The Skeptics Guide to Emergency Medicine

Date: March 4th, 2021 Guest Skeptic: Dr. Anand Swaminathan is an Assistant Professor of Emergency Medicine at St. Joseph’s Regional Medical Center in Paterson, NJ. Managing editor of EM:RAP and Associate Editor at REBEL EM. Reference:  Reuben A et al. The Use of Tranexamic Acid to Reduce the Need for Nasal Packing in Epistaxis (NoPAC): Randomized Controlled Trial. Ann Emerg Med 2021 Case: A 70-year-old man presents with epistaxis. He’s got a history of atrial fibrillation and hypertension. His medications include apixaban, metoprolol and perindopril. He states that the nosebleed started that morning all of a sudden. Vitals are; a blood pressure 145/73 mmHg, heart rate 64 beats/minute, and oxygen saturation 99% on room air. You apply direct pressure for 10 minutes, but the bleeding continues. You administer phenylephrine topically, reapply pressure and, consider the use of tranexamic acid (TXA). Background: Epistaxis is a common Emergency Department (ED) complaint with over 450,000 visits per year and a lifetime incidence of 60% (Gifford 2008, Pallin 2005). The majority of refractory hemorrhages are seen in the elderly and in more than two-thirds of the time no cause for the epistaxis is identified. Standard anterior epistaxis treatment consists of holding pressure, use of local vasoconstrictors, topical application of silver nitrate and placement of an anterior nasal pack. The most common vasoconstrictor used in the US is oxymetazoline.  Emergency physicians have multiple tools in the toolbox to address this condition. We covered the topic of epistaxis on SGEM#53: Sunday Bloody Sunday. That episode we discussed 11 questions concerning epistaxis. It is a great review on the management of nosebleeds. The episode included the Dundee protocol for adult epistaxis management from 2012. I searched and could not find an updated version. ED patients with epistaxis often fail conservative management and end up with anterior nasal packs which are uncomfortable. This is even more common in the group of patients who are taking antiplatelet agents or anticoagulants. In recent years, TXA has been added to many physicians’ armamentarium based on a few relatively small studies. We reviewed two  of these randomized control trials (RCTs) on the SGEM including the 2018 publication looking at using TXA in patients taking antiplatelet drugs. (SGEM#210). Some of these RCTs looking at TXA for epistaxis have also been reviewed on REBEL EM and other FOAMed sites. The results were encouraging. Topical TXA has minimal safety concerns and is relatively inexpensive. However, the studies did have a number of limitations including, being single centered, relatively small sample sizes and a lack of blinding. The SGEM structured critical review was skeptical of TXA for treating nosebleeds and had a conservative bottom line: Despite some limitations in this un-blinded trial, topical tranexamic acid appears to improve some patient important outcomes in patients who are taking antiplatelet medications who present with epistaxis. Clinical Question: Does the use of topical, intranasal TXA reduce the need for application of anterior nasal packing in ED patients with epistaxis who fail conservative management? Reference:  Reuben A et al. The Use of Tranexamic Acid to Reduce the Need for Nasal Packing in Epistaxis (NoPAC): Randomized Controlled Trial. Ann Emerg Med 2021 Population: Patients older than 18 years of age presenting with persistent epistaxis after local pressure and/or ice was applied to the bridge of the nose for at least 10 minutes. If bleeding persisted (continued presence of blood on the upper lip after wiping emanating from the nares) patients were treated with cotton wool dental roll soaked with a topical vasoconstrictor and inserted into the affected nostril for 10 minutes. If the bleeding persisted after the removal of the vasoconstrictor dental roll, they were enrolled in the trial.

