The Skeptics Guide to Emergency Medicine

Date: July 1st, 2021 Guest Skeptic #1: Dr. Chris Carpenter is Professor of Emergency Medicine at Washington University in St. Louis and a member of their Emergency Medicine Research Core. He is a member of the SAEM Board of Directors and the former Chair of the SAEM EBM Interest Group and ACEP Geriatric Section. He is Deputy Editor-in-Chief of Academic Emergency Medicine. He is also Associate Editor of Annals of Internal Medicine’s ACP Journal Club and the Journal of the American Geriatrics Society, and he serves on the American College of Emergency Physician’s (ACEP) Clinical Policy Committee. Dr. Carpenter also wrote the book on diagnostic testing and clinical decision rules. Reference: Musey et al. Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department. AEM July 2021 This is an extra special SGEM. It is a combo of an SGEM Xtra and an SGEMHOP. The Society of Academic Emergency Medicine (SAEM) has decided to publish its own clinical practice guidelines (CPGs). They are called Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE). This episode will review the GRACE-1 guideline looking at low-risk recurrent chest pain. Because this is a new initiative by SAEM, I interviewed Dr. Chris Carpenter about these new GRACE guidelines. Dr. Chris Carpenter Listen to the SGEM podcast to hear him answer five background questions about these new CPGs. Who came up with the idea of doing CPGs? Why do we need more guidelines? Walk us through the GRACE process? Why pick recurrent, low-risk chest pain to be the first CPG? What do you hope to achieve with these CPGs Guest Skeptic #2: Dr. Suneel Upadhye is an Associate Professor of Emergency Medicine & Clinical Epidemiology at McMaster University. He is a founding member of the Best Evidence in Emergency Medicine (BEEM) program. Suneel is also the inaugural Research Lead for the EM Researchers of Niagara, which is a novel community-based EM research group within Niagara region, Canada. He is also a Guidelines Methodologist within CAEP and the SAEM GRACE groups. Case: You are seeing a patient who has returned to the emergency department (ED) with recurrent chest pain. It is their fourth visit in the last twelve months.  He has had his chest pain for approximately three to four hours now and is not classic for ischemic symptomatology.  His initial high-sensitivity (hs) troponin is negative, and his ECG is unremarkable.  In reviewing his records, you note that he has undergone significant cardiac testing in the recent past, which was unremarkable. This included a normal exercise stress test and CCTA 18 months ago.  You also note that he has an underlying anxiety disorder, which is being treated and followed by his family physician.   Background: This new SAEM GRACE initiative is committed to using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system, GRADE was pioneered at McMaster University, in creating rigorous, transparent, and trustworthy guidelines on common clinical problems for emergency medicine (EM) physicians that are not always directly studied in EM research activities. The steering group/panelists explored many different potential questions, and voted on the top eight, that were then reviewed in systematic fashion; evidence was rated using GRADE methods, and then final recommendations were made using the GRADE Evidence-to-Decision framework (Upadhye et al CJEM 2021 and Courtney and Lang AEM 2021).  The Methods team sought initial GRADE training, then shared that learned expertise with the question groups, many of whom were relative novices in guideline methodology. After two years, a comprehensive document is being published that answers the key diagnostic dilemmas in recurrent chest pain patients who have had recent normal cardiac investigations,

Date: July 1st, 2021 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com. Reference: Dankiewicz et al: TTM2 Trial Investigators. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest. NEJM 2021 Case: A 58-year-old man collapsed in front of his family. When paramedics arrived, they found him to be in cardiac arrest, with ventricular fibrillation on the monitor. Paramedics managed to get return of spontaneous circulation after a single defibrillation, but the patient is still comatose on arrival. The charge nurse turns to you and asks: should I grab the ice packs? Background: Hypothermia has been a mainstay of post-arrest care after the publication of two trials in 2002 that both suggested a benefit. This trial by Bernard and colleagues randomized 77 patients with an initial cardiac rhythm of ventricular fibrillation who had achieved return of spontaneous circulation (ROSC) but were persistently comatose. The trial was not truly randomized, as the groups were based on the day of the month, and they also weren’t blinded. The results of this Australian trial seemed too good to be true. Hypothermia resulted in a large improvement in neurologic outcomes, defined as well enough to be sent home or to a rehab facility. It was 49% of the hypothermia group