The Skeptics Guide to Emergency Medicine

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, and that time hypothermia was compared to normothermia (a goal of keeping temperatures less than 37.5). Once again, there was no statistical difference in outcomes between the two groups in all-cause mortality or neurologic function at six months. On the other hand, the HYPERION trial, which was covered in SGEM#275, was an RCT which include both OHCAs (73%) and IHCAs (27%). The trial comparing hypothermia (33 degrees) to normothermia. In that trial, there was a statistically significant improvement in their primary outcome of neurologically intact survival (10.2% TTM vs. 5.7% usual Care (absolute difference 4.5%), p=0.047 which gives an NNT of 22). The fragility index was 1 and the trial was unblinded, leaving us with significant uncertainty. Therapeutic hypothermia has also been trialed in the prehospital environment and not been found to be superior to usual care (SGEM#21 and SGEM#54). Therefore, there remains significant uncertainty about the value of therapeutic hypothermia after cardiac arrest, especially in the inpatient environment, where patients generally have better outcomes than the OHCAs we usually see in the emergency department. Clinical Question: Does hypothermia improve all-cause mortality in adult patients who remain comatose after inpatient cardiac arrest? Reference: Wolfrum et al. Temperature Control After In-Hospital Cardiac Arrest: A Randomized Clinical Trial. Circulation. September 2022 Population: Adult patients who remained unconscious (GCS <9) more than 45 minutes after inpatient cardiac arrest. Patients were eligible irrespective of cardiac rhythm or etiology of arrest. Exclusions: These can only be found in the supplemental appendix and include the following: active bleeding, suspected intracranial bleeding, immunodeficiency, severe heart rhythm disorders, known severe cognitive deficit, pregnancy, any condition that makes 6-month survival unlikely, major hemodynamic instability. Intervention: Temperature control with a target between 32 and 34 degrees Celsius for 24 hours, followed by slow rewarming. Comparison: Temperature control with a target of normothermia. No specific protocol was followed; it was just strongly recommended to avoid temperatures greater than 37.5 Celsius. Outcome: Primary Outcome: All-cause mortality at 180 days Secondary Outcomes:In-hospital mortality and favorable functional outcome after 180 days using the Cerebral Performance Categories (CPC) score <3 Type of Study: Multicentred, open-label, blinded-outcome-assessor, randomized controlled trial Authors’ Conclusions: “Hypothermic temperature control as compared with normothermia did not improve survival nor functional outcome at day 180 in patients presenting with coma after IHCA. The HACA-IHCA (Hypothermia After In-Hospital Cardiac Arrest) trial was underpowered and may have failed to detect clinically important differences between hypothermic temperature control and normothermia.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the ED. No The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Unsure The patients in both groups were similar with respect to prognostic factors. No All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Unsure Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. No Financial Conflicts of Interest. Several authors declared fCOIs Results: Of 1,055 patients assessed for eligibility, 249 were randomized, and 238 are included in the final analysis. The mean age was 73 years, 64% were male, 54% were on the medical ward, and 73% were witnessed arrests. Key Result: No statistical difference in all-cause mortality at six months. Primary Outcome: All-cause mortality at 180 days. 72.5% with hypothermia and 71.2% with normothermia, RR 1.03, 95% CI 0.79-1.40, p=0.89. Secondary Outcomes: No statistical difference for in-hospital mortality and favourable functional outcome after 180 days. In-hospital mortality, ICU length of stay, and hospital length of stay were all also statistically insignificant. Lack of Blinding: Although blinding a trial of hypothermia would be incredibly difficult, the lack of blinding could have a significant impact on the results. In a modern ICU, decisions about life and death are contingent on the choices of physicians, and the way we present prognosis to patients. Clinicians beliefs about the efficacy of hypothermia might have shaped their clinical decisions or how they counselled patients, and that could have biased even a seemingly objective outcome like all cause mortality. Small Study Stopped Early: This trial was supposed to include 440 patients based upon their sample size, but they only enrolled 249. The trial was stopped early for futility, but there were no predetermined criteria for this decision. The result is a study less than half the size that they calculated was required to identify a 16% absolute decrease in all-cause mortality. Even without stopping early, this study was probably under-powered. A 16% absolute decrease in all cause mortality is a completely unheard-of benefit in modern critical care, so designing a trial with that goal seems overly optimistic. (To be fair to the researchers, that was the benefit supposedly seen in the original HACA trial.) Imbalanced Groups: Perhaps because it was stopped early, the groups are not balanced at baseline.

