The Skeptics Guide to Emergency Medicine

Date: March 3rd, 2022 Reference: Macnow et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatrics 2021 Guest Skeptic: Dr. Catherine Varner is an Assistant Professor and Clinician Investigator in the Department of Family and Community Medicine at the University of Toronto. She is an emergency physician at Mount Sinai Hospital and a Clinician Scientist and the Deputy Director of the Schwartz-Reisman Emergency Medicine Institute. Dr. Varner's research interests are in concussion and pregnancy care in the ED. Case: An 18-year-old female presents to the emergency department (ED) after falling off a moving snowmobile and hitting her head on the ground. It was a witnessed fall; she was wearing a helmet at the time and there was no loss of consciousness. There were no other injuries reported and she is found to have a GCS score of 15 after the injury. The Acute Concussion Evaluation–Emergency Department (ACE-ED) Tool is used, and she scores a 2 for headache and feeling foggy. She knows about taking it easy physically for the next couple of days but wonders if she must stay off her computer as well? Background: Concussions or mild traumatic brain injury (mTBI) are commonly diagnosed in the Emergency Department (ED). Most patients recover within the first week; however, 15-30% of patients develop persistent post-concussive symptoms. An issue that often comes up with minor head injuries is do we need to get advanced imaging. A paper by Dr. Ian Stiell and his group gave us a tool to help us decide who to scan with the now infamous clinical decision instrument called the Canadian CT Head Rule [1]. This classic paper was published in Lancet 2001 and reviewed on SGEM#106. Another issue that comes up is whether children need strict rest after a concussion. SGEM#112 reviewed a small study by Thomas et al published in Pediatrics 2015 asking if there was a benefit to recommending strict rest after a child has a concussion [2]. The bottom line from that episode was that in children with concussion, two days of rest followed by a gradual return to activity is preferred over five days of rest followed by a gradual return to activity. The longer strict rest period appears to cause more post-concussive symptoms. Our episode together looked at the impact of light exercise in adults with mild concussions on the likelihood of developing persistent symptoms up to 30 days following their injury (SGEM#331). We found there was not a statistical difference between light activities like walking and 48 hours of rest with gradual return to activity as tolerated. Our conclusions were that early light exercise may be encouraged as tolerated at ED discharge following mTBI, but this guidance is not sufficient to prevent persistent concussion symptoms [3]. The Acute Concussion Evaluation–Emergency Department (ACE-ED) tool is an instrument used by ED clinicians to diagnose a concussion and identify risk factors for prolonged recovery. It is both helpful for diagnosis and future management of symptoms. When a patient is recovering from a concussion, whether you are using ACE or another symptom scoring tool like the Postconcussion Symptom Scale or the Rivermead Post-concussion Symptom Questionnaire, future health care providers caring for the concussion patient may refer to the quantitative assessment of the patient’s symptoms in the acute phase of the injury. Clinical Question: Does screen time in the first 48 hours after concussion have an impact on the duration of concussive symptoms? Reference: Macnow et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatrics 2021 Population: Patients aged 12 to 25 years presenting to the emergency department within 24 hours of sustaining a concussion according to the Acute Concussion Evaluation–Emergency Department (ACE-ED) tool (Giola et al 2008)

Date: February 24th, 2022 Reference: Parish et al. An umbrella review of effect size, bias, and power across meta-analyses in emergency medicine. AEM 2021 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 resident has been following the literature over their four years of training. They have already seen several things come into fashion and go out of fashion during this short time. This includes therapeutic hypothermia for out-of-hospital cardiac arrest (OHCA), tranexamic acid (TXA) for epistaxis and electrolyte solutions for mild pediatric gastroenteritis. They wonder how strong the evidence is for much of what we do in emergency medicine. Background: There are many things in medicine that could be considered myth or dogma. We have covered some of these over the 10 years. Topical anesthetic uses of 24-48 hours for mild cornea abrasions will cause blindness- No (SGEM# 315) Epinephrine for adult out-of-hospital cardiac arrests (OHCAs) results in better neurologic outcomes – No (SGEM#238) TXA for intracranial hemorrhage, isolated traumatic brain