The Skeptics Guide to Emergency Medicine

Date: April 30th, 2021 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com. He is also one of the SGEM Hot Off the Press Faculty. Reference: Donaldson et al. Review article: Why is there still a debate regarding the safety and efficacy of intravenous thrombolysis in the management of presumed acute ischaemic stroke? A systematic review and meta-analysis. Emerg Med Australas 2016. This SGEM Xtra is based on the new recommendation on TheNNT website for tPA in acute ischemic stroke. This is the third time there has been a recommendation on this topic. The first review gave thrombolytics a "red color recommendation: no benefit." The second review gave alteplase, a single agent, a "green color recommendation: benefit>harm." Since no relevant trials were published between the two and both author groups examined essentially the same data and arrived at opposing conclusions, we wanted to understand and try to explain the conflicting interpretations. Our interpretation of the available literature was to give it a “yellow colour recommendation: net benefits and harms unclear due to uncertainty in data”. This resulted in the summary statistic of the benefit NNT (not reported: Uncertain) and Harms in NNT (not reported: Uncertain). More details on the NNT Rating System are available. It would be hubris to presume that our summary would arrive at the one true answer. But our goal wasn’t to provide an answer. Our goal was simply to explain the science as well as we could, so people could understand why there is a debate – and the uncertainty that underlies that debate. The Donaldson et al SRMA included 10,431 patients in 26 randomized trials comparing intravenous thrombolysis with placebo or standard care in acute ischemic stroke [1]. Their efficacy endpoint was good functional outcome, defined as a modified Rankin Score (mRS) of 3 or less. This is defined as some residual disability requiring assistance but able to walk and care for personal needs independently. The harm endpoints were symptomatic intracranial hemorrhage (as defined by individual trials) and overall mortality The authors report a 3.2% improvement in good neurologic outcome, a 5.4% increase in symptomatic intracranial hemorrhage, and a 2.5% increase in mortality. However, we question the certainty implied by these summary numbers. Emberson and colleagues reported only on alteplase (a problem we will discuss further) and found a 5% improvement in neurologic outcomes, a 5.5% increase in intracranial hemorrhage, and a 1.4% increase in 90-day mortality that was not statistically significant [2]. A 2014 Cochrane review by Wardlaw et al and arrived at similar conclusions with significant improvement in neurologic outcomes, increased intracranial hemorrhage, and increased mortality [3]. Thus, our conclusions and discussion are unchanged by choice of review and reflect our belief that pooling data on this topic is overly simplistic and masks profound uncertainty. We both really like TheNNT website, and the NNT as a concept. But there are problems with the NNT if used in isolation. One of the great conceptual difficulties of summary statistics like the number-needed-to-treat (NNT) is the implication of certainty. A major strength of the NNT is its simplicity, making complex research easier to understand. A weakness, however, is also its simplicity, because it can hide the complexity of research, ignore confidence intervals, and obscure biases. For most topics, these details are far more important than any individual number. There is an SGEM Xtra on some of the limitations of the NNT/NNH summary statistics called the NNT - WET or DRI? It was based on an article published Dec 2019 in AEM by Reeves and Reynolds. There are multiple sources or uncertainty around thrombolytics and stroke which we discussed in TheNNT recommendation.

