towards her left ear. That means that the fast component of the nystagmus is horizontal, to the left, and there is a slight rotation with the upper pole of the eyes beating towards the left as well. Background: We have looked at acute vestibular syndrome (AVS) on the SGEM with Dr. Mary McLean who was the guest skeptic on SGEM #310. The bottom line from that episode was that: Dr. Mary McLean "the available evidence does not support the use of the HINTS examination alone by emergency physicians in patients with isolated vertigo or AVS to rule out a posterior stroke." In that episode, the case patient was told they would be admitted to the hospital to have a neurologist do the HINTS exam and decide if an MRI was necessary. But the question remains: can emergency physicians be taught how to use the HINTS exam to make clinical decisions? This is a difficult task, in part because vertigo education for emergency physicians has historically contained lots of  misinformation.  If there’s one thing we learned from the current pandemic, it is that misinformation is easier to spread than to correct. The tsunami of misinformation around COVID-19 has been coined the “infodemic”. We talked about this with Simon Carley on an SGEM Xtra and he emphasized “principles EBM are even more important now than in any time in our career”. There is a great quote by Thomas Francklin in 1787 about misinformation that rings true over two-hundred years later in the age of social media. He said: “Falsehoods will fly, as it were, on the wings of the wind, and carry its tale to every corner of the earth; whilst truth lags behind; her steps, though sure, are slow and solemn.” There is quote from another famous Franklin, Ben, which is apropos to the HINTS exam. "You will observe with concern how long a useful truth may be known, and exist, before it is generally received and practiced on." Myths & Misinformation about Dizziness: Myth: Asking what they mean by dizzy is the most important question to ask a dizzy patient. In fact, the patient's description of the sensation of their dizziness cannot be used to generate a reliable differential diagnosis. Myth: Tables of central vs peripheral characteristics of vertigo are helpful. Let us just say they are not.  You can watch my YouTube video about this for more info. Myth: If it gets worse when you move your head, that means it’s a peripheral cause. All vertigo gets worse when you move your head. If it does not, it probably is not vertigo. Myth: A CT or CTA will prevent you from sending home a stroke presenting with dizzines...

Date: August 25th, 2022 Reference: Martin et al. Single-dose dexamethasone is not inferior to 2 doses in mild to moderate pediatric asthma exacerbations in the emergency department. Pediatr Emerg Care. 2022 Dr. Harrison Hayward Guest Skeptic: Dr. Harrison Hayward is a Pediatric Emergency Medicine fellow at Children’s National Hospital. He finished his General Pediatrics residency at Yale-New Haven Hospital. As an editor and writer of continuing medical education material for the clinical case-sharing app, Figure 1, he enjoys interprofessional learning and is passionate about improving health care delivery to children with complex medical needs. Case: A 7-year-old female with asthma presents to the emergency department (ED) with difficulty breathing in the setting of 1-2 days of cough and runny nose. She reports that her albuterol helped her feel better yesterday, but it is providing no relief today. On exam, she has diffuse expiratory wheezing but good aeration to bilateral lung bases with a respiratory rate of 22. She has some intercostal retractions. SpO2 97% on room air. She can speak in full sentences. You diagnose her with a mild asthma exacerbation and begin treating her with albuterol/ipratropium and a dose of dexamethasone. After you explain the plan to the family, her mother says to you, “last time she was here, we got another dose of that steroid medication to take the next day. Do you think she needs it? She doesn’t like taking it, and it makes it hard for her to get to sleep.” Background: Asthma affects around 9% of children in the United States and asthma exacerbations are a common cause for ED visits. Corticosteroids are commonly use for treatment of acute asthma exacerbations. Previous research has compared the efficacy of a multi-day course of prednisone/prednisolone to single dose or two doses of dexamethasone [1-4]. We covered one of these studies on the SGEM: Highway to the Dexamethasone (SGEM #194) “A single dose of