injury, post-partum hemorrhage or gastrointestinal bleed results in better primary outcomes - No (SGEM#236, SGEM#270, SGEM#214, and SGEM#301) Therapeutic hypothermia in adult OHCA saves lives – No (SGEM#336) Electrolyte solutions are needed in mild pediatric gastroenteritis - No (SGEM#158) A lot of medical practice is based on low quality research. Tricoci et al. JAMA Feb 2009 looked at the ACC/AHA guidelines from 1984 to 2008. They found 53 guidelines with 7,196 recommendations. The results were only 11% of recommendations were considered Level A, 39% were Level B and 50% were Level C. The definitions used for each level of evidence are as follows: An update was published by Fanaroff et al in JAMA 2019. The level of high-quality evidence had not changed much when looking at the ACC/AHA guidelines from 2008-2018. There were 26 guidelines with 2,930 recommendations. Now Level A recommendations were down to 9%, Level B 50% and Level C 41%. This lack of evidence is not isolated to cardiology. A recent study looked at the top ten elective orthopaedic procedures. It was an umbrella review of meta-analyses of randomized control trials (RTCs) or other study designs if no RCTs existed (Blom et al BMJ 2021). The comparison was the clinical efficacy of the most common orthopaedic procedures with no treatment, placebo, or non-operative care. The primary outcome was the quality of the evidence for each procedure. Only two out of ten common procedures, carpal tunnel decompression and total knee replacement, showed superiority over non-operative care. Clinical Question: What is the effect of faults such as underpowered studies, flawed studies (i.e. methodologic and statistical errors, poorly designed studies) and biases in the field of therapeutic interventions in the emergency medicine literature? Reference: Parish et al. An umbrella review of effect size, bias, and power across meta-analyses in emergency medicine. AEM 2021 Population: SRMAs 1990-2020 in the top 20 journals under the google scholar subcategory: emergency medicine; emergency medicine meta-analyses from JAMA, NEJM, BMJ, The Lancet, and the Cochrane Database of Systematic Reviews; emergency medicine topics across all PubMed journals; and an extraction of all studies from the Annals of Emergency Medicine Systematic Review Snapshots (SRS) series. Exclusions: Articles were excluded if they did not include a quantitative synthesis (meta-analysis); did not contain at least two summarized studies; did not make a comparison between ...

Date: February 21st 2022 Reference: Kim et al. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. AEM February 2022. Guest Skeptic: Dr. Kirsty Challen (@KirstyChallen) is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). She is Chair of the Royal College of Emergency Medicine Women in Emergency Medicine group and involved with the RCEM Public Health and Informatics groups. Kirsty is also the creator of the wonderful infographics called #PaperinaPic. Case: You are in discussion with your emergency department (ED) manager about the number of patients boarding for hours to days and you are both aware that many of these patients are attending with mental health crises. You wonder whether a model of care involving a specifically designed unit would improve their patient experience and ED boarding times. Background: We have covered mental health issues only a few times on the SGEM. The latest SGEM Xtra was a very powerful episode with Dr. Tim Graham sharing his story of burnout, anxiety, and depression. This was based upon his article published in the Canadian Medical Association Journal (CMAJ). We also had Dr. Tyler Black on that episode to provide his expertise as a suicidologist.  ED visits in the US for mental health conditions has increased by 44% from 2006 to 2014. Inadequately resourced provision for emergency mental health care is familiar to health care professionals in multiple jurisdictions and patients can spend days in the ED waiting for inpatient admission. We've talked about mental health issues in SGEM #252 in 2019. In that episode we concluded that clinician gestalt was likely to be as accurate and efficient in screening for suicidality as a specific tool (Convergent Functional Information for Suicidality screening tool). Also, in SGEM #313 we recognised that three or more ED attendances for alcohol-related issues was associated with a 1-year mortality risk of over 6%. Clinical Question: Does the implementation of a dedicated interdisciplinary unit for mental health patients presenting to an ED with suicidal ideation or a suicide attempt reduce inpatient admissions and ED boarding time? Reference: Kim et al. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. AEM February 2022. Population: Adults presenting to a single academic tertiary referral ED in Iowa with suicidal ideation or after a suicide attempt – determined using administrative data.. Excluded: Patients that were medically unstable, needed co-management of a medical condition, were incarcerated, actively violent or judged by the provider to be intoxicated. Also, patients with mental health conditions other than suicidal ideation or attempt. Intervention: Post-establishment of EmPATH unit Nov 2018 – May 2019. Comparison: Pre-establishment of EmPATH unit Nov 2017 – May 2018. Outcome: Primary Outcome: Proportion of patients admitted to inpatient psychiatric unit (direct from ED, via EmPATH Unit or by transfer). Secondary Outcomes: Any admission including psychiatry, intensive care, or medicine; complete vs incomplete psychiatric admission; hospital length of stay in those with a bed requested; ED length of stay; use of restraints in ED, scheduled follow-up, 30-day ED return; restraint use; code green Dr. Allie Kim This is an SGEMHOP episode which means we have the lead author on the show (Dr. Kim). And as a special treat we also have the senior author (Dr. Lee). Dr. Allie Kim graduated from emergency medicine residency at the University of Iowa last July and now works as an attending physician at Unity Point Health hospitals in Des Moines, Iowa. We also have senior author Dr.

Date: February 15th, 2022 Guest Skeptic: Dr. Tim Graham is a Clinical Professor of emergency medicine at the University of Alberta, and Associate Chief Medical Information Officer, Edmonton Zone, of Alberta Health Services from Edmonton, Alberta. Reference: Graham T. Physician heal thyself. CMAJ 2021 TRIGGER WARNING: As a warning to those listening to the podcast or reading this blog post, there may be some things discussed that could be upsetting. The SGEM is a free open access project 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 material we are going to be talking about on this episode could trigger some strong emotions. If you are feeling upset by the content, then please stop listening to the podcast or reading the blog. There will be resources listed at the end of the blog for those looking for assistance. Dr. Tim Graham This is an SGEM Xtra episode. Tim approached me about an article he wrote and published in the Canadian Medical Association Journal (CMAJ). The title of the article was "Physician, heal thyself" and was in the humanities section of the October 2021 issue. This article resonated with many people and was the 6th most read CMAJ article of 2021. Tim thanked his wife, Dr. Samina Ali, in the CMAJ article and on the podcast. Samina has been a guest skeptic on the SGEM. She is the one who suggested Tim share his story to reach an even wider audience. In this SGEM Xtra episode, Tim tells his experience with burnout. This is a topic we have discussed many times on the SGEM and I have shared my personal experience with burnout. SGEM Xtra: The Water is Wide SGEM#289: I Want a Dog to Relieve My Stress in the Emergency Department SGEM Xtra: CAEP Wellness Week 2019 SGEM Xtra: On the Edge of Burnout SGEM Xtra: Don’t Give Up – The Power of Kindness SGEM#178: Mindfulness – It’s not Better to Burnout than it is to Rust SGEM Xtra: Five Tips to Avoid Emergency Medicine Burnout A 2015 study by Shanafelt et al of US physicians showed that more 50% had at least one symptom of burnout. The highest prevalence of burnout was reported by emergency physicians. COVID19 has been hard on the health care system. Medscape just published a 2021 survey of 13,000 physician from 29 specialties and emergency physicians were still #1 reporting the highest level of burnout.  People have made a distinction between burnout and moral injury. Journalist Diane Silver describes moral Injury as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.” It is something that tears us apart at the fabric of what it is to be a physician. Tim discusses how he started getting suicidal ideations and what he did to try and address these thoughts. This included seeking professional help, medication, and lifestyle changes. Some interventions helped more than others. Tim reports he is now in the best place mentally and physically than he has been in many years. Tim also gives some advice to prevent others from going through a similar experience. This includes a wellness tool kit that starts with a healthy diet, regular exercise and good sleep. Two things he found really helpful were meditation and yoga. Suicidologist: Dr. Tyler Black When preparing this SGEM Xtra episode, I suggested to Tim we get an expert in mental health to give us some more information on the topic. I'm not an expert in this area and reached out to Dr. Tyler Black. Tyler is a suicidologist, emergency psychiatrist and pharmacologist from Vancouver. Dr. Tyler Black Tyler provided a definition for suicidologist. He discussed burnout and the association with suicidal ideation in physicians (Menon et al JAMA 2020. Tyler gave some potential reasons why physicians do not seek mental health care (stigma,...