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 Center for Reproductive Rights Planned Parenthood

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 The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Yes The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. Unsure All groups were treated equally except for the intervention. Unsure Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. No The treatment effect was large enough and precise enough to be clinically significant. No Financial conflicts of interest. No Results: They recruited 120 participants (60 in each group), the mean age was 37.6 years of age, 70% were male and 42% reported some vomiting. Key Result: Dexamethasone plus ketorolac was statistically superior to ketorolac alone for pain control at 30 minutes but not at 60 minutes in adults with suspected acute renal colic. Primary Outcome: Change in pain from baseline using VAS 30 Minutes: -5 intervention vs -3 control, p=0.014 60 Minutes: -7 intervention vs -5 control, p=0.07 Secondary Outcomes:  Grade of Vomiting: No statistical difference Need for Antiemetic: 12% vs 28%, p=0.02 Need for Opioids: 35% vs 58%, p=0.01 Did they Even Have Stones? The diagnosis was based upon cell blood count, urinary assay, US, or CT scan. I would need a CT diagnosis or an US with hydronephrosis correlated clinical to know whether these are actual stone related events. Did everyone get imaging? What was the incidence of hydronephrosis? How big were these stones? Where were these stones (proximal, mid or near the ureterovesical junction)? Flank pain can have many reasons and while the goal of this study is to address the pain, it may not be accurate to title the study using acute renal colic. Two Primary Outcomes? We know that there can be only one primary outcome. Why did they have two primary outcomes at 30 and 60 minutes?  Why would the results change after another 30 minutes? Is this clinically relevant anyway? Visual Analog Scale? Is the VAS score the most appropriate primary outcome clinically? It is a subjective outcome measure. A potentially and more important outcomes may be to see those who needed intervention due to poorly controlled pain or those who need opioids for the same. Secondary Outcome? In the trial registry they only had one secondary outcome (grade of vomiting). The publication had an additional two (need for antiemetic and need for opioids). It is unclear when these were added and if they were done post-hoc. In addition, there was no information on adverse events. We do not know if adding dexamethasone to ketorolac causes an increase, same or decrease number of adverse events. Without knowing the potential harms, it is difficult to put any potential benefits into proper context. Adjunct Medication? No information was provided if any adjunct medication was provided. Specifically, alpha-blockers like tamsulosin are still often used in many practice settings. While the goal of alpha blockers is for stone passage (and this is very controversial), they may also play a role in the management of renal colic as we see evidence of pain improvement in the setting of ureteral stents. It is unclear if patients were treated equally except for the addition of dexamethasone to the standard dose of ketorolac. Comment on Authors’ Conclusion Compared to SGEM Conclusion: We think the authors are over-interpreting their evidence. Without additional information on how accurate the diagnosis, stone size and location, rate of adverse events and use of adjunct medication we should consider this preliminary data hypothesis generating. SGEM Bottom Line: We cannot recommend the addition of dexamethasone to ketorolac in the treatment of adult patients with suspected renal colic. Case Resolution: The patient is provided with 15mg IV ketorolac and her pain improves. The CT scan shows a 4mm stone at the ureterovesical junction without any hydronephrosis. She is discharged home with a prescription for ketorolac, strainer for urine, instructions on when to return and referred to urology for an outpatient consult. Clinical Application: I will not be suggesting dexamethasone for patients presenting with suspected acute renal colic. I fully support ketorolac or NSAIDs in general as first line and this is certainly supported in the literature. I do applaud the consistency of this approach in this group. What Do I Tell the Patient?  You have a small kidney stone. Most people will be able to pass this size of stone. We are going to give you a prescription for some pain medicine. If your pain gets worse, you can’t keep anything down, develop a fever or are worried please return to the ED. A referral has been sent to the urologist on-call and their office will contact you about an appointment. Keener Kontest: Last weeks’ winner was Tim Kolosionek. He knew Inge Edler and Hellmuth Hertz are credited for publishing the first description of M-mode echocardiography in 1953. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

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. Electrical First Cardioversion As discussed in SGEM#133, clinicians routinely employ beta blockers or calcium channel blockers (CCBs) for rate control in patients with AF. Multiple studies have demonstrated that both agents are effective in decreasing ventricular rate to an acceptable range, and current AHA guidelines approve their use in uncomplicated AF. However, the use of beta blockers and non-dihydropyridine calcium channel blockers for rate control in patients with AF with RVR and concurrent decompensated heart failure with reduced ejection fraction (HFrEF) remains controversial. Current guidelines specifically recommend against the use of CCBs (1) despite limited evidence (Level C).  For the ED clinician, such a scenario poses a conundrum, as both the disease process and the intervention can worsen heart failure and contribute to cardiogenic shock. Clinical Question: In patients with HFrEF presenting to the ED in AF with RVR, are there significant differences in adverse outcomes for patients treated with IV diltiazem vs IV metoprolol? Reference: Hasbrouck et al. Acute management of atrial fibrillation in congestive heart failure with reduced ejection fraction in the emergency department. AJEM 2022 Population: Adult patients 18 years of age or older who presented to the ED with Atrial Fibrillation with Rapid Ventricular Response and had a formal echo with an EF less than or equal to 40% during the same encounter Excluded: Did not receive rate control agent in the ED within 12 hours, pregnant, incarcerated Intervention: Intravenous Diltiazem Comparison: Intravenous Metoprolol Outcome: Primary Outcome: Adverse events – hypotension (systolic BP<90 mmHg requiring fluid bolus or vasopressor administration), bradycardia (HR <60 bpm), worsening heart failure (increase in oxygen requirements by at least two liters within four hours or the need for inotrope within 48hrs) Secondary Outcomes: Incidence of rate control failure, admission level of care, ED length of stay, hospital length of stay, in-hospital mortality Type of Study: A single-center, retrospective study Authors’ Conclusions: “There was no difference in total adverse effects between HFrEF patients treated with diltiazem vs metoprolol for acute AF. However, patients with diltiazem had higher incidence of worsening CHF symptoms defined as increased oxygen requirement within four hours or initiation of inotropic support within 48 h.