dexamethasone is non-inferior to a three-day course of oral prednisolone in the treatment of children with acute asthma exacerbation presenting to the emergency department.” So why are we back here talking about corticosteroids and asthma again? Studies had compared prednisone/prednisolone with one or two-dose dexamethasone. However, no prospective clinical trial has directly compared single dose dexamethasone to two doses. Clinical Question: Is a single dose of dexamethasone non-inferior to two doses of dexamethasone in the treatment of mild to moderate pediatric asthma exacerbations? Reference: Martin et al. Single-dose dexamethasone is not inferior to 2 doses in mild to moderate pediatric asthma exacerbations in the emergency department. Pediatr Emerg Care. 2022 Population: Children aged 2 to 20 years with known history of asthma who presented to the ED between April 2015 and March 2018 with an acute mild (PAS 5-7) or moderate (PAS 8-11) asthma exacerbation. “History of asthma” defined as at least one prior episode of wheezing responsive to beta agonists. Pediatric Asthma Score (PAS) Exclusion: Severe exacerbation (PAS >=12), systemic steroid use in the last two weeks, chronic lung disease (ie cystic fibrosis), or vomiting of two doses oral steroids in the ED Intervention: Two-dose dexamethasone Comparison: Single-dose dexamethasone Outcome: Primary Outcome: Return visits to either the primary care physician/ED/urgent care for persistent asthma symptoms Secondary Outcomes: Length of time symptoms persisted, missed school days, vomiting, adverse events (appetite changes, insomnia, mood swings) Trial: Prospective, randomized, single-center, unblinded, parallel-group randomized clinical trial Authors’ Conclusions: “In this single-center, unblinded randomized trial of children and adolescents with mild to moderate acute exacerbations of asthma, there was no difference in the rate of return visits f...

Date: September 3rd, 2022 Reference: Milne WK, Carpenter CR and Young T. A Hero Is Rising – Season#8 Book Dr. Tayler Young Guest Skeptic: Dr. Tayler Young is a first year Family Medicine resident at Queen’s University. Her interests are quality improvement and Free Open Access to Medical Education (FOAMed). This is an SGEM Xtra to announce Season#8 has now been summarized into a free PDF book. The SGEM provided the content, and Tayler designed the book. She has experience designing infographics for the Emergency Medicine Ottawa Blog and Emergency Medicine Cases. Tayler also one of the authors of the fourth version of the Emergency Medicine Ottawa Handbook which is now live. Seven seasons of the SGEM have been summarized into books, each with a different theme. Season#7 was designed by my daughter Sage and was inspired by the classic 1982 movie Tron. You can click on the cover page below and get access to all seven previous SGEM books. Tayler chose a Marvel theme for Season#8. This is because she is a huge fan of the Marvel Cinematic Universe (MCU). Her favourite Marvel movie is Avengers: Endgame and her favourite Marvel character is Steve Rogers or Captain America. I’m more of a DC fan myself and my favourite character is obviously Batman. I like him because he did not possess any superpower. He did not get bitten by a radioactive spider, exposed to gamma radiation like the Hulk or get his strength from our yellow sun like Superman. Bruce Wayne had to train very hard physically and study very hard to become Batman. Reminds me of the physical and mental training of residency. SGEM Season#8 Each chapter starts with the title of the SGEM episode, the clinical question and the bottom line on the first page. It also tells you who the guest skeptic is for the episode with a superhero cartoon picture of that individual. Then the format continues with the following sections: Case presentation using Spiderman and some background information on the topic. PICO question is represented by Thanos’ gauntlet with each infinity stone representing the population, intervention, comparison/control and outcome. Authors’ conclusions from the abstract Appropriate quality check list to probe the study for its validity Ironman shows up to give the key results. Talk nerdy to me section has Dr. Strange’s medallion, the eye of Agamotto. Clinical application, what do I tell the patients and a case resolution End notes with other FOAMed resources, twitter poll results and the Paper in a Picture infographic by Dr. Kirsty Challen summarizing the episode Part of the SGEM knowledge translation project is the