The Skeptics Guide to Emergency Medicine

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

Date: December 21st, 2021 Guest Skeptic: Dr. Spencer Greaves is an Emergency Medicine resident at Florida Atlantic University. He received his Bachelors in Biomedical Engineering from Marquette University and his Masters in Public Health from Dartmouth College.  Spencer completed his medical doctorate at the Medical College of Wisconsin. He and his wife live in Boynton Beach, FL where they recently celebrated the birth of their first child. Disclaimer: "While I am proud to be attending this institution, my opinions expressed here are mine alone and do not represent my residency program, hospitals I work at, or any other affiliated organizations." Reference: Vallentin et al. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest - A Randomized Clinical Trial. JAMA 2021 This was an SGEM Journal Club and all the slides from the presentation can be downloaded using this LINK. As a reminder, here are the five rules for SGEM JC. Case: An EMS crew arrives at the home of a 68-year-old suffering from a witnessed out-of-hospital cardiac arrest (OHCA). They have a history of hypertension, elevated cholesterol, and smoked cigarettes for 50+ years. Bystander CPR is being performed. The monitor is hooked up. The paramedics performed high-quality CPR and follow their ACLS protocol. Intraosseous access is quickly obtained, and a dose of epinephrine is provided. CPR is continued while a supraglottic airway is placed successfully. The patient is transported to the emergency department with vital signs absent (VSA). Background: We have covered adult OHCA multiple times on the SGEM. This has included the following issues: Calcium has a theoretical benefit on patients with cardiac arrest as it has inotropic and vasopressor effects. Previous small, randomized control trials (RCTs) have shown no superiority to calcium for return of spontaneous circulation (ROSC). However, the point estimated did favor calcium. Clinical Question: Does administration of calcium during out-of-hospital cardiac arrest improve sustained return of spontaneous circulation? Reference: Vallentin et al. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest - A Randomized Clinical Trial. JAMA 2021 Population: Adults 18 years of age and older with OHCA in the central Denmark region from January 2020 to April 2021 who received at least one dose of epinephrine Exclusions: Traumatic cardiac arrest, known or strongly suspected pregnancy, prior enrollment in the trial, receipt of epinephrine outside the trial, or a clinical indication for calcium administration during the cardiac arrest. Intervention: Calcium chloride 5 mmol given IV or IO immediately after first dose of ACLS epinephrine up to two doses Comparison: Saline placebo given IV or IO immediately after first dose of ACLS epinephrine up to two doses Outcome: Primary Outcome: Sustained ROSC defined as no further need for chest compressions for at least 20 minutes Secondary Outcomes: Survival, favorable neurological outcome, and quality of life assessment at 30 and 90 days Trial: Double-blind, placebo-controlled, parallel group, superiority, randomized clinical trial Authors’ Conclusions: “Among adults with out-of-hospital cardiac arrest, treatment with intravenous or intraosseous calcium compared with saline did not significantly improve sustained return of spontaneous circulation. These results do not support the administration of calcium during out-of-hospital cardiac arrest in adults.” 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 whi...