Date: February 18th, 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: Brichko et al. Rapid Administration of Methoxyflurane to Patients in the Emergency Department (RAMPED): A Randomised controlled trial of Methoxyflurane vs Standard care. AEM Feb 2021. Case: A 46-year-old female presents to the emergency department (ED) with sudden onset, severe right flank pain. She is pacing around at triage in tears and says she has a history of kidney stones. She is asking for something to help with her pain, but the department is very busy, and it will be some time before she can get into a treatment space. Background: Pain is the primary reason patients present to the emergency in many cases (1-6).  Oligoanalgesia is the term used to describe poor pain management through the under use of analgesia (7-11).  Effective pain management is an important indicator of the quality of patient care (12). Multiple factors have been thought to contribute to oligoanalgesia (overcrowding, language barriers, age, gender, ethnicity, insurance status) (13-16).  Delays in providing adequate analgesia leads to poorer patient outcomes, prolonged ED length of stay and reduced patient satisfaction (17, 18). It can take a long time for someone in severe pain to receive an analgesic in the ED. Previous research in Australia has shown that the median time can be between 40-70 minutes for analgesia administration (19, 20). Delays are not unique to Australia and a study done in the USA reported a mean of 116 minutes for patients presenting to the ED with pain to receive analgesia (21). To minimize delays, different strategies have been implemented to address the problem (advanced protocols, provision of oral analgesics at triage, and the use of novel analgesic agents that do not require intravenous access) (22). Recently, there has been increased interest in using methoxyflurane (Penthrox), an inhaled non-opioid analgesic, to provide rapid short-term analgesia (23, 24).  In Australia, Methoxyflurane has been widely used at sub-anesthetic doses for analgesia in the pre-hospital setting since 1975. Its use has become more global in recent years and at low doses, it has a very reassuring safety profile. Furthermore, there have been no reports of addiction or abuse related to these inhaler devices (25-28). The majority of studies of methoxyflurane for pain focus on traumatic pain, this study aimed to assess its effectiveness in treatment of both traumatic and non-traumatic pain. Clinical Question: What is the effectiveness of methoxyflurane versus standard care for the initial management of severe pain among adult ED patients? Reference:  Brichko et al. Rapid Administration of Methoxyflurane to Patients in the Emergency Department (RAMPED): A Randomised controlled trial of Methoxyflurane vs Standard care. AEM Feb 2021. Population: Adult patients aged 18-75 years with severe pain defined as an initial Numerical Rating Scale (NRS) pain score greater than or equal to 8. Exclusion criteria: Transferred patients, HR <40 or >140 bpm, SBP <90 or >180 mmHg, RR <6 or >36/min, GCS <15, possible ACS, headache, pregnancy, breastfeeding, known renal or hepatic failure, previous malignant hyperthermia, known sensitivity to fluorinated anesthetics, or agitated/aggressive per nursing staff. Intervention: Inhaled Methoxyflurane 3 mL Comparison: Standard analgesic care which could include paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), tramadol and oral oxycodone or IV morphine Outcome: Primary Outcome: Proportion of patients that had at least a 50% reduction in their pain score at 30 minutes Secondary Outcomes: Median pain score at 15, 30, 60 and 90 minutes, and the proportion of patients that achieved a >2 point drop i...

Date: February 19th, 2021 This is an SGEM Xtra episode. I had the honour of presenting at the Lehigh Valley Health Network Grand Rounds on February 4th, 2021. The title of the talk "Dogmalysis: Five Medical Myths in Emergency Medicine". The presentation is available to listen to on iTunes and GooglePlay and all the slides can be downloaded using this LINK.   Five Medical Myths in Emergency Medicine Myth #1: The use of non-selective NSAIDs will cause a nonunion in long bone fractures Myth #2: Topical anesthetics will cause blindness if used in simple corneal abrasions for less than 48 hours Myth #3: Mild paediatric gastroenteritis is best treated with expensive oral electrolyte solutions Myth #4: Tranexamic acid (TXA) has been proven to saves lives and results in good neurologic function in patients with isolated traumatic brain injuries (TBI) Myth #5: Epinephrine in adult out-of-hospital cardiac arrests (OHCA) results in better patient-oriented outcomes (POOs) Each of the five myths is presented with some background information and the PICO (population, intervention/exposure, comparison and outcome). Key results are provided with a number of the study limitations (dog leash) identified. There is an SGEM bottom line and a link to the original SGEM episode to provide more results and critical appraisal. There is also a link to the original article for people to read the primary literature for themselves. Myth #1: The use of non-selective NSAIDs will cause a nonunion in long bone fractures When bones break, they usually heal with either surgical or non-surgical management. Sometimes the healing process can take longer than usual (delayed union), does not heal (non-union) or in poor alignment (malunion). Non-union is defined as “a failure of the fracture-healing process” and occurs in up to 1 in 10 fractures. Several risk factors have been associated with increased risk of delayed or non-union: issues about the fracture (open/closed, displacement, location, etc) tobacco use, older age, severe anemia, alcohol intake, diabetes, low vitamin D levels, hypothyroidism, poor nutrition, infection, open fracture and certain medications (ex. steroids).  