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Unsure Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Unsure Have the authors identified all important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Unsure Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Funding of the Study? No conflicts of interest noted Results: They screened 169 patients and included 125 (57 receiving diltiazem and 68 receiving metoprolol). The mean age was 62 years, 76% were male and the average ejection fracture was 16%. The mean initial dose was 16mg for diltiazem and 5mg for metoprolol. Key Result: No statistical difference in adverse effects due to the interventions Primary Outcome: Composite outcome of adverse effects due to the interventions (32% vs 21%, P = 0.217) No statistical difference in any of the components of the composite outcome except for worsening CHF symptoms (33% vs. 15%, P = 0.019). Worsening CHF was driven by increased oxygen requirement within four hours Secondary Outcomes: No statistical difference in any of the secondary outcomes. Admission level of care was 33% vs 32% general, 51% vs 44% step-down and 16% vs 24% ICU. The most obvious nerdy point limiting this study is the observational design. That means that unmeasured confounders cannot be controlled and could bias the results. Unbalanced Groups – Patients who received diltiazem were younger with higher baseline blood pressures (BP), so they may have been less likely to become hypotensive, which was defined primarily as systolic BP < 90 mmHg, rather than a measured drop in BP. Small Sample Size – There was an 11% absolute difference between the two drugs and incidence of adverse effects. This difference was not statistically significant. It is possible that a larger sample size would have reported a difference that was statistically significant. However, the observational nature of the study would only provide low-level evidence. Observer-Expectancy Effect – Discussion of the article mentions guidelines recommending against the use of diltiazem in patients with AF + RVR with HFrEF as it may worsen HF, despite minimal confirmatory evidence. Outcomes measured by increased oxygen requirement and inotrope administration can be subjective, and it is possible a greater number of patients in this cohort received interventions based on provider expectations. Lack of Comparator Group – It may have been useful to include a cohort of patients with AF + RVR without heart failure and examine whether their adverse effects would have been similar. Parametric and Non-parametric Data Analysis – Parametric data analysis is typically performed when data is normally distributed, and non-parametric data is best analyzed when data is not normally distributed. Common tests for parametric data analysis are the chi-square test, student t-test, ANOVA by sum of squares, among others; tests non-parametric data analysis are Fisher exact test, Wilcoxon signed rank test, Mann-whitney U test, ANOVA by rank, and Spearman rank coefficient.

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 0.2% in those with a positive urinalysis [5-6]. These studies, and others, have also highlighted risks to indiscriminate lumbar puncture, stemming from the relatively high rates of sterile pleocytosis in these infants, occurring in 18-24% of these infants [7,8]. Not surprisingly, these infants undergo longer hospitalizations with more IV antibiotics. Clinical Question: In a febrile infant ≤60 days with an abnormal urinalysis suggesting a UTI, do they really need a lumbar puncture or blood work? Reference: Mahajan et al. Serious bacterial infections in young febrile infants with positive urinalysis results. Pediatrics. October 2022 Population: Infants ≤ 60 days of age presenting to 26 emergency departments in the PECARN network between March 2011 and April 2019 with temperature ≥38°C who had urine, blood, and cerebrospinal fluid (CSF) testing at the time of visit Excluded: Prematurity (<37 weeks), significant comorbidities, antibiotic use in the preceding 48 hours, and those critically ill (requiring intubation or vasoactive infusions), UA was nor obtained, CSF not obtained and unable to contact parents at 7-day phone follow up. Intervention: Evaluation of invasive bacterial infections in blood and cerebrospinal fluid (CSF) Comparison: None Outcome: Primary Outcome: Prevalence of bacteremia or bacterial meningitis in infants with a positive urinalysis (growth of a pathogen in the urine or CSF culture) Secondary Outcomes: none Type of Study: Secondary analysis of prospective observational study Authors’ Conclusions: Among noncritical febrile infants ≤ 60 days of age with positive UA results, there were no cases of bacterial meningitis in those aged 29 to 60 days and no cases of bacteremia and/or bacterial meningitis in any low-risk infants based on low-risk blood thresholds in both months of life. These findings can guide lumbar puncture use and other clinical decision making. Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Yes Was the follow up of subjects complete enough? Yes (excluded if unable to contact at 7 days) How precise are the results? Unsure. Do you believe the results? Yes Can the results be applied to the local population? Unsure  Do the results of this study fit with other available evidence? Yes Conflicts of Interest: No Results: 7,180 infants were included in the analysis. 1090 (15.2%) had positive urinalysis results. Of those with a positive urinalysis, 541 (50.2%) had UTI. For those with a negative urinalysis, only 45 (0.8%) had a UTI. E. Coli was the most common cause of both UTI and bacteremia. Key Results: Risk of IBI was higher in infants with positive UA, largely driven the prevalence in bacteremia. No infants >28 days with positive UA had bacterial meningitis. Primary Outcome: Bacteremia Overall, 6% of infants with positive UA had bacteremia while only 1% of infants with negative UA had bacteremia. Bacterial Meningitis For infants in first month of life, rates of bacterial meningitis did not differ with positive or negative UA. For infants in second month of life, there were no cases of meningitis even with positive UA. No cases of meningitis in any infants with positive UA results and normal inflammatory markers based on PECARN febrile infant SBI prediction rule, ANC <4,000 cells/mm3 and procalcitonin <0.5 ng/mL. Listen to the SGEM Podcast for to hear Drs. Mahajan and Kuppermann respond to our 5 nerdy questions. 1) Urinalysis and UTI - We mentioned earlier that only around 50% of those with positive UA truly had a UTI. Why do you think there was such a pronounced discrepancy [9]? Bacterial Meningitis in those UTI 2) Community Setting: If I am working in a setting where I do not have access to procalcitonin, what laboratory or clinical criteria would you recommend to help risk stratify these infants [10-11]? 3) Quaternary Care Setting: If I am working in a setting where I have access to it all (procalcitonin, CRP, temperature, ANC), is there any benefit in using all of it to risk stratify? 4) Low Prevalence of Bacterial Meningitis and Bacteremia- How do you think the low rates of bacteremia and bacterial meningitis impact the power of your conclusions? Any thoughts on how we can overcome this barrier in future studies? 5) Generalizability- How can we leverage global research networks to help us solve the riddle of the febrile infant? Do you think we will ever get to a point where we find a clinical prediction rule that can be applied everywhere or are there too many shifting variables to consider [12]? Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusions. SGEM Bottom Line: In well-appearing infants ≤60 days with positive UA, continue to perform blood work and blood culture. However, infants with positive UA in the second month of life may not routinely need a lumbar puncture. Case Resolution: Blood test results demonstrate that procalcitonin is <0.5 ng/dL and the ANC is <4000. You have a conversation with the parents and tell them the results of both the blood and urine testing. You review the risks and benefits of performing a lumbar puncture versus empirically treating with antibiotics. Ultimately, the parents opt to forgo the lumbar puncture and receive empiric antibiotics with the plan to follow up closely with their pediatrician the next day. Clinical Application: In well-appearing febrile infants >28 days with positive UA and meeting low-risk laboratory criteria, it may not be necessary to perform a lumbar puncture.