versus only 26% of the normothermia group. This gives a NNT of 4. The reported p value was borderline at 0.046, and when I re-calculate, it comes out as 0.06 (not statistically significant). The other trial was the Hypothermia After Cardiac Arrest (HACA), also published in NEJM 2002. They randomized 273 comatose adult patients out of 3,551 screened patients. These were witnessed OHCA who had a shockable rhythm, achieved ROSC, and had a short downtime. This trial used an air mattress to cool patients and was also not blinded. This second trial done in Europe also showed impressive results for favorable neurologic outcome. It was 55% in the hypothermia group vs 39% in the normothermia group (NNT 6). They also reported a 14% absolute decrease in mortality with therapeutic hypothermia post-OHCA. As a result of these two-small trials, hypothermia was widely adopted. However, there were many voices in the evidence-based medicine world that reminded us of the significant uncertainty that remained, and the weaknesses of these two trials. The SGEM covered a few  trials looking at therapeutic hypothermia for OCHA in the pre-hospital setting. The bottom line is there is not good evidence that therapeutic hypothermia is superior to usual care and cannot be recommended. SGEM#21: Ice, Ice, Baby (Hypothermia post Cardiac Arrest) SGEM#54: Baby It’s Cold Outside (Pre-Hospital Therapeutic Hypothermia in Out of Hospital Cardiac Arrest) SGEM#183: Don’t RINSE, Don’t Repeat Because of that uncertainty, a much larger, multi-center trial was run. This is the original Target Temperature Management (TTM) trial by Nielson et al NEJM 2013. As almost everyone knows, they compared two difference hypothermia targets, 33C and 36C. The result was no benefit for their primary outcome of mortality at the end of the trial and no benefit Cerebral Performance Category (CPC), modified Rankin Score (mRS) or mortality at 180 days. We did a structured critical appraisal of the TTM trial on SGEM#82. The bottom line was that the trial did not demonstrate a benefit of a targeted temperature of 33C vs. 36C for survival of OHCAs. But both groups in the TTM trial were hypothermic, so although it was the highest quality evidence available, it didn’t tell us whether hypothermia was any better than normothermia. Which is why the TTM2 trial was performed. Clinical Question: Does hypothermia result in improved survival after cardiac arrest as compared to controlled normothermia? Reference: Dankiewicz et al: TTM2 Trial Investigators. Hypothermia versus Normothermia after Out-of-Hospital Car...

Date: June 25th, 2021 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Reference: Chinnock et al. Self-obtained vaginal swabs are not inferior to provider-performed endocervical sampling for emergency department diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis. AEM June 2021 Case: A 31-year-old female presents to the emergency department with pelvic pain and vaginal discharge for the past 24 hours. She is afebrile, vital signs are normal and she is having a significant amount of pain. She says the pain is so severe that she cannot even imagine having a pelvic exam done right now for STI testing. Background: Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) are the two most common sexually transmitted infections (STI) reported in the United States. Emergency departments (EDs) now diagnose an increasing percentage of NG/CT cases compared to STI clinics. (1,2) The standard of care for NG/CT diagnosis is nucleic acid amplification testing (NAAT), with the collection method being provider-performed endocervical sampling (PPES). PPES is uncomfortable for patients and has numerous other limitations, including the need for exam rooms, an available provider and often a female chaperone. These limitations can delay sample collection and can also add significant delay in a busy ED. The need for universal pelvic examination in the ED to perform STI testing has also come under increasing scrutiny. (3) Vaginal sample collection with self-obtained vaginal swabs (SOVS) was first developed and researched in non-ED settings based on these reasons and others. These studies demonstrated comparable sensitivity for NG/CT diagnosis when comparing SOVS to PPES, and high patient acceptability. (4-8) However, those studies were performed in a wide range of non-ED settings and were mostly asymptomatic screening rather than STI testing in an acute care environment. This study compares PPES with SOVS in an ED setting and explores patient’s acceptability or preference of SOVS versus PPES. Clinical Question: Do self-obtained swabs have noninferior sensitivity for the diagnosis of NG/CT compared to provider performed swabs in an ED setting using a rapid NAAT. Reference: Chinnock et al. Self-obtained vaginal swabs are not inferior to provider-performed endocervical sampling for emergency department diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis. AEM June 2021 Population: Female patients 18 years of age or older who were judged by the treating practitioner