One class of medication that has been implicated in negatively impacting bone healing is NSAIDs. Non-selective NSAIDs and COX-2 inhibitors. There have been multiple studies investigating this issue with mixed results. The final cohort consisted of 339,864 patients identified in over 15 years. Less than 1% were diagnosed with a nonunion (2,996/339,864). The mean age was in the 50’s and around 60% were female. The most common fractures were radius, neck of the femur and humerus. Key Result: Patients who filled prescriptions for selective COX-2 inhibitors and opioids but not non-selective NSAIDs were associated with an increased risk of nonunion. SGEM Bottom Line: There is no high-quality evidence to support the claim that non-selective NSAIDS cause an increased risk of nonunion. SGEM#317: Dese bones gonna heal again, with or without a non-selective NSAID Reference: George et al. Risk of Nonunion with Nonselective NSAIDs, COX-2 Inhibitors, and Opioids. J Bone Joint Surg Am. 2020 Myth #2: Topical anesthetics will cause blindness if used in simple corneal abrasions for less than 48 hours Even small corneal abrasions can cause significant pain because the cornea is highly innervated. The first documented use of topical ophthalmologic anesthetics was in 1818. A cocaine derivative was employed to effectively block nerve conduction in the superficial cornea and conjunctiva (Rosenwasser). A number of proposed dangers have limited the use of topical anesthetic agents for the treatment of corneal abrasion associated pain. These dangers include delayed healing secondary to mitosis inhibition and decreased corneal sensation. The latter issue is of concern because of the potential for the abrasion to progress to an ulcer without t...

Date: February 12th, 2021 Guest Skeptic: Dr. Dennis Ren is a paediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. Reference: Mintegi S et al. Clinical Prediction Rule for Distinguishing Bacterial from Aseptic Meningitis. Pediatrics 2020 Case: A 4-year-old immunized girl presents to the emergency department (ED) with a fever and rhinorrhea for the past four days. Her parents report that she has been complaining of a headache and seems more tired and sleepy in the past day. On exam, she is febrile to 38.5 ºC, appears tired, with meningismus on examination but answers questions appropriately. She does not have any petechiae or purpura on skin exam. You explain that you must obtain some blood for laboratory work and perform a lumbar puncture (LP) because you are concerned that she has meningitis. Her nervous parents agree to the LP. Her cerebrospinal fluid appears clear and preliminary cerebrospinal fluid (CSF) results show a pleocytosis with 16 white blood cells per µL without any red blood cells. Her parents ask you whether or not she will have to stay in the hospital or receive antibiotics. Background: Vaccines cause adults. Supporting this position is that since the introduction of conjugate vaccines the incidence of life-threatening bacterial meningitis has decreased. The first conjugate vaccine introduced was the haemophilus influenzae type b (Hib) vaccine. This vaccine has a reported efficacy of 98% (Makwana and Riordan 2007). The success of conjugate vaccines is that most cases of pediatric meningitis are now aseptic (viral cause). It is important to distinguish between bacterial vs aseptic meningitis. This is because bacterial meningitis is associated with serious morbidity and mortality and requires prompt antibiotic treatment; aseptic meningitis is self-limited and requires only supportive care. Patients with suspected bacterial meningitis require hospital admission with empiric antibiotics pending culture results (Sáez-Llorens and McCracken 2003). There is no single variable that can help discriminate between bacterial vs. aseptic meningitis.  