theme music. Most of the music comes from the best musical era the 1980’s and that is a hill I'm willing to die upon. At the end of the book there are a few pages dedicated to listing all the songs that correspond to each chapter of the book. There is also a QR code that takes you directly to the SGEM Spotify Season#8 play list.  2021-2022 has been a long hard year as COVID continues. People are exhausted, burned out and suffering from moral injury. Remember, it is ok not to be ok. Asking for help is a sign of strength not weakness. As my friend Simon McCormack says, you cannot keep others warm by lighting yourself on fire. To provide great patient care you need to take care of yourself. The SGEM will be back next episode to start Season#11. It will be 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 23rd, 2022 Reference: Schoenfeld et al. “Just give them a choice”: Patients’ perspectives regarding starting medications for opioid use disorder in the ED. AEM August 2022 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Case: A 24-year-old male presents to the emergency department (ED) after a fentanyl overdose. He is successfully resuscitated using naloxone and is stable after an observation period. You are interested in seizing this opportunity to offer some type of help to this patient to prevent another opioid overdose in his future. Background: We have done a few shows on opioids over the past decade: Incidence of opioid use disorder (SGEM#264) Observing patients after giving naloxone (SGEM#241) Department guideline to prevent opioid use disorder (SGEM#55) Drug overdose deaths continue to rise in the United States with opioids being the number one cause (1). There are several medications available to treat Opioid Use Disorder, including methadone and buprenorphine, which are the most effective means to decrease future illicit opioid use and death (2-5). The ED has been identified as a low barrier environment where medications for OUD (MOUD) can be initiated, even in resource-constrained settings (3,6,7). Despite the relatively easy availability of buprenorphine, less than 5% of patients discharged from the ED after a non-fatal opioid overdose fill a prescription for buprenorphine in the next 90 days (8-11). Past studies have focused on clinician-reported barriers to administering or prescribing buprenorphine in the ED (11-19). However, the perspectives and preferences of patients have not been so thoroughly explored. Shared decision making (SDM) puts patients at the center of clinical decisions and has been shown to increase knowledge, trust, and adherence in other clinical decisions (20-23). An SDM framework that fosters conversations and addresses common misconceptions around MOUD initiation may improve the patient-provider interaction and ultimately increased ED-based MOUD administration. Clinical Question: What are patient’s perspectives regarding the initiation of medications for opioid use disorder in the ED? Reference: Schoenfeld et al. “Just give them a choice”: Patients’ perspectives regarding starting medications for opioid use disorder in the ED. AEM August 2022 As this is a qualitative study, we will use a modified PICO question Population: Patients with opioid use disorder Interest: Exploring patient perspectives and experiences with OUD and using medications for OUD Context: Improving the initiation and adherence to treatment with medications for OUD from the ED Dr. Elizabeth Schoenfeld This is an SGEMHOP episode and it is my pleasure to introduce Dr. Elizabeth Schoenfeld. She is an Emergency Physician and researcher, and the Vice Chair for research in the Department of Emergency Medicine at UMass - Baystate. Her research focuses on Shared Decision-Making (SDM) in the setting of Emergency Department care. Dr. Schoenfeld and her co-authors used the Ottawa Decision Support Framework for their study. Listen to the podcast to hear her describe this tool in more detail. Authors’ Conclusions: “Although participants were supportive of offering buprenorphine in the ED, many felt methadone should also be offered. They felt that treatment should be tailored to an individual’s needs and circumstances, and clarified what factors might be important considerations for people with OUD.”  CASP Checklist for Qualitative Research Was there a clear statement of the aims of the research? Yes Is a qualitative methodology appropriate? Yes Was the research design appropriate to address the aims of the research? Yes Was the recruitment strategy appropriate to the aim...