to need NG/CT testing Exclusions: Incarcerated any acute psychiatric condition precluded understanding instructions or giving informed consent, not English or Spanish proficient, or treated for NG/CT within the previous four weeks. Intervention: Self-obtained vaginal swab (SOVS) for NG/CT Comparison: Provider performed endocervical sampling swab for NG/CT Outcome: Primary Outcome: Noninferiority of SOVS sensitivity for NG/CT, with noninferiority being demonstrated if sensitivity was 90% or above. Secondary Outcomes: Kappa measurement of the SOVS and PPES, SOVS organism-specific sensitivity for NG and CT, acceptance rate of SOVS, rate of patients worried about doing SOVS correctly, and SOVS refusal rate. Dr. Brian Chinnock This is an SGEMHOP episode which means we have the lead author on the show. Dr Brian Chinnock is Professor in Department of Emergency Medicine at the UCSF-Fresno Medical Education Program, and Research Director. Authors’ Conclusions: “SOVS are noninferior to PPES in NG/CT diagnosis using a rapid NAAT in ED patients and surveys indicate high patient acceptability.” Quality Checklist for Observational Trials: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to an...

Date: June 11th, 2021 Guest Skeptic: Dr. Dennis Ren is a paediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. Reference: McLaren SH, et al. Invasive bacterial infections in afebrile infants diagnosed with acute otitis media. Pediatrics 2021 Case: You are working with a medical student at the emergency department when a 2-month-old boy is brought in by his parents for fussiness. They note that he has had upper respiratory symptoms for the past few days and fussier than usual. He has still continued to feed well and make wet diapers. He has not had any fever. Yesterday, they noticed that he seemed to be pulling at his right ear. On exam, he is afebrile, active, and alert. He cries and moves vigorously when you look into his ear. You see a bulging, red tympanic membrane. His left tympanic membrane is clear. The rest of his exam is unremarkable. You turn to the medical student and ask her what she would like to do for this patient. She replies that she thinks the patient has an acute otitis media (AOM) but given his age, she is also thinking about the possibility of an invasive bacterial infection (IBI) and would like to obtain some blood for labs and even consider a lumbar puncture for cerebral spinal fluid. How do you reply? Background: Acute Otitis media is the second most diagnosed illness in children and the most common indication for antibiotic prescription [1-2]. We have covered the of AOM twice on the SGEM: SGEM#132: One Balloon for Otitis Media with Effusion with Dr. Richard Lubell SGEM#278: Seen Your Video for Acute Otitis Media Discharge Instructions SGEMHOP with lead author Dr. Naveen Poonai? In 2013, the American Academy of Pediatrics (AAP) updated recommendations for the diagnosis and management of acute otitis media (AOM) for children older than 6 months. Unfortunately, there is limited guidance for patients younger than 6 months. The diagnosis of AOM becomes more complicated by the concern for concurrent invasive bacterial infections (IBI) in infants less than 3 months of age. Previous studies have demonstrated low prevalence of concurrent IBI in infants with AOM, but sample size has been small and included a mix of afebrile and febrile infants [3-4]. Additionally, the microbiology of pathogens causing AOM has shifted after the implementation of the pneumococcal conjugate vaccine with a higher proportion of patients having culture negative AOM [5]. This uncertainty has led to wide practice variation and controversy surrounding diagnostic testing (blood and cerebrospinal fluid testing), antibiotic administration (IV vs oral), and disposition (discharge vs admission) in infants with AOM. Clinical Question: What is the prevalence of invasive bacterial infections and adverse events in afebrile infants ≤ 90 days of age with acute otitis media? Reference: McLaren SH, et al. Invasive bacterial infections in afebrile infants diagnosed with acute otitis media. Pediatrics 2021 Population: Afebrile infants ≤ 90 days of age with clinically diagnosed acute otitis media across 33 pediatric emergency departments (29 USA, 2 Canadian and 2 Spanish EDs) from 2007 to 2017 Excluded: Temperature ≥38°C and <36°C in the ED or within 48 hours, antibiotic use (other than topical) within 48 hours of presentation, concurrent mastoiditis, evidence of focal bacterial infection, transferred to ED with previous diagnostic testing/antibiotics Intervention: Evaluation of invasive bacterial infections in blood or cerebrospinal fluid (CSF) Comparison: None Outcomes: Primary Outcome: Prevalence of IBI (bacterial meningitis and bacteremia) Secondary Outcomes: Variability in diagnostic testing for IBIincluding blood or cerebrospinal fluid (CSF), parenteral antibiotic administration, and hospitalization. Safety Outcome: AOM-associated adverse events Authors’ Conclusions: “Afebrile infants with clinician-diagnosed acute otitis ...