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, to be vulnerable. I am fortunate to work at an institution where colleagues commonly check on one another after a difficult patient encounter or bad outcome. I have also had colleagues and friends check on me when I have been going through difficult personal circumstances. This supportive community does not only have to be at your own institution but can extend through social media. Let’s normalize looking out for one another. 3. Batman Won’t Give Up “Maybe that’s what Batman is about. Not winning, but failing, and getting back up. Knowing he’ll fail, fail a thousand times, but still won’t give up.” (Batman-Zero Year) I don’t know about you, but I can’t imagine shouldering the responsibility and burden of being Batman. He is doing his day job of running Wayne Enterprises and no matter how great or poorly his day or how much he got hurt or injured in the previous night, Batman always suits up and goes out on patrol. You just must admire that discipline and tenacity. Our emergency medicine colleagues also exhibit this “won’t give up” attitude. They keep showing up despite the craziness of the past shift, past week, or even the past few years. 4. Turning Failures to Triumph Is it surprising that this theme has popped up again? Chris Carpenter and I spoke about this on the SGEM Top Gun episode. Sometimes despite our efforts, we can still “fail”. If you define failing as patients having bad outcomes or dying. It sort of reminds me of Star Trek the Next Generation and Captain Jean-Luc Picard. He said “it is possible to commit no mistakes and still lose. That is not a weakness. That is life.” That is also emergency medicine. It is possible to do everything right and a patient can still have an adverse event or even die. This “failure” can be turned into opportunities for us to learn and get even better at what we do. Constantly striving to improve what we do. Ultimately everyone will die but what do we learn and how can we grow from these situations? 5. Hard Work, No Complacency Because Batman has no innate superhero abilities, he is constantly training to maintain his skills just like we are in emergency medicine. The SGEM encourages everyone to keep reading, keep thinking critically, keep questioning, and keep adapting so patients get the best care based on the best evidence. 6. The Bat Family I think some people mistake Batman for being a strong, silent, brooding loner type. Some of that is true, but he is not alone. He has the support of the entire Bat family with Alfred, Robin, Jim Gordon. But he also has the entire Justice League to help him when it comes to saving the world. We want to acknowledge all the people we get to work with in the emergency department (nurses, cleaning staff, respiratory therapists, PAs, NPs, switchboard operators, consultants, lab technologists, diagnostic imaging, etc). It is truly wonderful when everyone comes together as part of Team Patient. We also want to acknowledge all the family and loved ones that accompanied us and supported us through medical training and our careers. We appreciate your patience and understanding when we’ve disappeared for months on end while studying for a certification exam or missed important life events. Without you all, we would not be able to do what we do. 7. We are Defined by Our Actions What has defined emergency medicine is to be the one specialty that is for anyone, for anything at any time. We are the light in the house of medicine that never goes out. Like a light house we offer safe harbour in stormy weather. It is these actions of being available for patients in their time of need that defines who we are in emergency medicine. 8. One Person Can Make a Difference Batman always reminds me that one person can make a difference. There are many things for which we do not have much control over. But we can always choose to be kind and take a moment to recognize that everyone has a story. How we choose to approach a challenging situation or patient may leave a lasting impression. I learned about this from my kindness mentor Dr. Brian Goldman. Kindness Mentor Dr. Goldman with BatDoc 9. Everyone is Batman A hero truly can be anyone. The best part about Batman is that we can all strive to be Batman, or BatPerson or BatDoc. 10. Batman as a Symbol “As a man; I am flesh and blood; I can be ignored, I can be destroyed. But as a symbol, I can be incorruptible. I can be everlasting.” I want to take a moment and acknowledge all the amazing work that Ken has done with the SGEM. I am incredibly grateful for his mentorship. To me, Ken represents the importance of skepticism and critical thinking in applying the principles of evidence-based medicine to provide the best care for patients. More importantly, I think Ken embodies a kindness of spirit that I hope to emulate. I am sure I am not the only one that feels this way. So, thank you, Ken, and the SGEM for being that symbol for us. 11. Hope For our last point, we want to again acknowledge that things are tough in healthcare right now. However, one of the greatest things that has come out of these times is the wonderful #FOAMed community that has developed around SGEM. We want to thank you for tuning in every week to listen, learn, and share your stories and expertise. 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. Kevin Conroy 1955-2022