Date: April 19th, 2021 Guest Skeptic: Dr. Kirsty Challen (@KirstyChallen) is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). She is Chair of the Royal College of Emergency Medicine Women in Emergency Medicine group and involved with the RCEM Public Health and Informatics groups. Kirsty is also the creator of the wonderful infographics called #PaperinaPic. Reference: Martel et al. Randomized Double-blind Trial Intramuscular Droperidol, Ziprasidone and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department. AEM April 2021 Case: You are sitting minding your own business charting on shift when you become aware of shouting and banging from your ambulance bay.  On investigating you find a collection of nursing, EMS and hospital security personnel surrounding an obviously agitated patient with blood on his head who is attempting to punch them. The nurse wants to know what medications he can get to chemically restrain the patient. Background: We have covered the issue of excited delirium back in SGEM#218 with a systematic review which found that the evidence base for most pharmacological treatments at that point was poor. Way back in 2013 we looked at haloperidol for agitation due to psychosis (SGEM#45) and concluded that it was an effective treatment but had common side effects. Droperidol has been used widely, particularly in Australasia, for acute severe agitation. Unfortunately, an FDA Black Box warning and supply issues meant that droperidol effectively vanished from the US armamentarium from 2013-2019 and other agents were used and investigated. Clinical Question: In patients needing parenteral sedation for acute agitation, is droperidol, ziprasidone or lorazepam intramuscularly  most effective and safe? Reference: Martel et al. Randomized Double-blind Trial Intramuscular Droperidol, Ziprasidone and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department. AEM April 2021 Population: Emergency department (ED) patients 18 years or old where the treating physician determined the need for parenteral sedation for acute agitation (it needed a patient or staff safety concern, not purely a high agitation score). Exclusions: Prisoners or those in police custody, pregnant or breast-feeding, or with documented allergy to any study medications. Intervention: Droperidol 5mg IM, Ziprasidone 10mg IM or Ziprasidone 20mg IM Comparison: Lorazepam 2mg IM Outcome: Primary Outcome: Adequate sedation at 15 minutes was defined as an Altered Mental Status Scale (AMSS) of zero Secondary Outcomes: Need for additional sedation, ED length of stay, respiratory depression (SpO2<90% requiring supplemental O2, EtCO2 falling by 10mmHg or rising by 15mmHg). Dr. Marc Martel This is an SGEMHOP episode, which means we have the lead author on the show. Dr. Martel is a practicing emergency physician at Hennepin County medical center in Minneapolis, Minnesota since 2000.  He has been a nocturnist for essentially his entire career.  Dr. Martel’s research focuses on finding the safest way to care for patients with acute agitation while respecting patient's dignity, limiting restraint use, and efficiently getting them care they need. Authors’ Conclusions: “Droperidol was more effective for sedation and was associated with fewer episodes of respiratory depression than lorazepam or either dose of ziprasidone.”  Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Unsure The study patients were recruited consecutively (i.e. no selection bias). No The patients in both groups were similar with respect to prognostic factors....

Date: April 16th, 2021 Guest Skeptic: Dr. Anthony Crocco is the Deputy Chief - McMaster Department of Pediatrics, Acting Head of Pediatric Cardiology, and creator of Sketchy EBM. Reference: Schuh et al. Effect of Nebulized Magnesium vs Placebo Added to Albuterol on Hospitalization Among Children With Refractory Acute Asthma Treated in the Emergency Department: A Randomized Clinical Trial. JAMA Nov 2020 Case: A four-year-old girl with a known history of asthma presents to your emergency department (ED) after a one-day history of runny nose and cough.  Her usual triggers are upper respiratory infections and cats.  You don the appropriate personal protective equipment (PPE) wondering if this is COVID.  On initial exam she has minimal air entry, has biphasic wheeze, is saturating 92% on room air and has suprasternal retractions.  You give her an initial Pediatric Respiratory Assessment Measure (PRAM) score of 8 - and consider her to be having a “severe” exacerbation.  You give her a dose of oral dexamethasone and start three back-to-back treatments of albuterol and ipatroprium bromide.  After one hour she is still working hard to breath and her PRAM has improved somewhat but is still 6 denoting “moderate” asthma.  