The Skeptics Guide to Emergency Medicine

Date: September 28th, 2021 Reference: Zampieri et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA 2021 Guest Skeptic: Dr. Aaron Skolnik is an Assistant Professor of Emergency Medicine at the Mayo Clinic Alix School of Medicine and Consultant in the Department of Critical Care Medicine at Mayo Clinic Arizona. Board certified in Emergency Medicine, Medical Toxicology, Addiction Medicine, Internal Medicine-Critical Care, and Neurocritical Care, Aaron practices full time as a multidisciplinary intensivist. He is the Medical Director of Respiratory Care for Mayo Clinic Arizona and serves proudly as the medical student clerkship director for critical care medicine. Case:  A 66-year-old woman is brought in by EMS from home with lethargy and hypotension.  Chest x-ray is clear, labs are remarkable for a leukocytosis of 16,000 with left shift; exam is notable for left flank pain and costovertebral tenderness.  Straight catheter urinalysis is grossly cloudy, and pyuria is present on microscopy. Blood pressure is 85/50 mm Hg.  You wonder which intravenous (IV) fluid should you order? Background: In ten seasons of the SGEM we have not covered the issue of which IV solution is the best in critical ill patients. That includes both trauma patients and septic patients. The controversy has been long standing with the standard joke being that there is nothing “normal” about normal saline. Saline is a hypertonic acidotic fluid. Many critically ill patients receive intravenous crystalloids for volume expansion as part of their resuscitation.  Some bench work, observational studies, and now two large, unblinded, cluster-randomized single-center trials (SMART and SALT-ED) suggested a benefit to using balanced crystalloids (i.e. Lactated Ringer’s or Plasmalyte 148) over 0.9% saline. In the two large trials, this benefit was seen as a reduction in a composite outcome of major adverse kidney events within 30 days (MAKE-30). In the non-blinded SMART trial, there was no statistical difference in the individual components of the composite outcome (in-hospital death before 30 days, new renal replacement therapy or in creatinine >200% of baseline). The SALT-ED trial was also a single-centre unblinded trial, but the primary outcome was hospital free days. They reported no statistical difference between the two groups. Their secondary composite outcome of death, new renal-replacement therapy, or final serum creatinine >200% of baseline, was statistically better with balanced crystalloid vs saline. However, there was not a statistical difference in any of the individual components of the composite outcome. The BaSICS trial attempts to answer whether balanced solutions are superior to saline using a large, double-blind, factorial, multi-center randomized trial. Clinical Question: Does administration of a balanced solution (Plasma-Lyte 148) during intensive care unit (ICU) stay, compared with saline solution, result in improved 90-day survival in critically ill patients? Reference:  Zampieri et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA 2021 Population: Adult patients admitted the ICU for more than 24 hours, needing at least one fluid expansion and with at least one risk factor for acute kidney injury (age over 65, hypotension, sepsis, required mechanical ventilation or non-invasive ventilation, oliguria or increased serum creatinine level, cirrhosis or acute liver failure) Exclusions: Required or expected to require renal replacement therapy within 6 hours of admission, severe electrolyte disturbances (sodium < 120 mmol/L or > 160 mmol/L), death considered imminent within 24 hours, suspected or confirmed brain death,

Date: September 20th, 2021 Reference: Litell et al. Most emergency department patients meeting sepsis criteria are not diagnosed with sepsis at discharge. AEM 2021. Guest Skeptic: Dr. Jess Monas is a Consultant in the Department of Emergency Medicine at the Mayo Clinic Hospital, Phoenix, Arizona. She is also an Assistant Professor, Department of Emergency Medicine Mayo Clinic Alix School of Medicine in Scottsdale, Arizona. Jess also does the ultra summaries for EMRAP. Case: A 60-year-old man presents to the emergency department with a non-productive cough and increasing shortness of breath.  He has a history of chronic obstructive pulmonary disease (COPD), hypertension (HTN), congestive heart failure (CHF), and benign prostatic hypertrophy (BPH).  He’s afebrile.  He has a heart rate of 93 beats per minute, a blood pressure of 145/90 mm Hg, respiratory rate of 24 breaths per minute, and an oxygen saturation of 92% on room air. Initial labs come back with a slightly decreased platelet count (149) and a minimally elevated creatinine (1.21 mg/dl or 107 umol/L).  He triggers a sepsis alert, and you get a pop-up suggesting IV antibiotics and 30cc/kg of IV fluids.  So, you ask yourself, is this guy really septic and should we bypass those fluids? Background: We have covered sepsis many times on the SGEM since 2012.  