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 residency. Authors’ Conclusions: “Compared to all other ratios, the 1:1 FFP:pRBC ratio had the lowest 24-hour and 30-day mortality following older adult trauma consistent with findings in the younger adult population.” Quality Checklist for Observational Cohort Studies: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Unsure Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Confidence intervals are relatively broad, from 1.25-2.06 for the largest comparator group. Do you believe the results? Yes Can the results be applied to the local population? Yes Do the results of this study fit with other available evidence? Yes Funding/Conflicts of Interest? None Results: In this cohort of over 3,000 patients the odds of mortality increased in line with the transfusion ratio. The mean age was 73 years, 65% were male and 66% had at least one comorbidity. The most common comorbidities were hypertension (39%), diabetes mellitus (16%) and bleeding disorder (11%). KEY RESULT: A 1:1 RATIO OF PACKED RED BLOOD CELLS AND FFP IS ASSOCIATED WITH SIGNFICANTLY LOWER 24-HOUR AND 30-DAY MORTALITY THAN ANY OTHER TRANSFUSION RATIO Results from multivariable regression model for covariates independently associated with 24-h and 30-day mortality for the older adult population. Listen to the SGEM podcast to hear Rae respond to our five nerdy questions. Information Source – You got your information from the ACS TQIP national trauma database. This might not be familiar to all our listeners – can you tell us a bit more about it? Does it include all trauma centres of all levels and how reliable can its data be? Survivor Bias – It’s possible that some patients who died early didn’t get a 1:1 ratio because they didn’t have time to get the FFP before they died. Were you able to explore that at all and do you think it might have an impact on your results? Clustering – 1:1 transfusion might be a marker for other unmeasured quality factors. You have analysed by level of trauma centre but as we can see transfusion ratios varied across all levels. Did you consider analysing whether transfusion ratios were clustered by centre? Missing Variables – Obviously you can only analyse variables that are collected in the database. We’ve mentioned that we would like to have seen a measure of frailty – was there anything else you would have liked to see? Other Therapeutic Interventions – It’s interesting to see in Table 3 that as transfusion ratios increased the rate of surgery for hemorrhage control fell. Obviously, this is only hypothesising but did you get a feel for how those were related? Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusions. SGEM BOTTOM LINE: 1:1 TRANSFUSION OF PACKED RED BLOOD CELLS WITH FRESH FROZEN PLASMA IS ASSOCIATED WITH LOWER ODDS OF MORTALITY THAN OTHER TRANSFUSION RATIOS. Case Resolution: You ask the transfusion tech to send pRBCs and FFP in a 1:1 ratio. Dr. Kirsty Challen Clinical Application: I will be taking this information back to my home institution to review and discuss ourMassive Transfusion Protocol ratio of 1:1 for pRBC and FFS in older adults. What Do I Tell the Patient? You seem to be bleeding from your chest as well as your broken leg. We need to transfuse some blood to replace the blood you’ve lost. We will transfuse two important parts of blood in equal quantities. Keener Kontest: Last weeks’ winner was Dave Michaelson, a PA and repeat winner. He knew the name for the scaphoid is the navicular and it came from the Latin term for boat. It is now reserved for the tarsal bone. Scaphoid is the Greek term for boat. Listen to the SGEM podcast for this weeks’ question. If you know, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize. SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on massive transfusion protocol for older adults? Tweet your comments using #SGEMHOP.  What questions do you have for Rae and her team Ask them on the SGEM blog? The best social media feedback will be published in AEM. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.  References: Jiang, L., Zheng, Z. & Zhang, M. The incidence of geriatric trauma is increasing and comparison of different scoring tools for the prediction of in-hospital mortality in geriatric trauma patients. World J Emerg Surg 15, 59 (2020). https://doi.org/10.1186/s13017-020-00340-1 Dixon JR, Lecky F, Bouamra O, Dixon P, Wilson F, Edwards A, Eardley W. Age and the distribution of major injury across a national trauma system. Age Ageing. 2020 Feb 27;49(2):218-226. doi: 10.1093/ageing/afz151. PMID: 31763677; PMCID: PMC7047820. Albert A, McCaig LF, Ashman JJ. Emergency department visits by persons aged 65 and over: United States, 2009–2010. NCHS Data Brief 2013;130:1–8. Masud T, Morris RO. Epidemiology of falls. Age Ageing 2001;30:3–7. Yildiz M, Bozdemir MN, Kilicaslan I, et al. Elderly trauma: the two years experience of a university-affiliated emergency department. Eur Rev Med Pharmacol Sci 2012;16(Suppl 1):62–7. Centers for Disease Control and Prevention. Fatalities and injuries from falls among older adults–United States, 1993–2003 and 2001–2005. MMWR Morb Mortal Wkly Rep 2006;55:1221–4.