Date: February 7th, 2022 Reference: Williams et al. Short- vs standard-course outpatient antibiotic therapy for community-acquired pneumonia in children: the scout-cap randomized clinical trial. JAMA Pediatrics 2022 Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. Case: A three-year-old boy presents to the emergency department (ED) with fever and cough. On exam, he is breathing a little fast and his oxygen saturation is 94% on room air but otherwise appears comfortable. You appreciate some decreased breath sounds and crackles on your lung exam. You make a clinical diagnosis of community-acquired pneumonia (CAP) and plan to send him home with a 10-day course of amoxicillin. His mother asks you, “Last time he took antibiotics for that long, he had terrible diarrhea. Do you think we can do fewer days of antibiotics and still treat the pneumonia?” Background: We have covered the topic of pediatric community-acquired pneumonia before on the SGEM #338 (Are Children with CAP Safe and Sound if Treated for 5 days rather than 10 days of antibiotics?) with Dr. Andrew Tagg on the Canadian SAFER Trial [1]. This trial suggested that a 5-day course of antibiotics was not non-inferior to the traditional 10-day course of antibiotics for children with CAP treated as outpatients. Things were much simpler when I started my pediatric training. I learned that a well-appearing child presenting to clinic with fever, slight tachypnea, and focal lung exam findings could be diagnosed with pneumonia by history and physical exam alone and go home with 10 days of amoxicillin BID. But now for some reason, this topic feels more complicated…maybe because there are so many different ways people go about diagnosing pneumonia and such variability in the reliability of physical exam findings [2,3]. Since we covered the SAFER trial, we have also had the CAP-IT [4] trial from the United Kingdom and Ireland which evaluated both high and low-dose amoxicillin for the treatment of CAP over three or seven days. They found that both a lower dose and a shorter duration of antibiotic therapy was non-inferior to higher dose, longer duration antibiotic therapy. They did find that cough persisted longer with the group that received a shorter duration of antibiotic therapy but overall adherence to medication was better in the group receiving a shorter duration of antibiotics. Why so many pneumonia studies? Ultimately, we want to find that balance of treating an infection but avoiding antibiotic-associated adverse effects and antibiotic resistance. So where is that sweet spot?  Clinical Question: Is a 5-day course of antibiotics superior to a 10-day course for the treatment of non-severe community-acquired pneumonia in children with respect to clinical outcomes, adverse effects, and antimicrobial resistance? Reference: Williams et al. Short- vs standard-course outpatient antibiotic therapy for community-acquired pneumonia in children: the scout-cap randomized clinical trial. JAMA Pediatrics 2022 Population: Children 6 to 71 months of age from 8 US cities diagnosed with uncomplicated CAP demonstrating early clinical improvement (no fever, tachypnea, severe cough) on day 3 to 6 of their initially prescribed oral beta-lactam therapy. Excluded: Severe pneumonia (Hospitalization, radiographic evidence of parapneumonic effusion, empyema, lung abscess, pneumatocele or Microbiologically confirmed Staph aureus or Strep pyogenes pneumonia. Parenteral or combination antibiotic therapy. Undergoing surgery or invasive airway procedures 7 days prior to diagnosis of CAP. Beta-lactam allergy. Concurrent bacterial infection necessitating >5 days of antibiotics. Aspiration pneumonia, bronchiolitis, bronchitis, acute asthma exacerbation. Chronic medical conditions. History of pneumonia within prior 6 months Intervention: Short 5 days course of previously prescri...