You wonder whether magnesium is indicated now and rather than starting an IV to give it that way, you could just nebulize a dose instead. Background: Asthma is a common presenting complaint for children in the ED. We have covered asthma a few times on the SGEM: You mentioned the PRAM tool in the case scenario. Can you explain this further for those not familiar with the PRAM score? SGEM#52: Breakfast at Glenfield – Asthma, Social Media and Knowledge Translation SGEM#103: Just Breathe – Inhaled Corticosteroids for Asthma Exacerbations SGEM#142: We Need Asthma Education SGEM#194: Highway to the Dexamethasone – For Pediatric Asthma Exacerbations The PRAM score is a tool used to assess the severity of airway obstruction in pediatric patients. The PRAM was published in 2000 (Chalut et al) and validated in 2008 (Ducharme et al). The PRAM consists of five clinical elements: O2 saturation, suprasternal retractions, scalene muscle contraction, air entry and wheezing. A score of 0-3 is considered mild asthma, 4-7 is moderate and 8-12 is severe. The Canadian Pediatric Society (CPS) Guidelines  recommends the initial management of pediatric patients with severe asthma exacerbations consists of: keeping oxygen saturations >93%, inhaled beta agonists, inhaled ipatroprium bromide, oral steroids, consider IV steroids, consider continuous aerosolized beta-2 agonists, consider IV magnesium sulphate and keep NPO. For children with severe asthma, IV magnesium has been shown to significantly decrease hospitalization rates though practically these children are rarely sent home after this IV treatment (Cheuk et al 2005, Griffith et al 2016, Su et al 2018 and Liu et al 2016).  As IV magnesium requires an intravenous, a painful and often distressing procedure in of itself, and the magnesium itself given IV can cause hypotension, an alternate delivery system would be of benefit. Clinical Question: Does nebulized magnesium prevent hospitalization in children with moderate to severe asthma? Reference:  Schuh et al. Effect of Nebulized Magnesium vs Placebo Added to Albuterol on Hospitalization Among Children With Refractory Acute Asthma Treated in the Emergency Department: A Randomized Clinical Trial. JAMA Nov 2020 Population: Children 2 to 17 years of age with a previous diagnosis of asthma presenting to a pediatric ED with moderate to severe asthma after receiving one hour of treatments including 3 x inhaled albuterol treatments, 3 x inhaled ipatropium bromide treatments and oral corticosteroid. Moderate to severe asthma was defined by a PRAM score of greater than 4. Exclusions: Children less than 2 years of age, those requiring immediate airway management,

Date: April 6th, 2021 Guest Skeptic: Dr. Casey Parker is a Rural Generalist from the NW of Australia. He is a GP by training but works in Emergency Department, Anaesthesia, Internal Medicine and Paediatrics. Dr. Parker is currently studying to become a Sonologist. He has a wonderful #FOAMed blog and podcast called Broomedocs and also work with me on the Primary Care RAP team. Reference: Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia: The SALSA Randomized Clinical Trial. JAMA Intern Med 2021 Case: A 60-year-old man presents to the emergency department (ED) after his wife found him to be drowsy and confused at home. He had been vomiting that morning. He had a background of hypertension treated with a thiazide diuretic. His wife reports that he had experienced diarrhoea in the week prior to this presentation.  On arrival to the ED his vitals are normal aside from a decreased level of consciousness and he is found to have a serum sodium concentration of 118 mmol/L.  You are unsure as to the best way to correct his sodium and are aware that rapid overcorrection may lead to an osmotic demyelination syndrome.  However, he is also at risk of a seizure and further harm at this level. Background: The most common electrolyte abnormality in clinical practice is a low sodium level (hyponatremia). This imbalance occurs in 14% to 42% of admitted patients. There is a high mortality associated with hyponatremia [1-3].  Symptomatic hyponatremia has traditionally been treated with a careful slow continuous infusion of hypertonic saline. This has been to prevent the horrible adverse event called osmotic demyelination syndrome (ODS). ODS includes both central pontine myelinolysis and extrapontine myelinolysis. In recent times several expert consensus guidelines have recommended the use of rapid, intermittent boluses of hypertonic saline  instead of a slow continuous infusion [3,4].   There is very little randomized data to prove the superiority of either strategy prior to the SALSA trial.  Most of the trials were done in marathon and ultra-marathon runners whom we do not see very often in the ED [5-7]. Using a fixed bolus has a number of potential benefits [8-9]:  Efficacy: Ability to reach rapid partial correction hyponatremia Safety: It can limit the risk of overcorrection that can commonly occur with continuous infusion of hypertonic saline No Math: It omits need for calculations Clinical Question: When treating symptomatic hyponatremia what are the risks of overcorrection in patients using either a slow continuous infusion vs. a rapid intermittent bolus of hypertonic saline strategy? Reference: Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia: The SALSA Randomized Clinical Trial. JAMA Intern Med 2021 Population: Patients 18 years of age and older with moderate or severe symptomatic hyponatremia (corrected serum sodium [sNa] of 125 mmol/l or less). Moderate symptoms include nausea, headache, drowsiness, general weakness and malaise. Severe symptoms include vomiting, stupor, seizure, and coma (Glasgow Coma Scale [GCS] score ≤8).  Exclusions: Primary polydipsia; pregnant or breastfeeding; anuria, arterial hypotension, liver disease, uncontrolled diabetes mellitus; or had a history of cardiac surgery, acute myocardial infarction, sustained ventricular tachycardia, ventricular fibrillation, acute coronary syndrome, cerebral trauma, and increased intracranial pressure within 3 months prior to randomization.  Intervention: Rapid intermittent bolus (RIB) groups received 2ml/kg of 3% saline over 20 minutes. Patients were dichotomized into moderate or severe hyponatremia. The severely symptomatic patients had 2 separate boluses delivered initially.