Date: May 25th, 2021 Guest Skeptic: Dr. Garreth Debiegun is an emergency physician at Maine Medical Center in Portland, ME and clinical assistant professor with Tufts University School of Medicine. He also works at an urgent care and a rural critical access hospital. Garreth is interested in wilderness medicine and is the co-director of the wilderness medicine clerkship at Maine Med, and the medical director for Saddleback Ski Patrol and for Maine Region NSP. At work Garreth imagines himself as a student of evidence-based medicine trying to provide the best care based on the best evidence. References: Suzuki et al. Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial. JAMA 2021 Zi et al. Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke: The DEVT Randomized Clinical Trial. JAMA 2021 Case: A 74-year-old woman presents to your emergency department with 1.5 hours of right-sided weakness, aphasia, and neglect. On rapid bedside assessment you calculate the National Institute of Health Stroke Score/Scale (NIHSS) of 11 and a Field Assessment for Stroke Triage for Emergency Destination (FAST-ED) score of 7; you suspect a large vessel occlusion (LVO) based on the high NIHSS and FAST-ED score >3. A non-contrast CT shows no evidence of intracranial hemorrhage. A CT angiogram plus CT perfusion demonstrate a clot in the left proximal middle cerebral artery (MCA) with a small infarcted area and a large penumbra. Based on your institution’s current guidelines, the patient is a candidate for endovascular therapy, but they are also within the current window for the administration of thrombolytics. You wonder if you gotta be starting something?  Specifically, you wonder if you should give the thrombolytics while waiting for your neurointerventional/endovascular team? Background: Management of acute ischemic stroke has been discussed on the SGEM ever since this knowledge translation project was launched in 2012. My position remains that there is uncertainty as to whether tPA provides a patient-oriented outcome and this was summarized in the downgrading of the NNT recommendation to “yellow” with Dr. Justin Morgenstern from First10EM. The world of stroke management has changed in the last few years the more robust evidence to support endovascular therapy (EVT) for large vessel occlusion (LVO) strokes. The tipping point came with the publication of MR. CLEAN in 2015. It was a multicenter, randomized, unblinded trial of patients with an LVO stroke in the anterior circulation treated in less than six hours after onset of symptoms. The primary outcome was good neurologic function defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days. The trial included 500 patients and reported an absolute risk reduction of 14% (33% EVT vs 19% control) with a NNT of 7. Four other RCTs were stopped early due to the publication of MR. CLEAN.  All of these were published in the NEJM in the following six months. SWIFT PRIME (n=196) NNT of 4 EXTEND-IA (n=70) NNT of 2-5 depending on which outcome you picked REVASCAT (n=206) extended the window to eight hours NNT 6.5 ESCAPE (n=316) extended to 12 hours NNT 4 There are dangers with stopping trials early. Dr. Gordon Guyatt wrote in the BMJ that it can introduce bias towards efficacy. He said you should have a high level of skepticism regarding the findings of trials stopped early for benefit, particularly when those trials are relatively small, and replication is limited or absent. A systematic review and meta-analysis (SRMA) was published by Badhiwala, JH et al in JAMA 2015 looking at EVT for stroke. The first three RCTs reported no superiority. Then came MR. CLEAN and those four additional studies that were stopped early.