Date: January 25th, 2022 Reference: Beyde et al. Efficacy of empiric antibiotic management of septic olecranon bursitis without bursal aspiration in emergency department patients. AEM January 2022 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: You’re working in your busy freestanding emergency department (ED) getting absolutely crushed handing out COVID19 tests like candy and are relieved to see a patient with something different. A 27-year-old male construction worker building a local house presents with a tender, warm, erythematous olecranon and you diagnose him with septic olecranon bursitis. You offer to drain the bursa and get him back to work ASAP, and the patient looks very anxious and asks if you really must. Background: We have covered skin and soft tissue infections multiple times on the SGEM. The most recent time was with guest skeptic and SAEM FOAMed Excellence in Education Award winner Dr. Lauren Westafer (SGEM#348). We reviewed Dr. David Talan and colleagues’ study that was the October 2021 SGEM Hot Off the Press. That study investigated if a single-dose long-acting intravenous antibiotic could reduce hospitalization in patients with skin infections. The SGEM bottom line from that episode was in hospital systems with access to IV dalbavancin and the ability to establish expedited telephone and in-person follow up, this clinical pathway is associated with a decrease in hospitalizations for patients with moderately severe cellulitis. A couple of other SGEM episodes have looked at the management of cellulitis including SGEM#131 and SGEM#209. The treatment of abscesses has been covered four times on the SGEM (SGEM#13, SGEM#156, SGEM#164 and SGEM#311). The latest episode looked at the loop technique to drain uncomplicated abscesses. One topic we have not looked at is infected bursa. It’s estimated that about half of olecranon bursitis cases are septic[1]. Often, diagnostic aspiration is performed, but complications include fistula formation, further infection, and need for bursectomy [2-6]. Often the workup of septic bursitis is based upon anecdotal evidence [7]. This is likely due to the lack of high-quality evidence to direct our care. One area with limited information is the efficacy of empiric antibiotics without bursal aspiration. Clinical Question: What is the efficacy and outcomes associated with empiric antibiotic therapy, without aspiration, for septic olecranon bursitis? Reference: Beyde et al. Efficacy of empiric antibiotic management of septic olecranon bursitis without bursal aspiration in emergency department patients. AEM January 2022 Population: Adults >18 years old with olecranon bursitis Excluded: Declined authorization, underlying fracture, or surgery on the joint within 3 months Exposures: Antibiotics, aspiration, surgery or admission to hospital Comparison: None Outcome: Primary Outcome: Complicated versus uncomplicated bursitis resolution (Uncomplicated was defined as bursitis resolution without the need for bursal aspiration, surgery, or hospitalization) Secondary Outcome: Descriptive statistics of the cohort Study Design: Retrospective observational cohort study Dr. Ronna Campbell This is an SGEMHOP episode which means we have the senior author on the show. Dr. Ronna Campbell is an emergency physician practicing since 2007 in Rochester, MN. She enjoys mentoring medical students, residents and others in research. Authors’ Conclusions: “Eighty-eight percent of ED patients with suspected septic olecranon bursitis treated with empiric antibiotics without aspiration had resolution without need for subsequent bursal aspiration, hospitalization, or surgery. Our findings suggest that empiric antibiotics without bursal aspiration may be a reasonable initial approach to ED management of select patients with suspected septic ...