Date: August 18th, 2022 Reference: Munn et al. Fragility Index Meta-Analysis of Randomized Controlled Trials Shows Highly Robust Evidential Strength for Benefit of <3 Hour Intravenous Alteplase. Stroke 2022 Dr. Jeff Saver Guest: Dr. Jeff Saver is a Professor and SA Vice Chair for Clinical Research, Carol and James Collins Chair, Department of Neurology, Director of the UCLA Comprehensive Stroke and Vascular Neurology Program at the David Geffen School of Medicine at UCLA. This is an SGEM Xtra. Jeff and I have an interesting back story to how we met. I knew about Jeff from his multiple publications in the stroke literature. I did not know he knew about me until an EM physician sent me a video of a presentation that was given at an international stroke meeting. On one of the slides, Professor Daniel Fantovich and I were referred to as "Non-Expert EM Contrarians". I reached out to Jeff and we had a very good conversation. He clarified what he meant by “non-experts”: that we were not stroke neurologists or emergency physicians with subspecialty neuro expertise, such as having completed fellowship training in neurologic critical care. He did acknowledge that both Dr. Fatovich and I had expertise on critical appraisal of the medical literature. The conversation ended well with Jeff requesting one of the t-shirts I planned to make with the title of non-expert ER contrarian on the chest. Jeff recently reached out to me with his new publication called Fragility Index Meta-Analysis of Randomized Controlled Trials Shows Highly Robust Evidential Strength for Benefit of <3 Hour Intravenous Alteplase asking about my thoughts.  I thought this would be a great opportunity to dig deeper into the fragility index and have another expert in stroke neurology on the SGEM. Dr. Eddy Lang We have had a couple of individuals previously on the SGEM who strongly support the use of tPA in acute ischemic stroke (AIS). One was Dr. Eddy Lang who is a well-known Canadian researcher and emergency physician in Calgary, Alberta. Eddy appeared on the SGEM Xtra episode called the Walk of Life discussing AIS.  We had a debate on the issue of tPA for stroke published in CJEM 2020 as part of their debate series. Eddy is also the senior author on the CJEM article summarizing the Canadian Stroke Best Practice (CSBP) 2018 Guidelines. This Canadian guideline gives a level “A” recommendation for the use of tPA in AIS in patients last seen normal within 4.5 hours. “All eligible patients with disabling ischemic stroke should be offered intravenous alteplase (tPA). Eligible patients are those who can receive intravenous alteplase (tPA) within 4.5 hours” of symptom onset time or last seen normal (Evidence Level A; Section 5.3.i). We also had a neurology resident on to critically appraise a systematic review and meta-analysis of endovascular therapy plus/minus tPA as a bridging therapy (SGEM#349). A few more publications have come out since that podcast and the European Stroke Organization (ESO) recommends intravenous thrombolysis before mechanical thrombectomy in patients with acute ischemic stroke and anterior circulation large vessel occlusion. There have been several tPA skeptics on the SGEM including Dr. Hoffman, Dr. Fatovich, and Dr. Morgenstern. However, not until now have we had a stroke neurologist who is very much in support of using tPA in AIS. I think it is very important to try and mitigate against echo chambers, our own biases and listen carefully to other points views. Fragility Index Meta-Analysis of Randomized Controlled Trials Shows Highly Robust Evidential Strength for Benefit of <3 Hour Intravenous Alteplase. Jeff was asked a number of questions about his new publication. Some of the answers are listed as bullet points, but most of his responses can be heard in full by listening to the SGEM podcast: Who were your co-authors on this publication? Why did you decide to write this article?