Combinations of variables have been tried in the past as part of clinical scoring systems such as the Bacterial Meningitis Score (BMS) to identify children with CSF pleocytosis at low risk for bacterial meningitis (Nigrovic et al 2002). However, BMS did not take into account C-reactive protein and procalcitonin levels that have shown promise in risk stratifying febrile children at risk for bacterial infection (Van den Bruel et al 2011). Additionally, BMS has missed a few cases of bacterial meningitis. Specifically, 2 out of 1714 patients categorized as very low risk for bacterial meningitis had bacterial meningitis (sensitivity 98.3%, NPV 99.9%). Both patients missed were younger than 2 months old (Nigrovic et al 2007). The study we are reviewing today aimed to develop and validate a more accurate scoring system called the Meningitis Score for Emergencies (MSE) to distinguish between bacterial vs. aseptic meningitis in children 29 days to 14 years old with CSF pleocytosis based on four objective lab criteria. Clinical Question:  Can a clinical decision tool using laboratory data help distinguish between bacterial from aseptic meningitis in children 29 days to 14 years old with cerebrospinal fluid pleocytosis? Pleocytosis- CSF WBC ≥10 cells per µL. Corrected for presence of CSF RBCS (1:500 leukocytes to erythrocytes in peripheral blood) and CSF protein (every 1000-cell increase on CSF RBCs per mm3, CSF protein increased by 1.1 mg/dL) Bacterial meningitis defined as patient with either identification of bacterial pathogen in CSF culture and/or Neisseria meningitides or Streptococcus pneumoniae on polymerase chain reaction and either positive blood culture or blood PCR result for N meningitides or S pneumoniae Aseptic meningitis defined as CSF pleocytosis and negative CSF and blood bacterial cul...

Date: January 20th, 2021 Guest Skeptics: Dr. Thorben Doll and Dr. Johannes Pott. They are both fourth year resident doctors in anesthesiology, intensive care and emergency care in St. Bernward Hospital in Hildesheim, Germany. Thorben and Johannes have a knowledge translation project called Pin-Up-Docs. It is a German emergency medicine and intensive care podcast. Their mission is to share  knowledge with paramedics, nurses, medical student and also young doctors as they take their first steps in the field of emergency medicine.  Each month they post new content and focus two main topics, the medical therapy of the month as well as tricks for dealing with complex emergencies. All of their shared information is based on the latest medical studies and data. Additionally, they host selected guests for special episodes, and publish blogs dedicated to more advanced medical questions or topics. Reference: Ruberto et al. Intravenous Haloperidol Versus Ondansetron for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial. Annals of EM 2020. Case: A 32-year-old male patient presents to your emergency department (ED) with severe nausea, vomiting and abdominal pain. He reports the symptoms have been continuous for 4 or 5 hours. Over-the-counter medications like acetaminophen (paracetamol) and ibuprofen have not helped. His flatmate (roommate) says he only gets relief by taking really long, hot showers. On examination, his vital signs are normal, and he is afebrile. The abdomen exam shows no peritoneal sign and normal bowel sounds are heard. Laboratory values are unremarkable. An ultrasound does not show any free fluids or any signs of an Ileus, appendicitis or gallbladder disease. His pain and nausea are difficult to control with standard medications. You admit him to hospital and the next day he undergoes gastroscopy which is unremarkable. In the afternoon the patient is seen by a nurse when he is smoking “weed” (cannabis) in the garden of the hospital. He admits to being a heavy cannabis user and his symptoms do seem to get worse when smoking weed. You suspect he has cannabis hyperemesis syndrome and discharge him home with the recommendation to stop smoking as much weed. Background: Chronic marijuana use was recognized by Allen el al in 2004 to cause cyclical vomiting in patients from South Australia. Roche and Foster quickly reported in 2005 that this was not an isolated problem to the Adelaide Hills of South Australia. The medical condition became known as cannabinoid hyperemesis syndrome. We covered this on SGEM#46: Don’t Pass the Dutchie   Cannabis stimulates two receptors: CB1 and CB2. CB1 is also expressed in the GI-system and reduces motility and relaxes the esophageal sphincter tonus. If you conduct chronical cannabis abuse, it seems that the anti-nausea effect of cannabis vanishes and there is a continuous hyperstimulation of CB1. That’s why you have abdominal pain and nausea with continuous vomiting. There are some criteria proposed for the diagnosis of cannabinoid hyperemesis. An essential feature is long term cannabis use (often daily). There are five major features for the diagnosis and five supportive features for the diagnosis. These are listed in the table.  Clinical Question: Can haloperidol effectively treat patients with cannabis hyperemesis syndrome? Reference: Ruberto et al. Intravenous Haloperidol Versus Ondansetron for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial. Annals of EM 2020. Population: Adult patients 18 years of age and older presenting to the ED with a working diagnosis of hyperemesis cause by cannabis who had at least two hours of ongoing, witnessed emesis or retching. Patients needed to report at least three episodes of emesis in a cyclic pattern separated by greater than one month during the preceding two years, and near-daily to daily use of cannabis by inhalation for at least six months.