Date: January 22nd, 2022 Reference: Yu et al. Inhaled budesonide for COVID-19 in people at high risk of complications in the community in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial. Lancet 2021 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com. Case: A 65-year-old woman with a history of diabetes, hypertension, and gastroesophageal reflux disease (GERD) presents with three days of fever, cough, and myalgias. She is fully vaccinated against COVID-19. Her husband tested positive for COVID-19 yesterday, and she used a home rapid test this morning that is also positive. Her vitals signs are all normal and she feels well enough to isolate at home. As you are preparing to discharge her, she asks if there is anything you can prescribe her to help. She thinks her friend might have been prescribed a puffer of some sort. Background: I’ve tried not to focus too much on COVID-19. There are many great FOAMed resources that have done a good job of covering the topic. The SGEM has only done a few shows over the two years including: Debate regarding a universal mandate for masks early in the pandemic with Dr. Joe Vipond (SGEM Xtra: Masks4All in Canada Debate) Skeptical review of the early therapeutics with Dr. Sean Moore for the Canadian Association of Emergency Physicians (CAEP) Town Hall (SGEM Xtra: COVID19 Treatments – Be Skeptical) Diagnostic accuracy of various tests for COVID19 with Dr. Chris Carpenter (SGEM#299: Learning to Test for COVID19) Structured critical appraisal of the DANMASK trial with Dr. Joe Vipond (SGEM#309: That’s All Joe Asks of You – Wear a Mask) The First10EM has done more than 30 blog posts about COVID-19 at this point, with a lot more to come. I know we all wish COVID-19 would just go away. But unfortunately, wishful thinking won’t help us, but hopefully science will. There is strong evidence that systemic steroids improve outcomes in patients with severe COVID-19 (First10EM: Steroids for COVID). This has raised the question of whether inhaled steroids might be helpful. After all, the infection is primarily in the lungs. Early in the pandemic, there was some observational data that concluded that inhaled steroids were associated with an increased mortality from COVID-19 in patients with asthma and COPD (Schultze Lancet Resp Med 2020). However, the most likely explanation was not causal. Sicker patients are prescribed steroids more often, and so the association is not surprising. The STOIC trial was an initial phase 2 open-label randomized control trial of inhaled budesonide for patients with mild symptoms of COVID-19 (Ramakrishnan et al Lancet Resp Med 2021). It did report positive results. Their primary outcome was a ‘COVID-19 related’ urgent care visit, emergency department assessment, or hospitalization, and was significantly reduced in the budesonide arm (15% vs 3%, p=0.009). However, the unblinded trial design, less relevant composite outcome, and fact that the trial was stopped early limit confidence in the results. That bring us to the PRINCIPLE trial. Clinical Question: Does inhaled budesonide improve clinical outcomes in high-risk outpatients with COVID-19? Reference: Yu et al. Inhaled budesonide for COVID-19 in people at high risk of complications in the community in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial. Lancet 2021 Population: Outpatients with symptomatic COVID-19 within 14 days of symptom onset who were considered high risk for adverse events. This included adults over 65 years of age, or over 50 years of age with co-morbidities. Exclusions: Known allergy or contraindication to inhaled budesonide, were unable to use an inhaler, or already using inhaled or systemic glucocorticoids. Intervention: Inhaled budesonide 800 ug BID for 14 days

Date: January 16th, 2022 Reference: Matchett, G. et al. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med 2021 Guest Skeptic: Missy Carter, former City of Bremerton Firefighter/Paramedic, currently a professor of Emergency Medical Services at Tacoma Community College’s paramedic program. Missy is currently working in a community emergency department as a physician assistant and recently accepted a critical care position in Tacoma Washington. Case: You respond to a rapid response on the floor for a 58-year-old woman in septic shock who is requiring emergent rapid sequence intubation (RSI). As you prepare to intubate the pharmacist asks if you would prefer ketamine or etomidate for induction in this patient. Background: We have covered the issue of intubation multiple times on the SGEM. This has included looking at supraglottic airways for out-of-hospital cardiac arrests (SGEM#247), video vs. direct laryngoscopy (SGEM#95), tracheal intubation for in-hospital cardiac arrests (SGEM#197), apneic oxygenation (SGEM#186) and confirming intubation with POCUS (SGEM#249). One thing we have not covered is the choice of induction agent for intubation. There has been much debate regarding the use of etomidate verses ketamine for induction in the critically ill [1-4]. A 2009 randomized control trial conducted in French ICUs supported the use of ketamine in this patient population [5]. Both agents are considered hemodynamically stable, but any induction agent may precipitate shock in the critically ill. There is some conflicting evidence as to which agent is preferred for patients who are at high risk of peri intubation complications. Historically there has been concern about adrenal insufficiency caused by etomidate being harmful for patients with sepsis but this has not been shown to cause increased mortality in the literature [6, 7]. Ketamine has emerged as a reasonable alternative but in recent years there has been concern about increased cardiovascular collapse with ketamine especially in those with sepsis or a high shock index [1, 8].    Clinical Question: Which induction agent has a better day 7 survival for critically ill patients requiring emergency endotracheal intubation, ketamine or etomidate? Reference: Matchett, G. et al. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med 2021 Population: Adults 18 years of age and older in need of emergency endotracheal (ET) intubation Exclusions: Children, pregnant patients, patients needing ET intubation without sedation or allergic to one of the agents being used Intervention: Ketamine 1-2mg/kg IV Comparison: Etomidate 0.2-0.3mg/kg IV Outcome: Primary Outcome: 7-day survival Secondary Outcomes: 28-day survival, duration of mechanical ventilation, ICU length of stay, need for vasopressor use, SOFA scores and an assessment of a new diagnosis of adrenal insufficiency by the treating critical care teams. Trial: Prospective, randomized, parallel-assignment, open-label, single-center trial (NCT02643381) Authors’ Conclusions: While the primary outcome of Day 7 survival was greater in patients randomized to ketamine, there was no significant difference in survival by Day 28.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. 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. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the inte...