This has included the three large RCTs published in 2014-15 comparing early goal-directed therapy (EGDT) to usual care. All three showed no statistical difference between the two treatments for their primary outcome (SGEM#69, SGEM#92 and SGEM#113). There was also SGEM#174 which said don’t believe the hype around a Vitamin C Cocktail that was being promoted as a cure for sepsis and SGEM#207 which showed prehospital administration of IV antibiotics did improve time to get them in patients with suspected sepsis, but did not improve all-cause mortality.  The SGEM was part of a group of clinicians who were concerned about the updated 2018 Surviving Sepsis Campaign (SSC) guidelines. Specifically, the fluid, antibiotics, and pressor requirements within the first hour of being triaged in the emergency department. Despite the lack of high-quality evidence to support these sepsis bundles, many hospitals incorporated them into their electronic medical record (EMR).  They created these sepsis alerts with the intention of identifying septic patients, so they can be treated accordingly.  Most physicians agree that antibiotics should be given early in septic patients.  However, the jury is still out for other interventions with potential for harm, particularly, the infusion of 30cc/kg of IV fluids. Worldwide sepsis contributes to the death of 5.3 million hospitalized people annually.  It is the leading cause of death in the intensive care unit (ICU) in the US and the most expensive diagnosis.  Since 2015, the Centers for Medicare & Medicaid Services (CMS) have indexed the quality of hospital care for sepsis to the SEP-1 core measure.  Interventions, particularly early antibiotics, have been associated with improved mortality. Diagnosing sepsis can be challenging.  To adequately capture patients, specificity has been sacrificed for better sensitivity.  We care more about catching all the true positives and worry less if a few true negatives get mixed up in there.  Using vital signs and lab abnormalities certainly captures more patients, but it also identifies those without an infection.  Patients with cirrhosis, toxicities, those on dialysis.  It is possible that some of these patients can be at risk for harm from one of these interventions. Clinical Question: What proportions of patients meeting sepsis criteria were actually diagnosed with sepsis, and how many non-septic patients had risk factors for harm from aggressive fluid resuscitation? Reference: Litell et al. Most emergency department patients meeting sepsis criteria are not diagnosed with sepsis at discharge. AEM 2021.

Date: September 16th, 2021 Reference: Sippola et al. Effect of Oral Moxifloxacin vs Intravenous Ertapenem Plus Oral Levofloxacin for Treatment of Uncomplicated Acute Appendicitis. The APPAC II Randomized Clinical Trial. JAMA 2021 Guest Skeptic: Dr. Rob Leeper is an assistant professor of surgery at Western University and the London Health Sciences Center.  His practice is in trauma, emergency general surgery, and critical care with an academic interest in ultrasound and medical simulation. Rules of SGEM Journal Club Case: A 23-year-old man with CT confirmed uncomplicated appendicitis, mild abdominal pain, stable clinical signs, and essentially normal laboratory investigations has just concluded his bedside consultation with the on-call general surgery team.  The patient and surgeons have had an evidence-informed discussion and have arrived at a mutually agreed upon decision to proceed with non-operative treatment of his appendicitis.  The patient is recommended to undergo admission to hospital for serial observation and intravenous antibiotics.  The patient asks; “gosh doc, if this disease is so mild why can’t I just go home and take antibiotics by mouth?”. Dr. Eric Walser Background: The appendix is a structure about as long as your pinkie finger that hangs off the beginning of the colon, in the right lower quadrant of your abdomen. There are lots of theories about subtle functions of the appendix, but its most prominent role is to become inflamed or infected in approximately 7% of people. Usually appendicitis occurs because the lumen, or inside, of the appendix is obstructed by something. Often that is a piece of stool called a fecalith, but other times it can be lymph tissue or another process we may never actually identify. This causes the pressure in the appendix to increase eventually obstructing venous outflow and then arterial inflow. We used to assume that this was an ordered progression that always leads to appendiceal rupture in a stepwise fashion, but we now think that there is more of a spectrum of severity based on individual anatomic and other factors. While the presentation of appendicitis can vary from patient to patient, as our emergency medicine colleagues know well, most patients are not diffusely peritonitic or systemically unwell. Before we had things like surgery or antibiotics, appendicitis carried up to a 50% case fatality