Date: August 7th, 2022 Dr. Dennis Ren Host Skeptic: Dr. Dennis Ren is a pediatric emergency medicine attending at Children’s National Hospital in Washington, DC. You might remember him from the SGEM episodes on febrile infants, aseptic meningitis, and community acquired pneumonia. This is an SGEM Xtra episode. Season 10 is coming to an end. We want to thank all our listeners and skeptics who have tuned in for ten years. We have ~67,000 subscribers and the SGEM has been translated into four other languages. We have tried different initiatives over the years to improve the quality of the SGEM. Sometimes this has worked (Keener contest, Meme Monday, Twitter Poll Tuesday and Paper in a Pic Thursday) and sometimes it has not worked (Hot or Not and Continuing Medical Education Credits). For Season 11, we knew we had to do something special and turn it up to eleven.  To accomplish this we have invited Dennis to join the SGEM faculty and provide his pediatric expertise on a regular basis. Each month he will be leading an SGEM episode. Don't Panic! Dennis will use the same critical appraisal tools to probe the literature for its validity. The theme music may be more contemporary, but the content will still be fantastic FOAMed. We recognize that Dennis' clinical experience working in a tertiary centre may be different than the clinicians who provide care to the vast majority of pediatric patients that are seen in community EDs. The evidence-based medicine principles will still apply. The evidence discussed on the SGEM should inform your care but it should not dictate your care. You will still need to use your good clinical judgment and ask your patients about their values and preferences. The ultimate goal of the SGEM remains the same, to provide patients with the best care, based upon the best evidence. And we want to hear from you. Are you a passionate researcher who just published an amazing article? Or do you have an article or topic you want us to cover? Please send Dennis an email SGEMpeds@gmail.com to suggest an article or topic to cover. The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. So patients get the best care, based on the best evidence. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE

Date: July 28th, 2022 Reference: Brower et al. Point-of-Care Ultrasound-First for the Evaluation of Small Bowel Obstruction: National Cost Savings, Length of Stay Reduction, and Preventable Radiation Exposure. AEM July 2022 Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals. She is also the creator of all those wonderful Paper in a Pictures. Case: A 63-year-old woman presents to your emergency department (ED) with two-day history of nausea, vomiting and constipation. She tells you that she had appendicitis complicated by perforation and peritonitis ten years ago and you suspect she has adhesional small bowel obstruction. You call your surgical colleague who, predictably, asks you to order a CT. The patient asks if there is an alternative as she had several CTs on her last admission and is worried about her radiation exposure and her co-pay. Background: Somewhere between two and four percent of patients presenting to US EDs with abdominal pain have a small bowel obstruction (SBO) – those who are managed operatively (who are only 20-30%) account for 60,000 hospitalizations and 565,000 inpatient care days per year. We know that clinical examination has poor sensitivity and specificity for diagnosing SBO and that imaging is therefore necessary. CT is generally the first choice of imaging, the “abdominal series” of plain X-rays have been demonstrated to have poor predictive value, but a 2018 meta-analysis found 92.4% sensitivity and 96.6% specificity with ultrasound [1]. A 2020 national UK report into patients treated for bowel obstruction found delays in imaging and diagnosis and recommended CT with IV contrast as the first-line investigation [2]. Somewhat surprisingly, we’ve never covered SBO on the SGEM, although Ped EM Superhero, Dr Anthony Crocco shared his views on the (lack of) utility of abdominal X-rays in paediatric constipation back in 2016 (SGEM Xtra: RANThony#4). CLINICAL QUESTION: DOES USING POINT OF CARE ULTRASOUND FIRST LINE IN SUSPECTED SMALL BOWEL OBSTRUCTION REDUCE COST, LENGTH OF STAY AND RADIATION EXPOSURE? Reference: Brower et al. Point-of-Care Ultrasound-First for the Evaluation of Small Bowel Obstruction: National Cost Savings, Length of Stay Reduction, and Preventable Radiation Exposure. AEM July 2022 Population: Patients with ICD-10 coding “intestinal obstruction” from 2018 National Hospital Ambulatory Medical Care Survey. Intervention: POCUS-first approach Comparison: CT imaging as baseline Outcomes: Primary Outcome: Cost savings Secondary Outcomes: Reduction in ED length of stay, reduction in radiation exposure and preventable cancer Type: Monte Carlo Modelling This is an SGEM HOP episode, so we are pleased to have two of the authors on the show. Dr. Charles Brower is a second-year resident training in Emergency Medicine at the University of Cincinnati. His primary research interest is the intersection between clinical operations and ultrasound to improve patient outcomes in an efficient and cost-effective way. Also joining us is Dr. Andrew Goldsmith. He is the director of Emergency Ultrasound in the Department of Emergency Medicine at Brigham and Women’s Hospital at Harvard Medical School Authors’ Conclusions: “If adopted widely and used consistently, a POCUS-first algorithm for SBO could yield substantial national cost savings by averting advanced imaging, decreasing ED LOS, and reducing unnecessary radiation exposure in patients. Clinical decision tools are needed to better identify which patients would most benefit from CT imaging for SBO in the ED.” Quality Checklist for Cost Analysis Studies: Part 1: Are the recommendations valid? Did the investigators adopt a sufficiently broad viewpoint? Yes Are the results reported separately for patients whose baseline risk differs? No Were costs measured accurately? Yes Did investigators consider the timing of costs & ...