Date: January 22nd, 2021 Guest Skeptic: Dr. Steve Joseph. Steve completed his Sport Medicine fellowship training with the Fowler Kennedy Sport Medicine Clinic in 2017.  He served with the Canadian Forces as a Medical Officer and Flight Surgeon. Steve is currently an Assistant Professor in the Department of Family Medicine at Western University (London, Ontario) working at the Fowler Clinic and the Roth McFarlane Hand and Upper Limb Centre. Reference: George et al. Risk of Nonunion with Nonselective NSAIDs, COX-2 Inhibitors, and Opioids. J Bone Joint Surg Am. 2020 Case: A healthy 55-year-old woman was out for a walk and had a FOOSH (fall on outstretched hand) of her dominant arm. The X-ray demonstrates a fracture of the distal radius that is in an acceptable position and does not require a reduction. You immobilize her in a below elbow splint which provides significant pain relief and refer her to the local orthopedic fracture clinic. Upon discharge she asks what she should take for pain because she read somewhere that anti-inflammatory drugs like ibuprofen can prevent bone healing. She currently takes thyroid replacement therapy and has no known drug allergies. Background: There are conflicting studies about fracture healing and the use of non-steroidal anti-inflammatories (NSAIDs) in humans. It remains a controversial topic in the orthopaedic specialty. When bones break, they usually heal with either surgical or non-surgical management. Sometimes the healing process can take longer than usual (delayed union), does not heal (non-union) or in poor alignment (malunion). Non-union is defined as "a failure of the fracture-healing process” and occurs in up to 1 in 10 fractures. Several risk factors have been associated with increased risk of delayed or non-union. These factors include: Use of tobacco products, older age, severe anemia, alcohol intake, diabetes, low vitamin D levels, hypothyroidism, poor nutrition, infection, open fracture and certain medications (ex. steroids). The top risk factors for non-union according to a study by Santolini et al were open method of fracture reduction, open fracture, presence of post-surgical fracture gap, smoking, infection, wedge or comminuted types of fracture, high degree of initial fracture displacement, lack of adequate mechanical stability provided by the implant used, fracture location in the poor zone of vascularity of the affected bone, and a fractured tibia [1]. One class of medication that has been implicated in negatively impacting bone healing is NSAIDs. Non-selective NSAIDs block cyclooxygenase (COX)-1 and 2 while selective NSAIDs only inhibit COX-2. There have been multiple studies investigating this issue with mixed results. Clinical Question: Is there increased risk for fracture non-union with certain classes of NSAIDs? Reference: George et al. Risk of Nonunion with Nonselective NSAIDs, COX-2 Inhibitors, and Opioids. J Bone Joint Surg Am. 2020 Population: Adults (18 years and older) inpatient or outpatients with a diagnosis of certain long bone fractures (neck of femur/tibia/fibula/tibia and fibula/radius/ulna/humerus/clavicle) based on ICD-9 codes. Excluded: Patients less than 18 years of age, multiple fractures, metastatic disease, history of malunion fracture in the year prior or within 90 days Exposure: Filled prescription for a non-selective NSAIDs, selective COX-2 inhibitor and/or opioid within 30 days of the fracture Comparison: Not filling a prescription for a non-selective NSAIDs, selective COX-2 inhibitor and/or opioid within 30 days of the fracture Outcomes: Primary Outcome: Diagnosis of non-union within the 91 to 365 days post fracture. This was based on two definitions. The primary definition used ICD-9 code for nonunion with a procedure to treat nonunion within 30 days of the nonunion diagnosis. The secondary definition was an inpatient or outpatient diagnosis of nonunion.