rate. Luckily now, with these treatments the mortality rate is almost zero. For the last 135 years we have treated appendicitis with an appendectomy, which is now almost always performed in laparoscopic fashion. A laparoscopic appendectomy involves a general anesthetic, making three small incisions between 1 and 2 cm in length; and the operation usually takes somewhere between 30 to 60 minutes. Most patients go home the same day or the next morning, either with a short course of antibiotics or with none after surgery. Most patients who have this surgery are back to work and their usual routine at around the two-week mark. The chance of requiring additional procedures is quite low unless we find that the appendix has already perforated. It is a good, and generally very safe operation, with a high rate of patient satisfaction. Omar et al  published a study in 2008 showing just how safe laparoscopic appendectomies have become. They found in over 230,000 UK patients the death rate was less than half compared to the open procedure (0.64% vs 0.29%; p<0.001). Patrick Roy Nonoperative treatment of appendicitis (NOTA) was first described in the 1940s and moved into the public consciousness when Patrick Roy was treated with antibiotics alone during the 1994 Stanley Cup playoffs. In 2014, tennis star Rafael Nadal was diagnosed with acute appendicitis. He was participating in the Shanghai Masters Tennis Tournament at the time. Nadal opted to be treated with antibiotics and had his appendix removed via laparoscopic one month later.

Date: September 8th, 2021 Reference: Desch et al. The TOMAHAWK Investigators. Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation. NEJM 2021. Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. He heads curriculum and conference for the academic year and is passionate about resident education on- and off-shift, from procedural to evidence-analytical.  Dr. Kaushal Khambhati is also a fourth-year resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program.  He is interested and experienced in healthcare informatics, previously worked with ED-directed EMR design, and is involved in the New York City Health and Hospitals Healthcare Administration Scholars Program (HASP). Five Rules of the SGEM Journal Club Case: A 70-year-old woman is found unresponsive and apneic at home by her partner.  EMS arrives and finds the patient in monomorphic ventricular tachycardic (VT) cardiac arrest. She has a history of hypertension and non-insulin dependent diabetes mellitus. The paramedics achieve return of spontaneous circulation (ROSC) after CPR, advanced cardiac life support (ALCS), and Intubation.  She arrives in the emergency department (ED) with decreased level of consciousness and shock.  The EKG shows sinus tachycardia with nonspecific changes and no ST segment elevations, Q waves, or hyperacute T waves.  Her point-of-care ultrasound (POCUS) shows appropriate-appearing global ejection fraction and no marked wall motion abnormalities.  Cardiology has been consulted and asks for a neurology consultation given her mental status. Background: The American Heart Association estimates there are approximately 350,000 EMS-assessed out-of-hospital cardiac arrests (OHCAs) in the United States per year. Half of these arrests are witnessed with the other half being un-witnessed. Many of these OHCAs are due to ventricular fibrillation or pulseless VT. Defibrillation is the treatment of choice in these cases but does not often result in sustained ROSC (Kudenchuk et al 2006). Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients. There is evidence that taking those patients with ROSC and EKG showing STEMI directly for angiography +/- angioplasty is associated with positive patient-oriented outcomes. The AHA has a statement with recommendations based on the available data. They suggest to perform catheterization and reperfusion for post-arrest patients with ST-segment elevation, even if the patient is comatose  However, there is no consensus if this strategy should be employed in patients without ST-segment elevation (Yannopoulos et al, Circulation 2019). The 2015 AHA Guidelines make the following recommendations: Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG (Class I, LOE B-NR). Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG (Class IIa, LOE B-NR). Lemke et al 2019 published a multicentre RCT done in the Netherlands looking at patients without ST segment elevation in OHCA with ROSC.  Patients were randomized to receive immediate coronary angiography or delayed coronary angiography performed after neurologic recovery. They found no superiority to the immediate strategy for their primary outcome of survival at 90 days. One of the limitations of the COACT trial is they only included patients who had an intra-arrest shockable rhythm which only accounts for 60% of OHCA patients. Clinical Question: Does early coronary artery angiography following resuscitation of Out-of-Hospital Cardiac Arrest benefit patient out...