Date: December 28th, 2021 Reference: Kulvatunyou et al. The small (14 Fr) percutaneous catheter (P-CAT) versus large (28–32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial. J Trauma and Acute Care Surgery. November 2021. Guest Skeptic: Dr. Chris Root is a second-year resident physician in the Department of Emergency Medicine at the University of New Mexico Health Sciences Center in Albuquerque, NM. He is also a resident flight physician with UNM’s aeromedical service, UNM Lifeguard. Prior to earning his MD, he worked as a paramedic in the New York City 911 system. Case: A 43-year-old male presents to your emergency department (ED) the day after being involved in an all-terrain vehicle (ATV) accident. He reports he was riding his ATV along an embankment when it rolled, landing on top of him briefly. He did not seek medical attention at the time of the incident, but he has had persistent chest wall pain and worsening shortness of breath since yesterday evening. He is hemodynamically stable, oxygen saturation is 91% on room air, physical exam reveals ecchymosis and tenderness over the right chest wall with diminished right sided lung sounds. CT scans reveal multiple right sided rib fractures and a hemothorax estimated to measure 500cc with no additional injuries. Background:  We have discussed chest tubes a couple of times on the SGEM. This is usually with the master himself, Dr. Richard (Thoracic Rick) Malthaner. The first time was looking at a study about where to put the chest tube in a trauma patient. It turns out location (high or low) does not matter. The most important thing is placing the chest tube in the triangle of safety in the plural space (SGEM#129). The other episode on chest tubes looked at conservative vs interventional treatment for spontaneous pneumothorax (SGEM#300). This randomized controlled trial demonstrated that conservative management was non-inferior to placing a chest tube in a patient with a large first-time spontaneous pneumothorax. Another SGEM episode we did looked at the location of needle decompression for tension pneumothorax (SGEM#339). This was done with our good friend and frequent guest skeptic Dr. Robert Edmonds. This observational study did not support the claim that the second intercostal space-midclavicular line is thicker than the fourth/fifth intercostal space-anterior axillary line. This new SGEM episode looks at the size of chest tubes needed to successfully treat a traumatic hemothorax. Traditionally, these are treated by inserting a large bore chest tube (LBCT). There is increasing evidence supporting the use of smaller, percutaneously inserted chest tubes or pigtail catheter (PC) for the drainage of pleural effusions and pneumothoraces as well as some evidence of their efficacy for hemothorax. Clinical Question: Are small (14fr) pigtail catheters as effective as large (28-32 fr) chest tubes for the treatment of hemodynamcially stable patients with traumatic hemothorax? Reference: Kulvatunyou et al. The small (14 Fr) percutaneous catheter (P-CAT) versus large (28–32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial. J Trauma and Acute Care Surgery. November 2021. Population: Hemodynamically stable adult patients 18 years or older suffering traumatic hemothorax or hemopneumothorax requiring drainage at the discretion of the treating physician. Exclusions: Emergent indication, hemodynamic instability, patient refuses to participate, prisoner or pregnancy Intervention: Placement of small (14 fr PC) chest tube using a percutaneous seldinger technique Comparison: Placement of a large (28-32 fr LBCT) chest tube using a traditional surgical thoracostomy Outcome: Primary Outcome: Failure rate defined as radiographically apparent hemothorax after tube placement requiring an additional intervention such as second tube placement,