Date: January 20th, 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 and as an Associate Editor for the NEJM Journal Watch Emergency Medicine. Reference: Pines et al. Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain. AEM January 2021 Case: A 50-year-old male presents to the Emergency Department (ED) with left lower quadrant abdominal pain. The patient is seen by an advanced practice provider (APP). He wants to know if being seen by an APP alters his chance of diagnostic testing or hospital admission. Background: We covered the use of advanced practice providers (APPs) on the SGEM#308. That SGEMHOP episode asked how the productivity of APPs compare to emergency physicians and what is its impact on ED operations? The key result from that study of 13 million ED visits across 94 states was that physicians were more productive than PAs and NPs. The SGEM bottom line was that increasing APP coverage has minimal effect on ED flow and safety outcomes based on the data. Over the past two decades, the use of APPs has increased. APPs have a significantly truncated medical training (about 2 years of training) and practice experience compared with the traditional 4 years of medical school and 3-4 years of residency for emergency physicians. There has been a concern about post-graduate training of NPs and PAs in the ED. A joint statement on the issue was published in 2020 by AAEM/RSA, ACEP, ACOEP/RSO, CORD, EMRA, and SAEM/RAMS. The American Academy of Emergency Medicine (AAEM) has a position statement on what they refer to as non-physician practitioners that was recently updated. The American College of Emergency Physicians (ACEP) also has a number of documents discussing APPs in the ED. The difference in training between and emergency medicine physician and APPs is well recognized. A concern is that some APPs may compensate for this training gap by increased testing. Clinical Question: Is ED evaluation by an APP associated with higher test utilization and hospitalization compared with evaluation by a physician? Reference: Pines et al. Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain. AEM January 2021 Population: All ED patients with a chief complaint of chest pain or abdominal pain triaged as an Emergency Severity Index (ESI) 2,3, or 4 who were seen independently by either an APP or emergency physician Excluded: Patients who left without treatment or against medical advice, those who were dead on arrival or died in the ED. They also excluded those with a triage level ESI 1 or 5, as these are less common, as well as those with a final diagnosis of injury or poisoning – as in those cases the diagnosis would generally be apparent. Intervention: Evaluated by an APP Comparison: Evaluated a physicial Outcome: Primary Outcomes: Laboratory tests, ECGs, imaging studies as well as hospital admissions (including transfer to other hospitals and observation admissions) Secondary Outcomes: Testing based on evidence-based practice Dr. Jesse Pines This is an SGEMHOP episode which means we have the lead author on the show. Jesse Pines MD is the National Director for Clinical Innovation at US Acute Care Solutions and a Professor of Emergency Medicine at Drexel University. In this role, he focuses on developing and implementing new care models including telemedicine, alternative payment models, and also leads the USACS opioid programs. Authors’ Conclusions: “We demonstrate that the care delivered in the ED b...

Date: January 5th, 2021 Reference: Shipman et al. Short-Term Topical Tetracaine Is Highly Efficacious for the Treatment of Pain Caused by Corneal Abrasions: A Double-Blind, Randomized Clinical Trial. Annals of EM 2020 Dr. Glaucomflecken Guest Skeptic: Dr. Will Flanary is an ophthalmologist, writer, and comedian who moonlights in his free time as “Dr. Glaucomflecken” on Twitter and TikTok. Effortlessly blending humor with education, Dr. Glaucomflecken has spent the last five years informing audiences on a wide range of topics, like navigating the confusing world of over-the-counter eyedrops, the horrifying consequences of sleeping in contact lenses, and his recent experiences as a patient in the medical system. Case: A 32-year-old healthy man presents with left eye pain. He was giving his 9-month-old a hug and got poked in the eye with a sharp little fingernail.  