Date: August 31st, 2021 Reference: McLean et al. Interphysician weight bias: A cross-sectional observational survey study to guide implicit bias training in the medical workplace. AEM Sept 2021 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: You are working in the emergency department (ED) with the new resident, one of whom is overweight. You overhear his colleagues wonder where he went, chuckling, and one of them comments that “he probably went for second breakfast.” Realizing that these residents are making fun of their colleague’s weight, you decide to address the issue. Background: We have talked about biases many times on the SGEM. Usually when we use the term bias it is in the context of something that systematically moves us away from the “truth”. Science does not make truth claims and the term is used as a shorthand for the best point estimate of an observed effect size. An example in the medical literature would be selection bias. This is when subjects for a research study are not randomly selected. This can skew the results and impact the conclusions.  Another example would be publication bias. Studies with “positive” results are more likely to be published while those with “negative” results are more likely to end up in the bottom of the file drawer. There are many other types of bias in the practice of medicine. Some of my favourite ones are anchoring bias, base-rate neglect, and hindsight bias. For a description of these and many more check out Dr. Pat Croskerry list of 50 cognitive biases in medicine. You can also click on the codex for an extensive list of different biases. This SGEM episode focuses on a kind of bias as defined by the common English language as “a particular tendency, trend, inclination, feeling, or opinion, especially one that is preconceived or unreasoned”. It is a sense of prejudice or stereotyping and the formation of a foregone conclusion independent of current evidence. There are many biases in the house of medicine. We have discussed some of them on  the SGEM. They include things like age, gender, socioeconomic status, race, and other factors. The gender pay gap is one of the topics that has been spoken about most on the SGEM. A paper by Wiler et al AEM 2019 showed females in academic emergency medicine were paid ~$12,000/year less than their male colleagues (SGEM#248). The September 2021 issue of AEM is a special issue focusing on biases in emergency medicine. It includes articles on racial, ethnic and gender disparities. One specific topic jumped out as something that has not received much attention, weight bias. There is literature on physicians’ weight biases towards patients and patients’ weight bias towards physicians. However, there is limited information on physician-to-physician weight bias. Clinical Question: What is the prevalence of interphysician implicit, explicit, and professional weight bias? Reference: McLean et al. Interphysician weight bias: A cross-sectional observational survey study to guide implicit bias training in the medical workplace. AEM Sept 2021 Population: Practicing physicians and physicians-in-training in North America Excluded: Those who did not consent; did not identify as physicians or physicians-in-training; or were not currently residing in North America. Intervention: Survey instruments measuring implicit weight bias (IWB), explicit weight bias (EWB), and professional weight bias (PWB) Comparison: None Outcome: Descriptive analyses along with correlative models Dr. Mary McLean This is an SGEMHOP episode which means we have the lead author on the show. Dr. Mary McLean is an Assistant Program Director at St. John’s Riverside Hospital Emergency Medicine Residency in Yonkers, New York. She is the New York ACEP liaison for the Research and Education Committee and is a past ALL NYC EM R...