Date: May 28th, 2021 Guest Skeptics: Heather Logan is the executive Strategy lead for the Canadian Agency for Drug and Technologies in Health (CADTH). Dr. Wendy Levinson is the Chair of Choosing Wisely Canada (CWC) and a Professor of Medicine, University of Toronto This SGEM Xtra is based on document created by CADTH and presented at Choosing Wisely Canada National annual meeting May 13, 2021. The title of the report is Using Health Care Resources Wisely After the COVID-19 Pandemic: Recommendations to Reduce Low-Value Care. We have discussed Choosing Wisely before on SGEM Episodes: SGEM#15: Choosing Wisely SGEM Xtra: CAEP Choosing Wisely SGEM Xtra: Right, You’re Bloody Well Right, You’ve got the Bloody Right to Care Choosing Wisely Canada (CWC): Dr. Wendy Levinson It is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices. Choosing Wisely Canada is led by a team of clinicians and staff based at St. Michael’s Hospital (Toronto), the University of Toronto, and in collaboration with the Canadian Medical Association. Choosing Wisely Canada mobilizes and supports clinicians and organizations committed to embedding campaign recommendations into practice. There are close to 350 documented quality improvement projects across the country that are building capacity for the spread and scale of Choosing Wisely. These efforts are underway in hospitals, long-term care homes, and primary care clinics. Many of these innovative projects, including their evidence-based tools and methods, have been packaged into easy to follow toolkits that are broadly circulated in order to encourage widespread adoption. This has allowed Choosing Wisely Canada to foster a network for those looking to implement campaign recommendations into practice. Canadian Agency for Drug and Technologies in Health (CADTH): Heather Logan It is an independent, not-for-profit agency funded by Canadian federal, provincial, and territorial governments (except Quebec) to provide credible, impartial advice and evidence-based information about the effectiveness of drugs and other health technologies to Canadian health care decision-makers. CADTH believes that credible, objective evidence should inform every important health care decision. When you want to know what the evidence says, ask CADTH. Created in 1989 by Canada’s federal, provincial, and territorial governments, CADTH was born from the idea that Canada needs a coordinated approach to assessing health technologies. The result was an organization that harnesses Canadian expertise from every region and produces evidence-informed solutions that benefit patients in jurisdictions across the country. South Huron Hospital Association (SHHA) is known as the "Little Hospital that Does". SHHA has been choosing wisely since 2012 selecting five items every three years. SHHA Choosing Wisely 2012 Influenza shots for staff with privileges SGEM#20 Use Ottawa ankle and knee rules SGEM#3 and SGEM#5 No routine use of antivirals for Bell’s Palsy SGEM#14 No routine use of antibiotics for simple cutaneous abscesses SGEM#13 No routine use of proton pump inhibitors for upper GI bleeds SGEM#16 SHHA Choosing Wisely 2015 Utilize Canadian CT head rules to guide our decisions on getting CT heads SGEM#106 Utilize Canadian C-Spine rules to guide our decisions on obtaining plain film c-spine imaging SGEM#232 Do not do annual physical exams on asymptomatic adults with no significant risk factors Do not screen women with Pap smears if under 21 years of age or over 69 years of age Do not order echo cardiograms routinely SHHA Choosing Wisely 2018 Only use supplemental Oxygen for STEMI patients that are hypoxic (saturations < 90%) SGEM#...