Date: July 22nd, 2022 Reference: Perry et al. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. The Lancet 2022 Guest Skeptic: Dr. Tessa Davis is a Paediatric Emergency Consultant at the Royal London Hospital, Senior Lecturer at Queen Mary University of London, Co-founder of Don’t Forget The Bubbles (DFTB). Tessa also has a weekly newsletter with tips to help you level up your use of everyday technology and to optimise your writing and to reach the audience you want. Case: Jack is nine years old, and he presents to emergency department (ED) with an arm injury. Today he was running at school, and he fell over onto his outstretched arm. His right arm is neurovascularly intact, with no swelling or deformity. He has bony tenderness at the distal radius. The X-ray shows a buckle fracture of his right distal radius. Background: We covered buckle fractures way back in Season#1 of the SGEM on SGEM#19. In that episode from ten years ago we made the distinction between a buckle fracture and greenstick fractures. Buckle fractures (also called torus fractures) are defined as a compression of the bony cortex on one side with the opposite cortex remains intact. In contrast, a greenstick fractures the opposite cortex is not intact. Buckles of the distal radius are the most common fracture seen in children and very commonly present to the ED [1-2]. Despite being a common injury they are often managed differently. Some clinicians apply casts, some a splint, some have orthopedic follow up, some have no follow up [3]. This practice variation is not new. A survey done almost 20 years ago in Canada demonstrated the variability of managing buckle fractures by Pediatric orthopedic surgeons and pediatric emergency physicians [4]. An RCT published 12 years ago reported that a soft bandage wrapping treatment for four weeks was not statistically different for discomfort, function or fracture displacement compared a below elbow back slab cast for one week followed by circumferential cast for three weeks despite some more pain in the first week with the soft bandage [5]. Yet here we are ten years later doing an SGEM episode on whether it is ok to put a soft bandage on these pediatric patients with a distal radius buckle fracture. It is a great example of how knowledge translation can take years or even decades for clinically relevant information to reach the patients’ bedside due to leaks in the EM knowledge translation pipeline [6-7]. Clinical Question: What is the appropriate management of torus fractures in children? Reference: Perry et al. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. The Lancet 2022 Population: Children between 4 and 15 years of age with a distal radius torus fracture that had been confirmed by x-ray. Exclusions: Other fractures, although a concomitant ulnar fracture did not lead to exclusion. Injury over 36 hours old, any cortical disruption seen on x-ray, and any reasons that meant follow-up would not be possible, such as a language barrier, lack of internet access or developmental delay. Intervention: Rigid immobiisation Comparison: Tensor (crepe) bandage Outcome: Primary Outcome: Pain on day three measured using the Wong-Baker FACES Pain Rating Scale [8]. Participants also recorded their pain score on day one, seven and weeks three and six. Secondary Outcomes: Measured a variety of other outcomes at the same time points, unless otherwise specified: Functional recovery using the PROMIS (Patient Report Outcomes Measurement System)Upper Extremity Score – a patient or parent-reported measure of physical function of the upper limbs. Health-related quality of life outcomes, using a EuroQol EQ-5DYa standardised questionnaire, suitable for children, which asks about quality of life,