Date: August 27th, 2021 Reference: Gagnon et al. Direct-access physiotherapy to help manage patients with musculoskeletal disorders in an emergency department: Results of a randomized controlled trial. AEM 2021 Dagny Haas Guest Skeptic: Dagny Kane-Haas is a physiotherapist who also has a master’s degree in Clinical Science in Manipulative Therapy. Case: A forty-year-old woman presents to the emergency department (ED) with a sore lower back after moving some boxes at home over the weekend. She tried acetaminophen with limited relief. Her pain is eight out of ten on the zero-to-ten-point numeric pain rating scale (NPRS). She has no red flags (TUNA FISH) and is diagnosed as having mechanical back pain without imaging as per ACEP Choosing Wisely. You know mechanical low back pain is difficult to treat effectively and are trying to set expectations. While preparing her for discharge you wonder if seeing a physiotherapist before going home from the ED would improve her outcome. Background: Acute and chronic back pain has been covered many times on the SGEM. There is no high-quality evidence that acetaminophen, NSAIDS, steroids, diazepam, muscle relaxants or combinations of pharmacologic modalities provide much relief. SGEM#87:Let Your Back Bone Slide (Paracetamol for Low-Back Pain) SGEM#173: Diazepam Won’t Get Back Pain Down SGEM#240: I Can’t Get No Satisfaction for My Chronic Non-Cancer Pain SGEM#304: Treating Acute Low Back Pain – It’s Tricky, Tricky, Tricky We do know that opioids are very effective at reducing many types of pain including muscular skeletal pain. However, opioids have many side effects and concerns about substance misused. The ACEP 2020 clinical policy on the use of opioids states: “Preferentially prescribe nonopioid analgesic therapies (nonpharmacologic and pharmacologic) rather than opioids as the initial treatment of acute pain in patients discharged from the emergency department. For cases in which opioid medications are deemed necessary, prescribe the lowest effective dose of a short-acting opioid for the shortest time indicated.” (Level C Recommendation) There are several non-pharmaceutical treatments that have also been tried to treat low back pain. They include: Cognitive Behavioural Therapy and mindfulness (Cherkin et al JAMA 2016), chiropractic (Paige et al JAMA 2017), physical therapy (Paolucci et al J Pain Research 2018) and acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013). None of these other treatments has high-quality evidence supporting their use. We have covered a randomized control trial looking at acupuncture to treat painful conditions presenting to the ED, including acute back pain, on SGEM#187. That trial reported no difference in clinical or statistical relevant reduction of pain at one hour between groups (acupuncture only, acupuncture plus pharmacotherapy or pharmacotherapy alone). However, we have not done a structured critical appraisal of an RCT looking at physiotherapy for this clinical condition. Clinical Question: Does access to a physiotherapist in ED help patients who present with minor musculoskeletal disorders (MSKD)? Reference: Gagnon et al. Direct-access physiotherapy to help manage patients with musculoskeletal disorders in an emergency department: Results of a randomized controlled trial. AEM 2021 Population: Adult patients 18-80 years of age presenting to the ED with suspected minor MSKD, traumatic or not. Minor was defined using the Canadian Triage and Acuity Scale (CTAS) score of 3, 4 or 5. Excluded: Non-minor MSKD (ex: open fractures or open wounds), red flags, clinically unstable, hospitalized patients, or those in long-term care facilities. Intervention: Physiotherapist evaluated the patient post triage in the ED. They would recommend interventions based on their clinical assessment. This could include advice, technical aids, imaging, prescribed or over-the-counter medication,

Date: August 19th, 2021 Reference: Pantell et al. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics 2021 Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. Case: A 25-day-old, full-term boy presents to the emergency department with fever. His parents report that he felt warm that evening, and they found that he had a rectal temperature of 38.2°C (100.8°F). He has an older sister at home with a cough and rhinorrhea. Overall, he has no symptoms and appears well. He has continued to feed normally and produce wet diapers. The parents ask you, “Do you really think he needs any additional testing? He probably caught something from his sister, right?” Background: Parents often bring their infants to the ED with concerns about fever. They can develop a real “fever fear” or “feverphobia” and often need reassurance that fever alone is not dangerous. We have talked about pediatric fever and fever fear with Dr. Anthony Crocco from Sketchy EBM back on SGEM#95 and made a “Ranthony” video on the topic. The American Academy of Pediatrics says that “…fever, in and of itself, is not known to endanger a generally healthy child.  