Date: May 20th, 2021 Guest Skeptic: Dr. Robert Edmonds is an emergency medicine physician in the Air Force in Dayton, Ohio, and a University of Missouri-Kansas City residency alumni from 2016. Reference: Jhunjhunwala et al. Reassessing the cardiac box: A comprehensive evaluation of the relationship between thoracic gunshot wounds and cardiac injury. Journal of Trauma and Acute Care Surgery. September 2017 DISCLAIMER: THE VIEWS AND OPINIONS OF THIS PODCAST DO NOT REPRESENT THE UNITED STATES GOVERNMENT OR THE US AIR FORCE. This SGEM episode was recored live for the Truman Medical Centers Multidisciplinary Trauma Conference. We did the session over zoom as an SGEM Journal Club. If you would like a copy of the slides from the presentation you can download them free open access at this LINK. Case: You receive a call on the Biocom for an incoming Type A trauma, three minutes out.  The patient is an adult male with a gunshot wound to the chest, and they’re combative with emergency medical services (EMS). Upon arrival in the emergency department (ED), the patient is incoherently speaking, has a pulse of 135 beats per minute, blood pressure of 85/50 mm Hg, and an obvious open wound in their left mid-axillary line at the level of the nipple. Background: Penetrating trauma is a major disease burden in the United States, and gunshot wounds cause 30,000 deaths annually [1] . As a country, penetrating trauma accounts for about 10% of all trauma cases [2] , but at some trauma centers it can reach much higher numbers. Here at the Truman Medical Center the average penetrating trauma for gunshot wounds alone represents ~19% of all traumas.  Naturally, patients with a direct cardiac injury from a gunshot wound (GSW) require prompt identification and management, so tools have sprung into existence to attempt to risk stratify patients at a higher risk of an underlying cardiac injury. One of the more common tools is the “cardiac box”. This three-dimensional area is at the highest risk of cardiac injury. The anatomical area is defined anteriorly as between the clavicle and xyphoid, and between the bilateral midclavicular lines. Per the authors, “The dogma of the cardiac box is largely based on small studies with primarily stab wounds. The underlying issue is that stab wounds are low kinetic energy and result from instruments with a fixed length. Thus, most stab wounds usually only result in a cardiac injury if the entrance is in very close proximity to the heart or there is a long weapon. Because these studies did include gunshots, the concept of the “box” was ultimately uniformly applied to all mechanisms. Injuries from high kinetic energy projectiles, however, can cause cardiac injury from entrance wounds to any area of the torso, especially the thorax.” Although it may be obvious to some that injury outside the cardiac box doesn’t rule out injury to the heart, the existence of such a tool colors our language and shifts the perceived risk in the clinician’s head.  According to a recent study in the Journal of Surgical Research [3] , 44% of all penetrating thoracic trauma patients presented to a non-trauma center (not a level 1 or level 2 ACS defined trauma center). For clinicians in these settings, use of the “cardiac box” nomenclature can have a significant impact on the perceived injuries when communicating with an on-call surgeon or when transferring the patient to another facility. If the injury is outside the cardiac box, it can be perceived as less concerning and may give the treating team a false sense of security. Clinical Question: Are the anatomic borders of the cardiac box adequate to predict cardiac injury from gunshot wounds? Reference: Jhunjhunwala et al. Reassessing the cardiac box: A comprehensive evaluation of the relationship between thoracic gunshot wounds and cardiac injury. Journal of Trauma and Acute Care Surgery. September 2017

Date: May 21st, 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 a research methodology editor for Annals of Emergency Medicine and an Associate Editor for the NEJM Journal Watch Emergency Medicine. Reference: Varner et al. A randomized trial comparing prescribed light exercise to standard management for emergency department patients with acute mild traumatic brain injury. AEM May 2021 Case: A 32-year-old female presents with headache after a low-speed motor vehicle collision as a restrained driver. She was ambulatory on scene. The patient is not anticoagulated, has no midline neck pain, and no evidence of other injuries. She is generally well appearing without any deficients on neurological examination, given her minor mechanism, and normal examination no imaging or further testing is required. You tell her you believe she has a concussion. 