Date: December 21st, 2021 Guest Skeptic: Dr. Howard “Howie” Mell began his career as a firefighter / paramedic in Chicago. He became double board certified in Emergency Medicine (EM) and Emergency Medical Services (EMS). Howie also has a Master of Public Health. Reference: Grotta JC et al. Prospective, multicenter, controlled trial of mobile stroke units. NEJM 2021 Case: The Mayor of your community consults you as an expert in public health, EMS and as an EM physician on whether they should purchase a mobile stroke unit (MSU) ambulance. Background: No one who has listened to the SGEM will be surprised we are covering another paper looking at stroke. We have often discussed the use of thrombolysis for acute ischemic stroke (AIS) with or without endovascular therapy (EVT). However, the SGEM has also looked at secondary stroke prevention on previous episodes (SGEM#24, SGEM#303). The SGEM has looked at pre-hospital stroke care using early administration of nitroglycerin by paramedics to see if it would improve neurologic outcome in patients with a presumed acute stroke (SGEM#269). The results from the RIGHT-2 trial reported no statistical difference in functional outcome as measured by the modified Rankin Scale (mRS) score at 90 days. The SGEM bottom line was that very early application of transdermal nitroglycerin by paramedics in the pre-hospital setting cannot be recommended at this time in patients with a suspected stroke. Mobile Stroke Unit The issue of having a MSU has also been discussed on  SGEM#330. A systematic review and meta-analysis which included seven randomized controlled trials and four observational studies including 21,297 patients was critically appraised.  The primary outcomes reported better neurologic outcome at seven days but not at one day post treatment by a MSU compared to conventional care (Fatima et al Int J Stroke 2020). The SGEM bottom line from that episode was we cannot recommend the use of MSU based on the available evidence. Clinical Question: Should mobile stroke units be purchased and deployed in your community? Reference: Grotta JC et al. Prospective, multicenter, controlled trial of mobile stroke units. NEJM 2021 Population: Patients calling EMS with a history and physical/neurological examination consistent with acute stroke who is last seen normal (LSN) possibly within 4 hours and 30 minutes and who had no definite tPA exclusions per guidelines, prior to CT scan or baseline labs. Daytime hours and mostly weekdays. Intervention: Care by a mobile stroke unit (MSU) Comparison: Care by traditional EMS referred to as standard management (SM) Outcome: Primary Outcome: Score on the utility-weighted modified Rankin scale (uw-mRS) at 90 days in patients who were adjudicated to be eligible to receive tPA on the basis of subsequent blinded review Secondary Outcomes: There were twelve secondary endpoints in their final protocol listed in hierarchical sequence of importance Agreement between on-board vascular neurologists (VN) and the remote VN Exploratory cost-effectiveness analysis (CEA) Outcomes comparing patients found eligible for tPA on MSU weeks compared to patients on SM weeks Ordinal (shift) analysis of mRS at 90 days, and Proportion of patients achieving 90 day mRS 0,1 vs 2-6 30% improvement from baseline to 24hr NIHSS Outcomes comparing all patients treated with tPA (whether or not adjudicated as tPA eligible) on MSU weeks compared to patients on SM weeks. Uw-mRS at 90 days Ordinal (shift) analysis of mRS at 90 days, and Proportion of patients achieving 90 day mRS 0,1 vs 2-630% Improvement from baseline to 24hr NIHSS Outcomes of those treated within 60 min LSN compared to those treated from 61 to 270 minutes Change in uw-mRS from baseline at 90 days Ordinal shift analysis of MRS at 90 days Proportion of patients achieving 90 day mRS 0,1 vs 2-6