Date: December 13th, 2021 Reference: Lee et al. Addressing gender inequities: Creation of a multi-institutional consortium of women physicians in academic emergency medicine. AEM December 2021 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com Case: At the completion of her 1-month elective in your rural emergency department (ED), you are discussing career plans with a medical student. She says that she is very interested in emergency medicine, but she isn’t sure if it is the right choice for her. She has worked in five EDs so far, and a man has filled almost every leadership position. She also just got back from an emergency medicine conference, and more than 90% of the speakers were white males. She loves the clinical work in emergency medicine, but she is worried that these apparent gender inequities will limit her career opportunities. Background: Gender equity is something we have spoken about often on the SGEM. Some listeners are happy we cover this topic while others have expressed concern. We recognize this can be an emotional issue. Our position is gender inequity exists in the house of medicine and it should be an issue everyone is interested in addressing. Here are some of the previous SGEM episodes that discussed gender equity: SGEM Xtra: From EBM to FBM – Gender Equity in the House of Medicine SGEM Xtra: Unbreak My Heart – Women and Cardiovascular Disease SGEM#248: She Works Hard for the Money – Time’s Up in Healthcare SGEM Xtra: Money, Money, Money It’s A Rich Man’s World – In the House of Medicine SGEM Xtra: I’m in a FIX State of Mind It is hard to believe some people deny the significant gender inequities that currently exist in medicine. Women are under-represented in leadership positions [1-3]. Women are less likely to be given senior academic promotions [4]. There are fewer women in editor positions in our academic journals [5]. Women receive less grant funding [6-7]. Women are paid less than men, even after accounting for potential confounders [2, 8-10]. Yet a recent twitter poll had more than 1/3 of respondents saying they did not think a physician gender pay gap existed in their emergency department. It is hard to move forward and address a problem when a significant portion of physicians do not even recognize that there is a problem. The literature describes many factors that contribute to gender inequity. Institutional policies related to promotion or advancement may inherently disadvantage women and are likely exacerbated by implicit bias and stereotyping. There are an insufficient number of women in current leadership positions, resulting in fewer mentors and role models for women earlier in their career. Policies around parental leave, emergency child-care, and breast-feeding support affect women disproportionately. Unfortunately, sexual harassment is also still widely documented in emergency medicine and has a major impact on career advancement and attrition [11-13]. The reasons for the gender gap are complex, and likely not completely understood. Existing gender balance within specialties, among other aspects of the "hidden curriculum", likely influence career decisions, with women trainees more likely to enter lower paying specialties. Current leadership positions are dominated by males, who may consciously or not be more supportive of other males for future promotions. Furthermore, there are numerous gender differences, both internal and external, that influence salary expectations and negotiations [14]. Female physicians are more likely to have female patients, and medical pay structures are often inherently biased. For example, in Ontario, where we both work, a biopsy of the penis pays almost 50% more than a biopsy of the vulva. Similarly, incision and drainage of a scrotal abscess pays twice as much as incision and drainage of a vulvar abscess [14].

Date: December 10th, 2021 Guest Skeptic: Dr. Carly Eastin is an Associate Professor, Division of Research and Evidence Based Medicine, Department of Emergency Medicine, University of Arkansas for Medical Sciences. She is also the Chair of the SAEM Evidence Based Healthcare and Implementation (EBHI) Interest Group. Carly was a guest skeptic on the SGEM two years ago. That was in the BC Times- (Before Covid). We had the pleasure of recording a live episode of the SGEM at the University of Arkansas.  Back in 2019 we were talking about Vitamin C for sepsis (SGEM#268). SGEM Bottom Line: “There is not enough evidence to support the routine use of vitamin C in critically ill patients.” Not much has changed over the last two years. There have been at least two randomized control trials published that do not support the use of Vitamin C in sepsis. Fujii et al (VITAMINS RCT) JAMA 2020: n=216 patients with septic shock. No statistical difference in their primary outcome for duration of time alive and free of vasopressor administration up to day 7 or the secondary outcome of 90-day mortality. Moskowits et al (ACTS RCT) JAMA 2020: n=205 patients with septic shock. no statistical difference in primary outcome of SOFA scores at 72 hours or the secondary outcome of 30-day mortality. It was Dr. Paul Marik who has been a big advocate for Vitamin C sepsis. We did an SGEM episode on his before-after study (SGEM#174: Don’t Believe the Hype) with a dozen skeptics expressing their concern the results were too good to be true. Dr. Marik has also been promoting the use of Vitamin C for COVID19. However, there is insufficient evidence to support the routine use of Vitamin C in the treatment of critically ill or non-critically