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. Historically, cognitive and physical rest have been recommended following the diagnosis of mTBI and patients have been advised to resume exercise only once symptoms have abated. Recent studies have challenged this dogma of "rest is best" with one multicenter study finding that early return to physical activity within a week of injury was associated with an improvement in time to symptom reduction. One of the issues that comes up with minor head injuries is do we need to get advanced imaging. We looked at the Canadian CT Head Rule (CCHR) published by Dr. Ian Stiell in the Lancet 2001 on SGEM#106. You can find this clinical decision instrument on MDCalc. The SGEM has also covered the issue of getting CT scans in pediatric patients with minor head injuries. That used the PECARN data which has a protocol for children less than two years of age and those older than two years of age. That SGEM#112 episode on pediatric concussions was covering a study that asked if there is a benefit to recommending strict rest after a child has a concussion. 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. We have also looked at the diagnostic accuracy if the CCHR in patients 65 years of age or older in predicting clinically important brain injuries (SGEM#266). The published study opened the door for reducing the number of unnecessary head CTs in this cohort of patients, but further high-quality prospective studies are required prior to clinical application. There is limited information on the best strategy for preventing post-concussion syndrome (PCS). Clinical Question: Are patients presenting to the ED with mild concussion who are prescribed light exercise less likely to develop post-concussive syndrome at 30 days compared with those given standard discharge instructions? Reference: Varner et al. A randomized trial comparing prescribed light exercise to standard management for emergency department patients with acute mild traumatic brain injury. AEM May 2021 Population: Adults 18-64 years old presenting to the ED with a mild TBI. This was defined as a direct blow to body with force transmitted to the head resulting in somatic, cognitive, emotional, or behavioral or sleep symptoms within the prior 48 hours. Exclusions: Patients with acute intracranial injury, multisystem injuries preventing light exercise,

Date: May 6th, 2021 Guest Skeptic: Dr. Daniel Schwerin is employed with Prisma Health-Upstate as a clinical assistant professor, emergency medicine GME director for emergency medical services and medical director for several local EMS agencies and has lectured on prehospital stroke management. Reference: Fatima et al. Mobile stroke unit versus standard medical care in the management of patients with acute stroke: A systematic review and meta-analysis. International Journal of Stroke 2020 Case: A 70-year-old man develops sudden right-sided weakness beginning shortly after breakfast and his partner appropriately calls emergency medical services (EMS). Their local EMS service arrives quickly with a conventional ambulance. He has heard about these special ambulances with CT Scanners and wonders if that will make an important difference for his partner. Background: We have discussed stroke so many times on the SGEM. It is one of the five most popular topics like TXA, PE, POCUS and ketamine. Justin Morgenstern from First10EM and I recently downgraded the NNT website recommendation for tPA in acute ischemic stroke to “yellow”. A yellow recommendation means the benefits and harms are unclear due to the uncertainty in data. But something that often comes up when discussing stroke treatment is we need to go fast because time is brain. The term “time is brain” was coined by Dr. Camilo Gomez back in 1993. He modified his position in 2018 and said: “It is no longer reasonable to believe that the effect of time on the ischaemic process represents an absolute paradigm. It is increasingly evident that the volume of injured tissue within a given interval after the estimated time of onset shows considerable variability in large part due to the beneficial effect of a robust collateral circulation.” We never did have high-quality evidence to support the position that treating stroke patients earlier was better. All we had was an association because there were no RCTs that randomized stroke patients into getting thrombolytics early or late. This means there could have been unmeasured confounders responsible for the observed effect. The largest placebo controlled RCT looking at tPA for acute ischemic stroke was IST-3 which was covered on SGEM#29. There were several serious problems with that trial including: Largely unblinded trial (91%) Stopped early Self-reported outcome by telephone or mailed questionnaire No superiority for primary outcome 4% absolute increase in early mortality Another interesting point about IST-3 is the subgroup analysis did not support the claim that time was brain. There was no statistical difference between the <3hrs, 3-4.5hrs and >4.5hrs. However, the