In contrast, fever may actually be of benefit; thus, the real goal of antipyretic therapy is not simply to normalize body temperature but to improve the overall comfort and well-being of the child.”  However, fever without source in infants less than three months of age represents a significant diagnostic dilemma for clinicians. Several clinical decision instruments had been developed previously, including the Rochester (Jaskiewicz et al 1994), Boston (Baskin et al 1992) and Philadelphia (Baker et al 1993) criteria to help clinicians stratify the risk of significant bacterial infections. A new clinical decision instrument called the Step-by-Step approach was reviewed on SGEM#171. SGEM#171 Bottom Line: If you have availability of serum procalcitonin measurement in a clinically relevant time frame, the Step-by-Step approach to fever without source in infants 90 days old or younger is better than using the Rochester criteria or Lab-score methods. With the caveat that you should be careful with infants between 22-28 days old or those who present within two hours of fever onset. We have been trying to optimize our approach to evaluating and managing febrile infants for more than four decades.  Our goal is to identify the febrile infants with urinary tract infection, bacteremia, and bacterial meningitis (or what was referred to as serious bacterial infections) while simultaneously trying to spare them from invasive and potentially unnecessary procedures like lumbar punctures or the possible iatrogenic consequences of empiric antibiotics or hospitalization. Several risk stratification tools have been published over the years. These clinical decision instruments included subjective clinical criteria along with pre-determined thresholds for lab criteria like white blood cell count (WBC) and immature to total neutrophil ratio. Unfortunately, these criteria may not be appropriate in the current era. In fact, the Modified Boston and Philadelphia Criteria for invasive bacterial infections may misclassify almost one-third of infants with bacterial meningitis. With routine screening of pregnant women, improvements in food safety, and conjugate pneumococcal vaccines, we have seen a decrease in Group B streptococcus, Listeria, and Streptococcus pneumoniae infections in infants. Instead, there has been a shift to Gram-negative organisms being the most common culprits in bacterial infections in infants. Simultaneously, our ability to test for infection has advanced with the use of inflammatory markers (IM) like procalcitonin and C-reactive protein (CRP) as well as polymerase chain reaction (PCR) testing for rapid identification of multiple viruses and bacteria.

Date: August 12th, 2021 Reference: Daya et al. Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Circulation 2020 Guest Skeptic: Missy Carter is a PA practicing in emergency medicine in the Seattle area and an adjunct faculty member with the Tacoma Community College paramedic program. Missy is also now the director for Difficult Airway EMS course in Washington State Case: An EMS crew arrives to your emergency department (ED) with a 58-year-old female who suffered a witnessed ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA). They performed high-quality CPR and shocked the patient twice before giving amiodarone via intraosseous (IO). After giving hand off the medic tells you she had difficulty finding intravenous (IV) access and went straight to an IO. She wonders if she should have spent more time on scene trying to get the IV versus the tibial IO she has in place. Background: We have covered OHCA multiple times on the SGEM. This has included the classic paper from Legend of EM Dr. Ian Stiell on BLS vs. ACLS (SGEM#64), the use of mechanical CPR (SGEM#136), and pre-hospital hypothermia (SGEM#183). ALPS Trail The issue of amiodarone vs lidocaine has also been covered on SGEM#162. This was the ALPS randomized control trial published in NEJM 2016. The bottom line from that SGEM critical appraisal was that neither amiodarone or lidocaine were likely to provide a clinically important benefit in adult OHCA patients with refractory VF or pulseless ventricular tachycardia. We did do an episode on IO vs IV access for OHCA (SGEM#231). This was a critical appraisal of an observational study published in Annals of EM (Kawano et al 2018). The key result was that significantly fewer patients had a favorable neurologic outcome in the IO group compared to the IV group. However, we must be careful not to over-interpret observational data. There could have been unmeasured confounders that explained the difference between the two groups. In recent years there has been an effort to lower the cognitive load in the pre-hospital setting and focus resources on the interventions that positively effect patient outcomes. There has been a trend to place supraglottic devices over intubation with some evidence to support this move (SGEM#247).  Another trend is to use IO access over IV access to free up pre-hospital providers to focus on more meaningful interventions. Clinical Question: Does it matter if you give antiarrhythmic medications via IV or IO route in OHCA? Reference: Daya et al. Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Circulation 2020 Population: Adult patients with non-traumatic out-of-hospital cardiac arrest and shock refractory ventricular fibrillation or pulseless ventricular tachycardia after one or more shocks anytime during resuscitation. Excluded: Patients who had already received open-label intravenous lidocaine or amiodarone during resuscitation or had known hypersensitivity to these drugs Intervention: Amiodarone, Lidocaine or placebo given IO Comparison: Amiodarone, lidocaine or placebo given IV Outcome: Primary Outcome: Survival to hospital discharge Secondary Outcomes: Survival to hospital admission, survival with favorable neurologic outcome (modified Rankin Scale score of 3 or less) Authors’ Conclusions: We found no significant effect modification by drug administration route for amiodarone or lidocaine in comparison with placebo during out-of-hospital cardiac arrest. However, point estimates for the effects of both drugs in comparison with placebo were significantly greater for the intravenous than for the intraosseous route across virtually all outcomes and beneficial only for the intravenous route. Given that the study was underpowered to statistically assess inter...

Date: August 7th, 2021 Dr. Susanne DeMeester Guest Skeptic: Dr. Susanne (Susy) DeMeester is an Emergency Physician practicing at St. Charles Medical Center in Bend, Oregon. She has been very involved with EMRAP's CorePendium as the cardiovascular section editor and has a chapter coming out soon on women and acute coronary syndrome. Dr. DeMeester was on SGEM#222 as part of the SGEMHOP series. She was the lead author of a study looked at whether an emergency department algorithm for atrial fibrillation management decrease the number of patients admitted to hospital. The SGEM Bottom Line: There are clearly patients with primary atrial fibrillation who can be managed safely as outpatients. There are no evidence-based criteria for identifying high-risk patients who require admission, so for now we will have to rely on clinical judgement. This SGEM Xtra episode is the result of some feedback I received from a listener following SGEM#337 episode on the GRACE-1 guidelines for recurrent low-risk chest pain. The person lamented that it would be nice if a cardiac case scenario was of a female patient. This made me review past SGEM episodes which confirmed there has been a gender bias. While there were a half-dozen episodes that did have female patients, they were the minority. So, I felt a good way to address the issue would be to invite an expert like Dr. DeMeester to discuss this gender bias. There is a difference between gender and sex. Despite having different meanings they are often used interchangeably. Gender refers to social constructs while sex refers to biological attributes. This is not the first SGEM episode that has addressed the gender gap in the house of medicine. I had the honour of presenting at the 2019 FeminEM conference called Female Idea Exchange (FIX19). My FIX19 talk was called from Evidence-Based Medicine to Feminist-Based Medicine. It looked at the three pillars of EBM: relevant scientific literature, clinicians, and patients. I realized that each of the three pillars contained biases against women. In the presentation, multiple references were provided to support the claim that a gender gap does exist. The conclusion from the FIX19 talk was that we should be moving from Evidence-Based Medicine (nerdy and male dominated) to Feminist-Based Medicine (recognizing the inequities in the house of medicine) to Gender-Based Medicine (acknowledging the spectrum of gender and sexuality) and ultimately to Humanist- Based Medicine. The SGEM did a regular critical appraisal of a recent publication with Dr. Ester Choo (SGEM#248). It covered the study published in AEM looking at the continuation of gender disparities among academic emergency physicians (Wiler et al AEM 2019). We also did an entire SGEM Xtra episode with Dr. Michelle Cohen on the broader issue of the gender pay gap (SGEM Xtra: Money, Money, Money It’s A Rich Man’s World – In the House of Medicine). This was based on the Canadian Medical Association Journal article focusing on closing the gender pay gap in Canada (Cohen and Kiren 2020). Five questions about gender disparities when it comes to cardiovascular disease. What is the burden of cardiovascular disease in females and is it the same as males? We know females are often excluded from being subjects in medical research. Are female represented proportionally in cardiovascular disease  clinical research? Are there differences between males and females with regards to cardiovascular disease risk factors? Do females who have a cardiovascular event present differently to the emergency department? Have any sex differences been identified in the treatment and outcomes of females with cardiovascular events? Please listen to the SGEM podcast to hear Dr. DeMeester's answers to these five questions. What can be done to address this gender gap? The Lancet gathered a group of international experts to answer th...