ill COVID19 patients (NIH COVID19 Treatment Guidelines and Thomas et al JAMA 2021). There is also no high-quality evidence that Vitamin C can prevent COVID19. There is a Phase II interventional randomized placebo-controlled trial testing whether treatment with Vitamin C can prevent symptoms of COVID19 (ClinicalTrials.gov). This SGEM Xtra episode is not to talk about Vitamin C, COVID19 or even do a structured critical appraisal of a recent publication. This is an SGEM Xtra episode to pay tribute to a friend and champion of the EBM community, Dr. Rakesh Engineer. Dr. Rakesh Engineer Rakesh died suddenly in 2019 and the Society of Academic Emergency Medicine (SAEM) reflected upon how best to honour him. SAEM decided to name an award after Rakesh, focusing on his passion for implementation science. Dr. Chris Carpenter knew Rakesh well and was asked to give a brief introduction to those who did not know him. You can listen to his introduction at this LINK. Chris Carpenter: "[Rakesh] was a devoted husband and dedicated father to three sons.  He was born in Cleveland, Ohio and attended Ohio State University where he earned both his Bachelors and MD. After his internship at Barnes Jewish Hospital at Washington University St. Louis. He trained in Emergency Medicine at Spectrum Health in Grand Rapid Michigan. After that, he joined the Cleveland Clinic to be with his family, to educate the next generation of emergency physicians and launch his own clinical research career. Rakesh's vision epitomized implementation science, in which knowing is not enough: we must apply. As an emergency medicine clnical researcher, Rakesh thrived at the interface between published evidence and pragmatic application at the bedside.  He was a friend and I miss him dearly." Carly: "I did not have the privilege of knowing Rakesh personally very well, but was following him because I was a member of the SAEM Evidence-Based Healthcare and Implementation group when he was active and I was still trying to find my way in the EBM world. He was such a good speaker and was really funny. I also remember that it was Rakesh that gave me my first real understanding of implementation science,

Date: November 16th, 2021 Reference:  Hammouda et al. Moving the Needle on Fall Prevention: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement. AEM November 2021 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: Mid-shift, you realise that the next patient you are about to see is the third in a row aged over 70 who has fallen at home, and that this is her third attendance for a fall in the last two months. You wonder if any emergency department (ED)-based interventions would help her and people like her be safe. Background: We looked at geriatric falls on an SGEM Xtra in 2015. Back then we found that at one academic site older adults attending ED with falls didn't receive guideline-based assessment, risk stratification or management. Dr. Chris Carpenter In 2014 the SGEM looked at a systematic review by Dr. Chris Carpenter, which concluded that there wasn't a good tool to help us predict which ED patients are at risk of recurrent falls (SGEM #89). Close to three million adults aged 65 and over visit American EDs annually after a fall [1]. Falling is the most common cause of traumatic injury resulting in older adults presenting to the ED [2]. Approximately 20% of falls result in injuries, and falls are the leading cause of traumatic mortality in this age group [3-5]. The SAEM Geriatric Emergency Medicine Task Force recognized fall prevention as a priority over 10 years ago. There is the Geriatric Emergency care Applied Research (GEAR) network, which is trying to improve the emergency care of older adults and those with dementia and other cognitive impairments. GEAR looks to identify research gaps in geriatric emergency care support research and evaluation of these areas. GEAR 2.0 has recently been launched with funding opportunity in conjunction with EMF. There are three other GEAR 1.0 manuscripts which have been published: Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings AEM 2020 Care Transitions and Social Needs AEM 2021 Research Priorities for Elder Abuse Screening and Intervention J Elder Abuse Negl 2021 Clinical Question: In older patients presenting to ED with falls do risk stratification or fall prevention interventions influence patient-centered or operational outcomes? Reference:  Hammouda et al. Moving the Needle on Fall Prevention: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement. AEM November 2021 This publication presents two related but different scoping reviews so there are  two PICOs. PICO #1 Population: Systematic search that found 32 studies of fall prevention interventions for patients aged 60 or over who presented to ED with a fall. Exclusions: Abstracts repeating data already included in full, not original research. Intervention: Fall prevention interventions including multifactorial risk reduction, medication review, exercise training, models of care like Hospital-at-Home. Comparison: Standard of Care. Outcomes: Quality of care ED metrics, ED operational outcomes like length of stay, patient-centered outcomes like ED returns, further falls, fear of falling, functional decline, institutionalization. PICO #2 Population: Systematic search that found 17 studies of risk stratification and falls care plans in patients aged 60 or over in ED or pre-ED settings. Exclusions: As review 1. Intervention: Risk stratification and falls care plan. Comparison: No risk stratification and falls care plan.