His visual acuity is 20/20 bilaterally and he doesn’t wear corrective lenses or contact lenses. He tried some over-the-counter red eye drops that did not seem to work. In the emergency department (ED), tetracaine drops are applied prior to slit lamp examination and the pain is completely resolved. On examination, you see a vertical corneal abrasion with no evidence of ulceration and no foreign body. You prescribe antibiotic drop and prepare to discharge him home when he asks, “can I get some of those numbing drops to use at home”? Background: Even small corneal abrasions can cause significant pain because the cornea is highly innervated. The first documented use of topical ophthalmologic anesthetics was in 1818. A cocaine derivative was employed to effectively block nerve conduction in the superficial cornea and conjunctiva (Rosenwasser). A number of proposed dangers have limited the use of topical anesthetic agents for the treatment of corneal abrasion associated pain. These dangers include delayed healing secondary to mitosis inhibition and decreased corneal sensation. The latter issue is of concern because of the potential for the abrasion to progress to an ulcer without the patient noticing. Additionally, these agents may have direct toxicity to corneal epithelium with prolonged use, leading to increased corneal thickness, opacification, stromal infiltration, and epithelial defects. The fear of these complications has led to the pervasive teaching that topical anesthetics should never be used for outpatient management of corneal abrasions. This is reflected in the condemnation of their use in major Emergency Medicine textbooks, including Rosen’s and Tintinalli’s. Some of the evidence used to support the claim of local anesthetics causing corneal harm comes from case reports, animal models or local anesthetic injected directly into the anterior chamber of the eye for cataract surgery. More information on the where the no topical anesthetic use on corneal abrasions come from can be found on a REBEL EM blog post. We covered and randomized control trial by Waldman et al on topical tetracaine for simple corneal abrasions on SGEM#83. The bottom line from that episode was that tetracaine appears safe for uncomplicated corneal abrasions and provides more effective pain relief than saline eye drops. We also did a critical appraisal of a systematic review by Swaminathan et al looking at topical anesthetics for these types eye injuries on SGEM#145. The SGEM bottom line from that review was that the best evidence we currently have demonstrates that dilute topical anesthetic drops of either proparacaine or tetracaine are safe for use in ED patients with simple corneal abrasions to provide analgesia. The studies are small, but the data contained in them is far superior to the case series published 50 years ago which led to the dogma that using them is dangerous. Clinical Question: What is the efficacy of topical tetracaine in the treatment of simple corneal abrasions? Reference: Shipman et al.

Date: January 5th, 2021 Reference: Grunau et al. Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest. JAMA 2020 Guest Skeptic: Mike Carter is a former paramedic and current PA practicing in pulmonary and critical care as well as an adjunct professor of emergency medical services at Tacoma Community College. Case: During a busy emergency department (ED) shift the paramedic phone rings.  On the other end of the line is one of your local crews who have responded to a 54-year-old male with a witnessed cardiac arrest.  CPR is currently in progress with a single shock having been delivered.  The crew is asking if they should transport the patient with resuscitation ongoing? Background: Out-of-hospital cardiac arrest (OHCA) is something we have covered extensively on the SGEM over the years. This has included things like therapeutic hypothermia (SGEM#54, SGEM#82, SGEM#183 and SGEM#275), supraglottic devices (SGEM#247), crowd sourcing CPR (SGEM#143 and SGEM#306), and epinephrine (SGEM#238). One aspect we have not looked at is the “load and go” vs. “stay and play” approach for OHCA. Different countries have different approaches to this problem. There is the European model that is physician led and provides more care in the field while the North American model tends to scoop and run. However, there is a fair bit of heterogeneity between EMS systems even in the US. In patients with OHCA, some EMS agencies transport almost all patients regardless of ROSC, while others rarely transport if ROSC is not achieved. It is unclear from the existing literature which practice is superior to the other in providing patient-oriented benefit to among adult patients in refractory arrest who have suffered an OHCA. Clinical Question: What is the association of intra-arrest transport compare to continued on-scene resuscitation in regards to survival to hospital discharge in adult patients with an OHCA? Reference: Grunau et al. Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest. JAMA 2020 Population: Adults 18 years and older with non-traumatic OHCA between 2011 and 2015treated by 192 EMS agencies in the USA. EMS. OHCA was defined as persons found apneic and without a pulse who underwent either external defibrillation (bystanders or EMS) or chest compressions. Exclusions: Age less than 18 years, do-not-resuscitate (DNR) order being discovered, transport prior to cardiac arrest, missing data to classify as intra-arrest or to classify the primary outcome, missing variables required for propensity score analysis Intervention: Intra-arrest transport prior to any episode of return of spontaneous circulation (ROSC) defined as palpable pulse for any duration Comparison: Continued on-scene resuscitation Outcome: Primary Outcome: Survival to hospital discharge Secondary Outcomes: Survival with favorable neurologic outcome defined as a modified Rankin scale (mRS) score of less than 3 mRS is categorized to 7 different levels, with 0 being no disability and 6 being death. A 3 is defined as moderate disability requiring some help, but able to walk without assistance Authors’ Conclusions: “Among patients experiencing out-of-hospital cardiac arrest, intra-arrest transport to hospital compared with continued on-scene resuscitation was associated with lower probability of survival to hospital discharge. Study findings are limited by potential confounding due to observational design.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Unsure

Date: January 7th, 2021 Happy New Years to all the SGEMers. I know 2020 has been a bit of a dumpster fire. We have all faced challenges During the COVID19 global pandemic. I tried not to contribute to the large volume of information coming out on Sars-Cov2. There were only four episodes that directly addressed COVID19: SGEM Xtra: Mask4All Debate SGEM#229: Learning to Test for COVID19 SGEM Xtra: CAEP National Grand Rounds - COVID19 Treatments SGEM#309: That’s All Joe Asks of You – Wear a Mask There have been many other FOAMed resources (REBEL EM, First10EM, EM Cases, St. Emlyn's, and others) that have done a great job covering the pandemic. This is an SGEM Xtra episode to announce a few exciting new things for 2021. SGEM Continuing Medical Education Credits The BIG news is that the SGEM will now be offering Continuing Medical Education (CME) credits for all SGEM episodes. Click on this LINK to find out more. The Skeptics' Guide to Emergency Medicine (SGEM) is part of the Free Open Access to Meducation movement (FOAMed). The SGEM tries to cut the knowledge translation window down from over ten years to less than one year with the power of social media. The ultimate goal is for patients to get the best care, based on the best evidence. The FOAMed philosophy is that the information should be available to anyone, anytime, anywhere at no cost. This is similar to the philosophy of emergency medicine. It is the light in the house of medicine that is always on for anyone, at anytime, for anything. The SGEM has been free since it started in 2012 and will always be free open access. Many of you have asked about getting CME credits for listening to the SGEM podcast and reading the SGEM blog. We know physicians (MD and DO), Nurse Practitioners (NP) and Physician Assistants (PA) have to collect so many CME credit hours for their respective professional organizations. This can be more challenging with the cancelation of in-person conferences and meetings. The SGEM Hot Off the Press (SGEMHOP) episodes which are published once a month do offer CME credits. However, you can only claim these credits if you are a member of the Society of Academic Emergency Medicine (SAEM). This new initiative will allow anyone to claim CME credits for all of the SGEM episodes. Getting CME credits for the weekly SGEM episodes is something I have been wanting to do for years. The barriers to getting CME credits for the SGEM before now was that it takes a lot of time and costs a lot of money to get accreditation. The cancellation of in-person conferences due to COVID19 has been the push I needed to finally get this service added to the SGEM. This project has been made possible through a partnership with a Legend of Emergency Medicine, Dr. Richard Bukata, and his Center for Medical Education (CCME) company.  CCME has been providing providing medical education in the form of audio programs and conferences since 1977. They have the infrastructure to provide this type of service. They also have an arrangement to get the CME credits at a very reasonable price. Sign up by January 31st, 2021: There can be only one... The SGEM CME program offers up to 26 credits (1 credit hour per SGEM episode) over 6 months for only $195. If you sign up before January 31st, 2021 we will also give you 26 credits for free. This will be the previous six months of SGEM content that has already been approved for CME credits.  Basically it is a 50% off promotion to kick start the SGEM CME program. Signing up for your education credits is easy. This is because "there can be only one" subscription option. You can earn up to 26 credit hours in six months. The price is $195 ($7.50/credit hour) for the six months. Again, those that sign up by January 31st, 2021 will receive a bonus 26 CME credits for free. That makes it only $3.75 for every credit hour of SGEM content!. It is as easy as 1-2-3 to start earning your CME credit tod...