Date: November 30th, 2022 Reference: Johnson et al. One-year outcome of surgery compared with immobilization in a cast for adults with an undisplaced or minimally displaced scaphoid fracture: A meta-analysis of randomized controlled trials. Bone Joint J 2022 Guest Skeptic: Dr.Matt Schmitz is an Orthopaedic Surgeon specializing in Adolescent Sports Medicine and Young Adult Hip Preservation. DISCLAIMER: THE VIEWS AND OPINIONS OF THIS BLOG AND PODCAST DO NOT REPRESENT THE UNITED STATES GOVERNMENT OR THE US MILITARY. Case: A 32-year-old male construction worker presents to the emergency department (ED) after falling on his right dominant hand. He has swelling in his distal radius, snuffbox tenderness, decreased range of motion and is neurovascularly intact distal to the injury. X-rays demonstrate a minimally displaced midwaist fracture of the scaphoid. He’s got a big job coming up in a couple of months and can’t work with a cast. He asks if surgery would be a better option? Background: Fractures of the scaphoid are the most common carpal fractures presenting to the emergency department (ED). Initial x-rays pick up 17% with only 7% more being identified on follow-up x-rays (1,2). The classic history for a scaphoid fracture is a fall on outstretched hand (FOOSH). Clinicians need to be careful in taking the history because other mechanisms that hyperextend the wrist like a motor vehicle collision while holding the steering wheel can also apply enough force to fracture the scaphoid. Physical examination of patients with a FOOSH injury include palpating for snuff box tenderness. In a systematic review and meta-analysis (SRMA) by Carpenter et al they were only able to find six studies with a total of 170 patients found in the world’s literature looking at snuff box tenderness.  The evidence had a substantial amount of heterogeneity (3). The LR- to rule out a scaphoid fracture was 0.15 for snuffbox tenderness which is moderate evidence. However, it had a very wide 95% confidence interval around the point estimate (95% CI; 0.05 to 0.43).  There are many other physical exam maneuvers like thumb compression, vibration pain, clamp sign, ulnar deviation pain, radial deviation pain, scaphoid tubercle pain, and resisted supination pronation. None of these have a LR- low enough (<0.1) to reliably rule out a scaphoid fracture. We mentioned x-rays were unreliable as well to rule-out a scaphoid injury. Other imaging modalities like bone scan, ultrasound and CT scan have been used but found to be lacking in accuracy. The best imaging test is an MRI. Initial X-ray 0.24 (0.07–0.79) Follow-up X-ray 0.67 (0.50–0.89) Bond Scan 0.11 (0.05–0.23) Ultrasound 0.27 (0.13–0.56) CT Scan 0.23 (0.16–0.34) MRI 0.09 (0.04–0.19) Emergency physicians can use clinical decision instruments to help in diagnosing certain conditions. There are many validated instruments for fractures such as the Ottawa Ankle Rule (SGEM#3), Ottawa Knee Rule (SGEM#5) and the Canadian C-Spine Rules (SGEM#232). There is no validated clinical decision instrument to help ED physicians accurately rule in or out a scaphoid fracture (4,5). There is not a diagnostic dilemma in this case. The question is does the scaphoid fracture need to be treated operatively or non-operatively. The vast majority (90%) of scaphoid fractures are non-displaced and treated with cast immobilization (6). Displaced fractures increase the risk of non-union from 14% to 50% (7,8,9). If left with a non-union, they almost always result in secondary osteoarthritis of the wrist (10). Also, delayed unions and nonunions are more difficult to treat (i.e. bigger surgery) so there is a trend in orthopedics to perform urgent surgical fixation of scaphoid fractures as opposed to the traditional casting. Whether someone undergoes surgery is an informed decision made between the patient and the surgeon. However, emergency department patients often ask the EM physician if they need surgery. It is good to stay up on the literature so we can prepare the patient for the conversation with the surgeon. We have seen this recently with the non-operative treatment of acute appendicitis (NOTA) and covered this on the SGEM (SGEM#115, SGEM#256, and SGEM#345) Clinical Question: What is the effectiveness of operative vs nonoperative management of un-displaced and minimally displaced (≤ 2 mm) scaphoid fractures? Reference: Johnson et al. One-year outcome of surgery compared with immobilization in a cast for adults with an undisplaced or minimally displaced scaphoid fracture: A meta-analysis of randomized controlled trials. Bone Joint J 2022 Population: Adult patients older than 16 years of age with a un-displaced or minimally displaced (≤ 2 mm) fracture of the waist of the scaphoid. Exclusions: Non-RCTs, children, displaced >2 mm Intervention: Operative management Comparison: Non-operative management Outcome: Primary Outcome: Patient-reported outcome measure (PROM) of wrist function at 12 months Secondary Outcomes: Pain, grip strength, range of motion (ROM) of the wrist, and complications including radiological evidence of nonunion Type of Study: Systematic review meta-analysis of RCTs Authors’ Conclusions: “We found no difference in functional outcome at 12 months for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively. The complication rate was higher with operative treatment.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes The search for studies was detailed and exhaustive. Yes The primary studies were of high methodological quality. The assessment of studies were reproducible. Yes The outcomes were clinically relevant. Unsure There was low statistical heterogeneity for the primary outcomes. No The treatment effect was large enough and precise enough to be clinically significant. Unsure Results: Using the PRISMA guidelines and searching multiple databases they identified a total of 456 studies. There were seven trials ultimately included in the meta-analysis. Only four RCTs (n= 537) reported functional outcome at 12 months (primary outcome). The demographics of those four RCTs had a mean age of 32 years and 84% were male. Key Result: No statistical difference between operative and non-operative management. Primary Outcome: Patient-reported outcome measure (PROM) of wrist function at 12 months Non-statistical difference using Hedges’ g (0.15 [95% CI; -0.02 to 0.32]; p = 0.082) Secondary Outcomes: There were some statistical differences favoring operative management using fixed effect meta-analysis at 6 months for grip strength, ROM, and odds ratio for non-union. Complications were higher in the operative group. 