Date: November 10th, 2021 Reference: Andersen, et al: Effect of Vasopressin and Methylprednisolone vs Placebo on Return of Spontaneous Circulation in Patients With In-Hospital Cardiac Arrest. JAMA Sept 2021. Guest Skeptic: Dr. Neil Dasgupta is an emergency physician and ED intensivist from Long Island, NY, and currently an assistant clinical professor and Director of Emergency Critical Care at Nassau University Medical Center. Case: A code blue is called for a 71-year-old male in-patient that is boarding in the emergency department (ED). He had been admitted the night before for a new diagnosis of rapid atrial fibrillation. He has a history of hypertension, dyslipidemia, and type-2 diabetes. His medications include a beta-blocker, statin, angiotensin converting enzyme inhibitor (ACE-I), metformin, ASA and direct oral anticoagulant (DOAC). You arrive and see that the Advanced Cardiac Life Support (ACLS) algorithm is being followed for adult cardiac arrest patients with pulseless electrical activity (PEA). Cardiopulmonary resuscitation (CPR) is in progress. The monitor shows a non-shockable rhythm. Epinephrine is provided and you quickly place an advanced airway. A second dose of epinephrine is given, and you start to think about reversible causes and your next steps for in-hospital cardiac arrests (IHCA). SGEM#50: Under Pressure Background: We have looked an IHCA a couple of times on the SGEM. The first time we looked at this issue on (SGEM#50). This was also the first SGEM JC done where Dr. William Osler started the Journal Club initiative at McGill University. We reviewed a randomized, double-blind, placebo-controlled, parallel-group trial done in three Greek tertiary hospitals. This trial (n=268) reported increased return of spontaneous circulation (ROSC) and increased survival to hospital discharge with good neurologic function with a vasopressin, steroids, and epinephrine (VSE) protocol compared to epinephrine alone. We felt this was interesting but would need to be validated/replicated before changing our IHCA protocols. Corticosteroids have been suggested as a possible therapy in these cardiac arrest situations. A SRMA published in 2020 on the use of steroids after cardiac arrest reported an increase in ROSC and survival to discharge but was limited by the availability of adequately powered high-quality RCTs (Liu et al JIMR 2020). We covered another SRMA that was published in 2021 looking at the same issue of whether the use of corticosteroids impact neurologic outcomes and mortality in patients with a cardiac arrest (SGEM#329)? These authors reported a statistical increase in good neurologic outcome and survival to hospital discharge with steroids but not survival at one year or longer. This study provided weak evidence in support of using corticosteroids for IHCA as part of a VSE protocol. Answering clinical questions about cardiac arrest with clinical trials has always been fraught with difficulty. However, cardiac arrest is something we regularly treat in the emergency department, and we need more high-quality data to inform our care. Vasopressin had been included as a part of the American Heart Association (AHA) ACLS protocol for quite a while but was removed in favor of a vasopressor monotherapy strategy with epinephrine.  The tide now is shifting in resuscitation research to shift our focus from obtaining ROSC to measuring functionality and good neurologic outcomes.  In the context of questioning epinephrine’s role in ACLS after Paramedic2, we look at using the VSE protocol in cardiac arrest. Clinical Question: Does adding a combination of vasopressin and methylprednisolone increase the chance of achieving ROSC in cardiac arrest? Reference: Andersen, et al: Effect of Vasopressin and Methylprednisolone vs Placebo on Return of Spontaneous Circulation in Patients With In-Hospital Cardiac Arrest. JAMA Sept 2021. Population: Adult patients 18 years of age and older with an ...

Date: November 1st, 2021 Reference: Katsanos et al. Utility of Intravenous Alteplase Prior to Endovascular Stroke Treatment: A Systematic Review and Meta-analysis of RCTs. Neurology 2021 Guest Skeptic: Dr. Michal Krawczyk is in his fifth year of neurology residency at Western University in London, Ontario, Canada. He is interested in acute neurological illness, including cerebrovascular disease and epilepsy. Next year he will be beginning a Neurohospitalist fellowship at the University of Texas at Houston. Case: A 70-year-old male with a past medical history of hypertension and peripheral artery disease, last seen normal 1.5 hours ago, presenting with acute onset of aphasia and right sided face and arm weakness. He has a National Institute of Health Stroke Scale (NIHSS) score of 7. At 1am a CT angiogram is obtained that demonstrated a left M2 occlusion, and an Alberta Stroke Program Early CT Score (ASPECTS) of 10. Given the recent publications of trials assessing if mechanical thrombectomy alone is non-inferior to a bridging approach with tPA in addition to mechanical thrombectomy, you wonder whether these trials apply to your patient