point estimate favored tPA in <3hrs, then placebo between 3-4.5hrs and then back to tPA in >4.5hrs? You also need to look very carefully at the figure to see they used the 99% confidence interval instead of the standard 95% confidence intervals. If calculating the Odds Ratio for the 3-4.5hr group you find it is statistically significant favouring the placebo group. Clinical Question: Does a mobile stroke unit (MSU) with earlier imaging and delivery of tPA improve outcomes, or is the downstream effect of improved resources at a comprehensive stroke center that improves outcomes for patients with strokes? Reference: Fatima et al. Mobile stroke unit versus standard medical care in the management of patients with acute stroke: A systematic review and meta-analysis. International Journal of Stroke 2020 Population: This was a systematic search that found 11 articles that were either randomized controlled trials (RCTs), retrospective or prospective studies that compared the clinical outcomes among patients treated in either a mobile stroke unit or through conventional care/standard medical care for the acute stroke. Exclusions: Case–control studies, case series, and case reports

Date: May 7th, 2021 Guest Skeptic: Dr. Ryan Stanton is a community emergency physician with Central Emergency Physicians in Lexington, KY. He is on the Board of Directors for the American College of Emergency Physicians and host of the ACEP Frontline Podcast. He is an EMS medical director with Lexington Fire/EMS as well as the AMR/NASCAR Safety Team. Reference: Shah and Mitra. Use of Corticosteroids in Cardiac Arrest - A Systematic Review and Meta-Analysis. Crit Care Med Feb 2021 Case: A 58-year-old male has a witnessed cardiac arrest while admitted to the observation unit for a chest pain evaluation. CPR is initiated and a hospital rapid response team is called. The resuscitation team arrives and ACLS protocols are continued. The issue of whether corticosteroids should be administered is brought up during the code. Background: Cardiac arrests have  high morbidity and mortality rates both in-hospital cardiac arrests (IHCAs) and out of hospital cardiac arrests (OHCAs). It is estimated that the survival to discharge for an IHCA is approximately 18% with only 10% for OHCAs. This contrasts with what the public sees watching CPR being done on TV. Survival on screen is four to five times higher than reality, according to one study (see graphic). Improving outcomes for patients with cardiac arrests has been an ongoing challenge in pre-hospital and in hospital medicine. We have discussed many aspects of such care on the SGEM including: Therapeutic hypothermia (SGEM#54, SGEM#82, SGEM#183 and SGEM#275) Epinephrine (SGEM#64 and SGEM#238) IV vs IO Access (SGEM#231) Supraglottic Airways (SGEM#247) Crowd Sourcing CPR (SGEM#143 and SGEM#306) Mechanical CPR (SGEM#136) We understand more physiologic changes that take place following cardiac arrest and there have been several studies looking at the potential role of corticosteroids in the intra-arrest timeframe. SGEM#50 looked at a RCT published in JAMA 2013 looking to see if a vasopressin, steroids, and epinephrine (VSE) protocol for IHCAs could improve survival with favorable neurologic outcome compared to epinephrine alone. That RCT had 268 patients and demonstrated a better odds ratio for ROSC and survival to discharge with good neurologic outcome. The SGEM bottom line at the time was that the results were very interesting, but a validation study should be done to try and replicate the results. I have not seen a validation study published. We know that epinephrine can increase ROSC, survival to hospital, and even survival to hospital discharge based on the Paramedic 2 Trial. Unfortunately, epinephrine was not superior to placebo for the patient-oriented outcome of survival with good neurologic outcome. Corticosteroids have been suggested as a possible therapy in these clinical situations. However, there is an old RCT that looked at dexamethasone in OHCA and it failed to demonstrate an improvement in survival to hospital discharge (Paris et al AEM 1984). 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). Clinical Question: Does the use of corticosteroids impact neurologic outcomes and mortality in patients with a cardiac arrest? Reference: Shah and Mitra. Use of Corticosteroids in Cardiac Arrest - A Systematic Review and Meta-Analysis. Crit Care Med Feb 2021 Population: Randomized controlled trials and comparative observational studies of patients with in or out of hospital cardiac arrests Exclusions: Any single arm studies, case reports/ series, narrative reviews, and studies irrelevant to the focus of this article. Intervention: Corticosteroids as adjunct therapy in cardiac arrest Comparison: Patients that did not receive corticosteroids in cardiac arrest Outcome: Primary Outcomes: Good neurologic outcome (measured using the G...