1. Small Number of Studies: This was mentioned earlier. While they included seven RCTs only four were used for the meta-analysis of the primary outcome with n=537. 2. Uncertainty: With only a few studies to meta-analyze and different outcome measures there were wide 95% confidence intervals around the point estimate of the observed effect size. Four of the seven RCTs were rated as low-quality using the Cochrane Risk of Bias Tool V2.0. All these issues lead to a fair amount of uncertainty in the magnitude and precision of the primary and secondary outcomes. 3. Primary Outcome Measure (PROM): The primary outcome for each of the four RCTs used in the meta-analysis was different. This makes it hard to compare one study to another. It also contributes to the high I2 test as a measurement of heterogeneity for the primary outcome of PROM. It was 74% using the fixed effect model worse using the random effect mode (84%). Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) Patient Evaluation Measure (PEM) Patient-Rated Wrist Evaluation (PRWE) function subscale, Adapted Green O’Brien score In addition, is function and PROM at 12 months the purpose of operative treatment? Or is it getting people back to work quicker?  Treatment for scaphoid wrist fractures has typically been long immobilization in a thumb spica cast which is very cumbersome for a manual labourer.  So, it depends on what your patient would value and prefer. Grip strength and ROM favoured operative treatment at six months. This was a secondary outcome and considered hypothesis generating that could be explored further. They don’t mention earlier healing time in operatively treated fractures. There is a difference between rate of nonunion and time to union. Let’s not forget about complications. Some were related to “scar” 4cm incision that is not used any longer; others were arthroscopic assisted reductions 4. Hedges’ g: A Hedges’ g is a measurement of effect size. It was first described by Larry Hedges in 1981 (JSTOR). Typically, it is used to determine how much an group (experimental) is different from another group (control). It is very similar to Cohen’s d but is better when sample sizes are smaller (<20). Small effect size is considered 0.2, medium effect size 0.5, and a large effect size >0.8. The Hedges’ g for the primary outcome in this study was 0.15 (95% CI; -0.02 to 0.32); p = 0.082 representing a small effect size that was not statistically different between operative and not-operative group. 5. Bond Article: They seem to ignore the 2001 article by Bond et al that looked at a military population. This study showed a quicker return to full duty and quicker healing times. Comment on Authors’ Conclusion Compared to SGEM Conclusion: A friendly amendment to their conclusions would be that they did not find a “statistically difference” between the two treatments rather than saying “no difference”.

Date: November 16th, 2022 Reference: Lipsett SC, Monuteaux MC, Shanahan KH, et al. Nonoperative Management of Uncomplicated Appendicitis. Pediatrics 2022 Dr. Angelica DesPain Guest Skeptic: Dr. Angelica DesPain is an Assistant Professor of Pediatrics and a pediatric emergency medicine physician at the Baylor College of Medicine Children’s Hospital of San Antonio in San Antonio, TX. Case: A 10-year-old boy comes into the emergency department (ED) with right lower quadrant (RLQ) pain for the past two days. He also has had nausea, vomiting, loss of appetite but no fevers. You order an ultrasound and find that he has acute appendicitis without evidence of perforation or appendicolith. His white blood cell count is 11,000 and his C reactive protein (CRP) is mildly elevated. After you tell the family the news, the parents express concern about their child having surgery. They ask you and the surgeon, “Does he absolutely need surgery, or can we treat this medication alone?” Background: The SGEM has covered diagnosing appendicitis using speed bumps (SGEM#23), a clinical decision instrument (SGEM#155) and point of care ultrasound (SGEM#274). The current standard of care for nonperforated acute appendicitis is immediate laparoscopic appendectomy. However, over the last decade nonoperative treatment of appendicitis (NOTA) with antibiotics alone has become an alternative treatment option for non-perforated acute appendicitis. These authors call this alternative nonoperative management of uncomplicated acute appendicitis (NOM). The SGEM has looked at the evidence for NOTA/NOM in adults a few times including SGEM#115, SGEM#256 and SGEM#345. We have also looked at it specifically in children with pediatric general surgeon and rock star Dr. Ross Fisher with an episode called: The First Cut is the Deepest (SGEM#180). In adults, randomized control trials suggest that nonoperative management with antibiotics alone may be a reasonable treatment approach for individuals without appendicolith [1-3]. Although, up to 39% of patients may experience failure by the five-year mark [4]. In children, there have been two randomized and several nonrandomized prospective trials. Most recently, the two prospective pediatric studies published their 5-year data and observed a similar five-year failure rate of nonoperative management of 30-40% [5-6]. The shift from immediate operative management to now up to 3 in 10 cases being treated with IV antibiotics leaves a lot of questions as to whether nonoperative management is an appropriate option for nonperforated pediatric acute appendicitis.  Clinical Question: How do the risks and complications compare between nonoperative management vs immediate operative intervention for acute nonperforated appendicitis?  