and what is the best course of action. Background: There are two treatments for acute ischemic stroke, systemic tPA and mechanical thrombectomy (MT). We have covered some studies looking at both treatment modalities on the SGEM. SGEM#29: Stroke Me, Stroke Me SGEM#70: The Secret of NINDS (Thrombolysis for Acute Stroke) SGEM#85: Won’t Get Fooled Again (tPA for AIS) SGEM#137: A Foggy Day – Endovascular Treatment for Acute Ischemic Stroke SGEM#292: With or Without You – Endovascular Treatment with or without tPA for Large Vessel Occlusions SGEM#297: tPA Advocates Be Like – Never Gonna Give You Up SGEM#333: Do you Gotta Be Starting Something – Like tPA before EVT? Mechanical thrombectomy is indicated only for patients with large vessel occlusions (LVOs) on imaging. There were a few earlier studies on MT that failed to demonstrate superiority, but it was the study MR CLEAN published in NEJM 2015 that really changed practice. It was a multicenter, randomized, unblinded trial treating 500 patients with an anterior circulation LVO within six hours of symptom onset. The primary outcome was mRS 0-2 at 90 days and it showed an absolute difference of 14% favoring MT. This gives a NNT of 7. Six RCTs have been published since MR CLEAN.  All supported MT and all were stopped early (SWIFT PRIME, EXTEND-IA, REVASCAT, ESCAPE, DAWN, and DEFUSE). For patients with LVOs it is unclear whether there is any additional benefit with administering tPA before thrombectomy, also known as a bridging approach, in contrast to skipping tPA and directly proceeding with MT. There are several theoretical advantages of a bridging approach. These potential advantages include thrombus debulking allowing easier clot retrieval, distal emboli lysis, recanalization prior to MT, and it may be beneficial in cases of unsuccessful MT. Conversely, a direct to MT approach may lead to fewer intracerebral hemorrhages (ICH) and quicker initiation of endovascular thrombectomy. Recently, three randomized control non-inferior trials on this topic have been published, two from China (DIRECT-MT, and DEVT) and one from Japan (SKIP). Two trials demonstrated non-inferiority while one trial failed to show that direct MT was non-inferior. Clinical Question: What is the best strategy for treating patients with an acute large vessel occlusion stroke, direct to mechanical thrombectomy or a bridging approach with tPa followed by mechanical thrombectomy? Reference: Katsanos et al. Utility of Intravenous Alteplase Prior to Endovascular Stroke Treatment: A Systematic Review and Meta-analysis of RCTs. Neurology 2021 Population: Randomized controlled trials of patients with acute large vessel occlusion stroke qualifying for MT Exclusions: Observational studies and non-randomized trials ...

Date: October 20th, 2021 Reference: Talan et al. Pathway with single-dose long-acting intravenous antibiotic reduces emergency department hospitalizations of patients with skin infections. AEM October 2021 Guest Skeptic: Dr. Lauren Westafer an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the cofounder of FOAMcast and a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and research methodology editor for Annals of Emergency Medicine. Lauren also recently won the SAEM FOAMed Excellence in Education Award. Case: A 46-year-old male with a history of diabetes controlled on metformin presents with erythema and warmth to his right lower leg measuring 27 cm by 10 cm for the past four days. The patient is neurovascularly intact and there is no evidence of deep vein thrombosis (DVT) on ultrasound. He has no fever, and his white blood cell count is 12,500. Background: Emergency department visits for skin and soft tissue infections (SSTI) are common and increasing [1]. These types of infections include cellulitis and abscesses. The SGEM has a couple of episodes on the treatment of cellulitis with antibiotics (SGEM#131 and SGEM#209). The treatment of abscesses has been covered a few more 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. The result was no statistical difference in failure rates between the loop and standard packing. Our conclusion was to consider using the loop technique on your next uncomplicated abscess. Most patients can be managed as outpatients. However, the average length of stay for inpatient care is one week and costs close to $5 billion dollars a year in the USA [2]. The mortality rate for hospitalized patients with SSTI is <0.05% [3, 4]. The only reason for in-patient management in 40% of patients was to provide parenteral antibiotics [5]. This has led to greater interest in long-acting parenteral antibiotics as a possible alternative to admission.  