Date: March 31st, 2021 Guest Skeptic: Prof Daniel Fatovich is an emergency physician and clinical researcher based at Royal Perth Hospital, Western Australia. He is Head of the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research; Professor of Emergency Medicine, University of Western Australia; and Director of Research for Royal Perth Hospital. Reference: Toyoda et al. MRI-guided thrombolysis (0.6 mg/kg) was beneficial for unknown onset stroke above a certain core size. THAWS RCT Substudy. Stroke 2021 Case: A 74-year-old man presents to the emergency department after waking up with left sided weakness. He was last seen well when going to bed at 10pm the night before. He has a history of hypertension and dyslipidemia. His medications include an angiotensin-converting enzyme inhibitor and a statin. The NIHSS score is 7. The MRI shows an occlusion of the right MCA-M2, the DWI-ASPECT is 9, and lesion volume is 3.5ml. Background: We have talked about stroke management a number of times recently including SGEM#297 on the reanalysis of ECASS-3 by Alper et al 2020.  The SGEM bottom line was that the "reanalysis of the original ECASS-3 data does not support the potential benefit of tPA given between 3-4.5 hours after onset of stroke symptoms and confirms the known potential harm". There have been 13 foundational trials looking at thrombolysis for acute ischemic stroke. Of the 13, eleven failed to show benefit for their primary outcome and four were stopped early due to harm or futility. Only two RCTs claimed benefit for their primary outcome. Those were ECASS-3 in 2008 and the NINDS trial from 1995. Both of those “positive” studies have been reanalyzed and question the potential efficacy while confirming the potential harm. Dr. Jackson We wrote an article together for the Lown Institute summarizing some of the stroke literature. The question asked was: will it take 50 or 100 years to get the right answer about tPA for acute ischemic stroke? One aspect that we did not address was the newer trials that are using advanced imaging techniques like MRI to extend the window beyond 4.5 hours after the onset of stroke symptoms (Extend NEJM 2019 and ECASS-4: Extend 2016). Both of these trials were stopped early which can introduce additional bias towards efficacy. The majority of patients included in the two trials extending the time window past 4.5 hours would now qualify for endovascular therapy (EVT) clot retrieval. EVT does have more robust evidence for efficacy and safety than systemic thrombolysis. A SRMA was published by Mistry et al Stroke 2017. This included 13 studies, three randomized control trials (25% of all patients) and ten observational studies (75% of all patients). Good neurologic outcome was defined as a modified Rankin Scale (mRS) score of 0-2. The number needed to treat (NNT) was 17. However, there was no statistical difference if you only look at the higher quality RCT data and excluded the lower quality observational data. Yang P et al. published a non-inferiority RCT in NJEM 2020 looking at this issue. The primary outcome was mRS at 90 days and found EVT alone was not non-inferior to EVT plus tPA. Two recent RCTs were published in JAMA investigating this issue. Suzuki et al failed to demonstrate non-inferiority while in contrast Zi et al found EVT alone was non-inferior to EVT plus tPA. These two EVT trials are going to be covered on a future episode of the SGEM in the near future. The trial we are reviewing today is a sub analysis of the THAWS (Thrombolysis for Acute Wake-Up and Unclear-Onset Stroke) randomized control trial of using low dose tPA in patients with symptoms on awaking or unknown time of onset. Clinical Question: Is MRI guided thrombolysis (0.6 mg/kg) beneficial for patients with an unknown stroke onset time? Reference: Toyoda et al. MRI-guided thrombolysis (0.6 mg/kg) was beneficial for unknown onset strok...