There are actually four questions these authors are trying to address with this paper. What are the trends in NOM of nonperforated acute appendicitis? What are the early and late treatment failure rates with NOM? How does subsequent healthcare utilization compare between children undergoing immediate operative management and those undergoing NOM? How do the rates of perforated appendicitis and postsurgical complications compare between children undergoing immediate operative management and those who experience failure of NOM? Reference: Lipsett SC, Monuteaux MC, Shanahan KH, et al. Nonoperative Management of Uncomplicated Appendicitis. Pediatrics 2022 Population: <19 years of age seen across 47 EDs in the Pediatric Health Information System (PHIS) database from January 2011 through March 2020 who were ascribed a primary diagnosis of appendicitis based on ICD-9 and 10 codes. To increase the specificity of the case definition, the study only included patients who either underwent appendectomy or received a parenteral antibiotic during the index visit. Excluded: complex chronic condition and those with a previous visit with a diagnosis of appendicitis or a procedure code for an appendectomy (these would exclude prior cases of nonoperative management)  Intervention: Nonoperative management (NOM) of nonperforated acute appendicitis  Comparison: Appendectomy for nonperforated acute appendicitis  Outcomes: Because they had four questions they were trying to answer, we are not actually sure what their primary versus secondary outcomes were. They were all just…outcomes. Trends in NOM Treatment failure rate for NOM, divided into early (≤14 days) vs late (>14 days); 1, 2, 5-year failure rates Subsequent healthcare utilization for NOM vs immediate management Rates of perforated appendicitis and postsurgical complications between children undergoing immediate operative management versus those who opted for NOM Type of Study: Retrospective cohort study using data obtained from the Pediatric Health Information System (PHIS), Authors’ Conclusions: Nonoperative management of nonperforated pediatric appendicitis is increasing. Although the majority of children who undergo NOM remain recurrence-free years later, they carry a substantial risk of perforation at the time of recurrence and may experience a higher rate of postoperative complications than children undergoing an immediate appendectomy. Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Unsure  Was the outcome accurately measured to minimize bias? Unsure Have the authors identified all-important confounding factors? Unsure  Was the follow up of subjects complete enough? Unsure How precise are the results? Unsure Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Funding of the Study: None Results: They included 73,544 patients who had non-perforated appendicitis in the study group. 63,150 (85.9%) underwent appendectomy at the index visit and 10,394 (14.1%) underwent nonoperative management (NOM). Median age was 11.4 years and 61.2% were male. Key Result: NOM for acute nonperforated appendicitis has grown in popularity. It is associated with a risk of perforation at the time of failure, higher rates of subsequent healthcare utilization, and slightly higher rates of postsurgical complications. Outcomes: Trends: NOM increased from 2.7% (2011) to 32.9% (2020). Odds ratio 1.1 per study quarter [1.01-1.51] Failure Rate: 2084 (20.1%) failed NOM. Median time to failure was 2 days [IQR 1-5 days]. 4% early and 1.7% late. 7% perforated vs 37.5% at index visit (p<0.001). Failure rate at 1, 2, 5 years Subsequent Healthcare Utilization: NOM higher rate of: ED visits: 8% vs 5% Hospitalization: 4.2% vs 1.4% Abdominal imaging that included ultrasound and CT Postsurgical Complications and Perforated Appendicitis: Higher risk of post-surgical complications within 12 months: 1.9% vs. 1.2% 1. Accuracy of Coding: This was a retrospective study using a large database, PHIS. While it houses a tremendous amount of data, there are limitations to its use. It relies on accuracy in coding and data that is inputted by all the hospitals that contribute. The non-prospective and non-randomized nature of this study leaves a lot to clinician preference and coding. Additionally, it may not capture some nuanced situations. For example, if the family opted for NOM but the child perforated on initial visit, it is possible that patients were coded as perforated appendicitis and not included in this study. Another example is if the family opted for NOM which failed on initial visit and was taken to the OR, that patient may have been coded as immediate surgical management. 2. Selection Bias: With the transition from ICD-9 to IC-10 coding during the study period, the authors chose to exclude hospitals that demonstrated an absolute change of 50% in the rate of either perforated appendicitis or NOM. This was made under the assumption these shifts were likely due to coding issues and excluded 20.7% (31,341 out of 150,983) of patients who had met inclusion criteria.  Was this assumption correct? How did they choose this cutoff of 50%? Why not 30%, 40%? Was this too conservative or too lenient? How would the hospitals whose patients were excluded by this decision have impacted the data? 3. Subsequent Encounters: This study evaluated whether there were any subsequent encounters for patients who opted for NOM. But what if that patient did not return to the initial hospital where they received treatment? There is a portion of pediatric acute appendicitis that is managed in the community and not at academic centers. There is a chance these patients may have been missed and skew the results to make it appear like NOM actually did better. They included subsequent related ED visits for complaints of abdominal pain, vomiting, diarrhea, and dehydration in their analysis. I am not certain how they made the determination that these visits were “related” to appendicitis. 4. Clinical Data: The PHIS database does not contain any clinical information and clinical judgment is one of the pillars of evidence-based medicine. What were the reasons that some cases of appendicitis underwent NOM vs laparoscopic appendectomy? What were the other clinical, laboratory, or radiographic findings that influenced management decisions? For those patients that were included in the treatment failure population, how many of those had elective interval appendectomies versus true recurrences? What were the histopathologic findings after the appendix was removed? We do not have that information. 5.