Clinical Question: Does the use of a clinical pathway, including a dose of intravenous dalbavancin, in emergency department patients with skin and soft tissue infections reduce hospitalizations? Reference: Talan et al. Pathway with single-dose long-acting intravenous antibiotic reduces emergency department hospitalizations of patients with skin infections. AEM October 2021 Population: Patients ≥18 years old with abscess, cellulitis, or wound infection believed or confirmed to be due to gram-positive bacteria and an area of infection of at least 75 cm2. Excluded: Unstable comorbidity (e.g. severe sepsis), immunosuppression, injection drug use and fever, pregnancy, breastfeeding, bilateral lower extremity involvement, severe neurologic disorder, allergy to glycopeptide antibiotics, suspected gram negative infection or infection likely to need more intensive care or broad spectrum antibiotics, suspected osteomyelitis, septic arthritis, or endocarditis. Intervention: Clinical pathway included a single dose of intravenous (IV) dalbavancin 1500 mg (creatinine clearance ≥30 mL/min) or 1,125 mg for creatinine clearance <30 mL/min not on dialysis Telephone follow up call 24 hours after the visit and a follow up appointment 48-72 hours after discharge Comparison: Usual care pre-implementation of the new clinical pathway Outcome: Primary Outcome: Hospitalization rate at the time of initial care in the population that received at least one antibiotic dose Secondary Outcomes: Hospitalizations through 44 days, health resource utilization (length of stay, level of care, major surgical interventions, ICU admissions), adverse events, and patient-related outcomes (satisfaction, work productivity, and quality of life surveys at 14 days)

Date: October 7th, 2021 This is an SGEM Xtra episode. I had the honour of co-presenting at the Renaissance School of Medicine, Stony Brook University, Department of Emergency Medicine Grand Rounds. The title of the talk "From EBM to FBM - Gender Equity in the House of Medicine. You may be wondering: why is a middle aged, white, heterosexual, cis gender, male, atheist, nerd co-presenting on gender equity in the house of medicine? "And isn’t it ironic, don't you think? A little too ironic. And, yeah, I really do think".  According to Sir Patrick Steward (Captain Jean-Luc Picard from Star Trek), “People won’t listen to you or take you seriously unless you’re an old white man, and since I’m an old white man I’m going to use that to help the people who need it” My co-presenter was Dr. Suchismita Datta. She is an Assistant Professor in the Department of Emergency Medicine and GME Diversity Leader for the NYU Long Island School of Medicine. The presentation is available to listen to on iTunes and GooglePlay and all the slides can be downloaded using this LINK. Three Objectives Recognize gender inequity in medicine Identify gender inequities in each of the three pillars of of evidence-based medicine (EBM) Understand how gender inequities can impact the cardiovascular care of women Dr. Datta's Journey Dr. Datta Dr. Datta shares her personal journey from medical school to attending physician and discusses the challenges she faced along the way. She and her husband Neil met at medical school. They both matched to the same emergency medicine (EM) program. After graduation they began working at a high-volume, high-acuity critical access hospital.  After a few years they moved back to New York. Dr. Datta describes her unpaid and paid maternity leave, difficulties in pumping breast milk while on shift and the pay gap she experienced. Gender Inequities Using the EBM Model There are three pillars of EBM. The literature should inform care, guide care but it should not dictate care.  Clinicians must also use their good clinical judgment in applying the literature. We also need to ask patients about what they value and prefer. This can be summarized into a Venn diagram capturing the Dr. Sackett's definition of EBM. The Medical Literature: Who gets most of the grant money in medicine? Men Who rises to the top academic positions at universities? Men Who rises to the top academic positions in medicine? Men Who rises to the top academic positions in Emergency Medicine? Men Who is most likely to be the first author on a medical publication? Men Who is most likely the first author on a emergency medicine publication? Men Who is most likely to be the first author on a Pediatric Emergency Medicine (PEM) Paper? Men Who are often excluded from being subjects in medical research? Women The Clinicians: Who historically has been the clinician in the room? Men Who is most likely to rises to top leadership positions within the hospital structure? Men Who gets paid more in medicine? Men Who gets paid more in academic medicine? Men Who gets paid more in academic Emergency medicine? Men Who is more likely to be introduced with their professional title at grand rounds? Men Who get's paid more in Ontario, Canada? Men What can be done about the gender pay gap? CMAJ 2020 The Patients: Who traditionally was more likely to access health care? Women Who is typically responsible for most family health care needs? Women Who has been systemically under-treated when it comes to painful conditions? Women Who are provided less care for life threatening illnesses like STEMIs? Women   Cardiovascular Disease in Women Gender biases and inequities can seriously impact our clinical management. Cardiovascular disease in women is understudied, women are underrepresented in clinical trials,