Date: March 17th, 2021 Guest Skeptic: Dr. Emil Ejersbo Iversen is an emergency medicine resident at the University Hospital of Zealand, Denmark. He currently serves as Vice-Chair of the Danish Society for Emergency Medicine and Chair of the Young Doctors in Emergency Medicine in Denmark. He has a passion for FOAMed and is the creator of the Danish EM platform www.akutmedicineren.dk. Reference: Schuster et al. Spirometry not pain level predicts outcomes in geriatric patients with isolated rib fractures. J Trauma Acute Care Surg. 2020 Case: A 74-year-old woman who suffered a fall earlier today presents to the emergency department (ED) and is found to have five rib fractures to her right thorax, but no other injury. She is otherwise well, and her vitals are stable, but she is in some pain. Recent guidelines recommend admitting the patient to the intensive care unit (ICU), but the patient is eager to return home to her husband who is also well, and whom she claims will be able to help her. Background: Rib fractures are a common injury among the older population and can potentially lead to life-threatening complications such as pneumonia, pneumothorax or decreased inspiratory capacity. Some recent guidelines recommend admitting patients older than 65 years of age with two or more with rib fractures to an intensive care unit (ICU) or other step-down monitored setting [1]. Currently, patients with three or more rib fractures are often admitted for analgesia and monitoring and subsequently discharged without complications. Recent retrospective studies have suggested that early spirometry may be a useful indicator of prognosis in patients with multiple rib fractures [2]. Identifying patients with a good prognosis that could be safely discharged home with analgesia could potentially avoid unnecessary hospitalization. This would likely lower healthcare costs and decrease the risk of hospital-acquired infections. Spirometry includes metrics such as forced vital capacity (FVC), peak expiratory flow (PEF), forced expiratory volume 1 second (FEV1), and negative inspiratory force (NIF). The PEF has not been demonstrated to be closely correlated with patient outcomes [3]. However, FVC has been shown to correlate with patient outcomes and length of stay (LOS) in patients who have multiple rib fractures [4-5] These studies were limited by their retrospective observational nature. Hand grip strength has also been used to measure overall frailty. GeriEM guru Chris Carpenter has done some work in this area over ten years ago. His team found grip strength was weakly correlated with frailty in older ED patients [6]. Future research should confirm this association and assess the correlation of grip strength with other measures of frailty. Multiple other authors have investigated this simple and inexpensive tool for predicting frailty [7-8]. Clinical Question: Can spirometry testing identify patients 60 years and older with at least three rib fractures who can safely be discharged home from the ED? Reference: Schuster et al. Spirometry not pain level predicts outcomes in geriatric patients with isolated rib fractures. J Trauma Acute Care Surg. 2020 Population: Patients 60 years of age and older admitted to hospital with at least three rib fractures within 24 hours of injury Exclusions: Injury occurred >24hrs before presentation, significant additional musculoskeletal injury or cognitive impairment and able to cooperate with testing Exposure: Spirometry measuring (FVC, FEV1 and NIF) Comparison: Hand grip strength and pain assessment (VAS) Outcome: Primary Outcomes: Discharge disposition and length of stay (LOS) Secondary Outcomes:Mortality, pneumonia, intubation, unplanned transfer to higher level of care and readmission (within 30 days) Authors’ Conclusions: “Spirometry measurements early in the hospital stay predict ultimate discharge home,

Date: March 16th, 2021 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Reference: Westafer et al. Outpatient Management of Patients Following Diagnosis of Acute Pulmonary Embolism. AEM March 2021 Case: You are evaluating a 48-year-old female for pleuritic chest pain. She is low risk by Wells Criteria but PERC Rule positive because of an appendectomy last month. Her d-dimer comes back elevated, so you order a CT-PA to evaluate for pulmonary embolism (PE). The radiologist notes a distal sub-segmental PE on the right. The patient has normal vital signs and no comorbidities. Background: Historically most patients with PEs have been admitted to the hospital in the USA. This is in contrast to Canada where papers in the early 2000 demonstrated the safety of out-patient management of PEs (Kovacs). A study from 2010 showed that half of PE patient from one centre in Ontario were safely being treated as outpatients (Kovacs). Dr. Jeff Kline PE guru, creator of the PERC Rule and Editor-in-Chief of Academic Emergency Medicine, Dr. Jeff Kline, was senior author on a paper that looked at treating VTE with outpatient management using a DOAC (Bean et al AEM 2015). This relatively small study (n=106) reported successfully treating 51% of DVT patients and 27% of PE patients with rivaroxaban (SGEM#126). Literature from the USA reports that 90% of patients diagnosed with PE are admitted (Singer et al 2016). Another study showed less than 10% of PE patients are discharged home from the ED for out-patient therapy (Vinson et al 2017). A couple of international guidelines support the outpatient treatment of ED patients with low-risk PE. This includes the European Cardiology Society (ECS 2019) and the British Thoracic Society (Howard et al 2018). The American College of Emergency Physicians (ACEP) has a clinical policy that addresses this issue (Wolf et al 2018). The ACEP policy give outpatient management of PE patients a Level C recommendation: “Selected patients with acute PE who are at low risk for adverse outcomes as determined by PESI, simplified PESI (sPESI), or the Hestia criteria may be safely discharged from the ED on anticoagulation, with close outpatient follow-up.” PESI (Pulmonary Embolism Severity Index) is a risk stratification tool based upon studies by Donzé et al 2008 and Choi et al 2009.  