Date: July 29th, 2021 Reference: Azizi et al. Optimal anatomical location for needle decompression for tension pneumothorax: A multicenter prospective cohort study. Injury 2021 Guest Skeptic: Dr. Robert Edmonds is an emergency physician in the Air Force in Ohio.  This is Bob’s 14th episode cohosting the SGEM. DISCLAIMER: THE VIEWS AND OPINIONS OF THIS PODCAST DO NOT REPRESENT THE UNITED STATES GOVERNMENT OR THE US AIR FORCE. Case: You are driving home from a busy shift and see a car collision occur right in front of you.  The driver is a restrained self-extricated male who lost control of his vehicle into a light post and the vehicle’s airbags deployed.  After safely pulling over and having a bystander call 911, you evaluate the patient.  He is speaking in full sentences without confusion, has a strong, rapid pulse, significant pain in his chest and is having a very hard time breathing.  As you wait for EMS to arrive, you quickly dash back to your car to retrieve your stethoscope and an angiocatheter you have in your glovebox.  You notice a marked difference between breath sounds on the left side and decide the patient needs treatment for a tension pneumothorax.  After obtaining consent from the patient, you debate whether to decompress at the second intercostal space in the midclavicular line as you originally learned, or in the fourth/fifth intercostal space midaxillary line as per the current ATLS guidelines. Background: The latest ATLS guidelines were published in 2018. We covered them on the SGEM Xtra with Dr. Neil Parry. There were several changes to the new guidelines but one of them was changing the location for needled decompression for adult patients. Needle thoracostomy is subject to several complications compared to a tube thoracostomy primarily due to the shorter length of the needle as well as the smaller lumen, so site selection has focused on finding a short distance and a site unlikely to kink or get dislodged. Dr. Richard Malthaner We have covered chest tube thorocostomy a couple of times on the SGEM with Dr. Richard (Thoracic) Malthaner. SGEM#129 looked at where to put the chest tube on trauma patients and if a post-procedure chest Xray (CXR) was required. The conclusion from that episode was to put the tube on the correct side, within the triangle of safety, and within the pleural space. Continue to obtain a CXR post chest tube knowing it will probably not change management. Be more concerned if the patient is doing poorly or the tube is not draining. The other episode on chest tubes was SGEM#300. The clinical question was does everyone with a large first-time spontaneous pneumothorax need a chest tube? The answer from that episode was It is reasonable to provide conservative management (no chest tube) in a patient with large first-time spontaneous pneumothoraxes if you can ensure close follow-up. The changes in the ATLS guidelines were based in part on a small study (n=20) utilizing cadavers [1]. There were also studies using CT scans showing a preference for the fourth/fifth ICS AAL [2,3].  These studies were limited by heterogeneity (I2 83%-98%), possible publication bias, and not being randomized trials. These authors are adding to the literature by utilizing ultrasound on live patients. This could reduce some of the potential confounders in prior studies that were exclusively cadavers which may have differences in CWT due to post-mortem changes. The previous studies also focused on homogenous populations like military members and are therefore less generalizable to the general population. Additionally, by using ultrasound instead of CT, some of the confounders from arm placement during CT were reduced.  Clinical Question: Is the chest wall thickness at the second intercostal space in the midclavicular line not thicker than the fourth/fifth intercostal space anterior axillary line? Reference: Azizi et al.