The PESI consists of eleven criteria with a different number of points awarded for each variable. This can be complicated and there is an online calculator to help (MDCalc PESI Score). The PESI score has been made even easier to use with the creation of the Simplified PESI. It only has six criteria, each has only one point and can also be computed online using MDCalc sPESI. The Hestia Criteria is another scoring system to identify low risk PE patients that could be considered for outpatient PE treatment. Like the PESI score it has eleven criteria and an online calculator (MDCalc Hestia Criteria). If all eleven criteria are negative the patient is low risk with a predicted mortality of 0% and VTE recurrence of 2%. However, if any one of the criteria is positive the patient is not low risk. These patients are not considered eligible for outpatient management based on this score and it is recommended they be admitted for inpatient therapy. Clinical Question: What are the current disposition practices, and outcomes, for patients with PE in US hospitals? Reference: Westafer et al. Outpatient Management of Patients Following Diagnosis of Acute Pulmonary Embolism. AEM March 2021 Population: Patients 18 years of age or older between July 2016 and June 2018 presenting to one of 740 acute care hospitals and receiving a diagnosis of PE based upon ICD-10 codes Exclusion: Patients diagnosed with PE in the previous 90 days, and those patients who expired during the ED visit

Date: March 11th, 2021 Guest Skeptic: Dr. Robert Edmonds is an emergency physician in the US Air Force in Ohio. DISCLAIMER: THE VIEWS AND OPINIONS OF THIS PODCAST DO NOT REPRESENT THE UNITED STATES GOVERNMENT OR THE US AIR FORCE. Reference: Post et al. Ultra-early tranexamic acid after subarachnoid haemorrhage (ULTRA): a randomised controlled trial. Lancet 2021 Case: You’re working a busy evening shift in your community emergency department (ED) when a 58 year old female presents with a rapid onset terrible intensity headache.  She has no significant headache history and you are concerned for subarachnoid hemorrhage so you order a head CT which confirms your suspicions.  You page neurosurgery at the bigger ED in town, and while you wait for the page back, you wonder if giving tranexamic acid (TXA) could help improve the patient’s chances for a good outcome given its effects in other bleeding processes. Background: In the case presented, the woman would qualify using the Ottawa SAH Rule because of the rapid onset of an intense headache and her age. We have discussed the incredible work done by Dr. Jeff Perry and his group in the development of the Ottawa SAH Rule. Jeff was actually on the SGEM as the guest skeptic discussing this clinical decision instrument way back in 2013 (SGEM#48). The Ottawa SAH Rule is to be applied to alert patients older than 15 years of age with new severe non-traumatic headache reaching maximum intensity within one hour. It is not meant for patients with new neurologic deficits, previous aneurysms, SAH, brain tumor, or who have a history of recurrent headaches. This is defined as at least three or more episodes over the course of at least six months. Our SGEM Bottom Line eight years ago was that the Ottawa SAH “Tool” was not ready for prime time to rule out low risk patients from investigations. Fast forward to 2018 and the validation of the Ottawa SAH Rule by Dr. Perry and his group. The results of this prospective observational study were that the clinical decision instrument was 100% sensitive (missed no SAH patients) and 13.6% specific. Dr. Chris Carpenter The guest skeptic for SGEM#201 was Dr. Chris Carpenter, who literally wrote the book on diagnostic accuracy of clinical decision instruments in the ED with Dr. Jesse Pines. The SGEM bottom line from the episode was that the Ottawa SAH Rule needs external validation, a meaningful impact analysis performed, and patient acceptability of incorporating this rule into a shared decision-making instrument before being widely adopted. Dr. Perry did publish a prospective implementation of the Ottawa SAH Rule (Stroke 2019). This article was covered on the SGEM with EM Nerd Dr. Rory Spiegel. The results demonstrated that the Ottawa SAH Rule is highly sensitive (100%) but has very poor specificity (13%). It is unclear how it performs against unstructured clinical judgement or in non-urban tertiary care teaching hospitals (SGEM#283). Another issue the case brings up is whether a CT scan is good enough to rule out a SAH. The debate has historically been about whether or not you need to also get a lumbar puncture on these patients after a non-contrast CT head. Dr. Jeff Perry This brings us back to more work done by Jeff Perry. His team published a prospective cohort study that suggested if you got the CT scan done within six hours of headache onset, it was a third generation CT scanner, and it was read by a neuroradiologist, then you did not need to get an LP to rule out a SAH (BMJ 2011). There were some limitations to this observational study. Another study was done in the UK that tried to address this issue of LP post normal CT. This was covered on SGEM#134. It found that the NNTap (number needed to Tap) to diagnose one aneurysm not identified by CT scan was 250. The final issue the case identified was the use of TXA in treating patients with a SAH.

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...