The Skeptics Guide to Emergency Medicine

Date: May 29th, 2020 Reference: Erramouspe et al. Mortality and Complication Rates in Adult Trauma Patients Receiving Tranexamic Acid: A Single-center Experience in the Post–CRASH-2 Era. AEM May 2020 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: A 44-year-old male presents to your level 1 trauma center by EMS after a motor vehicle collision. He is hypotensive and tachycardic. You suspect abdomen and pelvic trauma and calculate his injury severity score (ISS) to be 22. Your hospital protocol is to give tranexamic acid (TXA) 1g IV over 10 minutes followed by a 1g infusion over eight hours. You wonder what his over-all chance of dying or developing a thromboembolic event when treated with TXA. Background: TXA is synthetic derivative of lysine that controls bleeding by inhibiting fibrinolysis and thus stabilizing clots that are formed.  We have covered TXA as a treatment modality a number of times on the SGEM. The evidence for TXA providing a patient-oriented outcome (POO) has been mixed. It seems to work for epistaxis (SGEM#53 and SGEM#210), failed to demonstrate a decrease in all-cause mortality in post-partum hemorrhage (SGEM#214), and did not result in an improved neurologic outcome in hemorrhagic strokes (SGEM#236). REBEL EM has looked at using TXA for those conditions plus a few others (we will include a table in the show notes). It is unclear if it provides a benefit for gastrointestinal bleeds (GIB). Nebulized TXA shows promise for both post-tonsillectomy bleeding and hemoptysis. However, better studies are needed to confirm these observations. Dr. Anand Swaminathan and I covered the classic CRASH-2 Trial (SGEM#80). This study published in 2010 showed an absolute mortality reduction of 1.5% in adult trauma patients giving a number needed to treat to prevent one death of 67 (Shakur et al. Lancet 2010) CRASH-3 was a well-designed, large, multi-centred randomized placebo controlled trial published in October 2019 (The Lancet). It asked if TXA had a mortality benefit in patients with isolated head trauma (SGEM#270)? While there was a suggestion of benefit in a secondary subgroup analysis, the primary outcome demonstrated no statistical difference in head-injury related mortality with TXA compared to placebo (18.5% TXA vs. 19.8% placebo, RR 0.94 [95% CI 0.86 to 1.02]). One of the limitations to both CRASH-2 and CRASH-3 was the external validity. The majority of sites involved were in middle to low income countries. CRASH-3 had one Canadian site and the USA had no participating centres. Transfusion practices and identification of adverse events may differ in developing countries compared to the USA. Clinical Question: What is the mortality and thromboembolic events in adult trauma patients receiving TXA an American Level 1 Trauma Center? Reference: Erramouspe et al. Mortality and Complication Rates in Adult Trauma Patients Receiving Tranexamic Acid: A Single-center Experience in the Post–CRASH-2 Era. AEM May 2020 Population: Adults (18 years or older) who received TXA after an acute traumatic injury Excluded: Patients who received oral TXA, received it for elective surgery or nontrauma indications, received TXA 8 hours or longer after the injury, and patients with cardiac arrest at time of ED arrival. Intervention: TXA 1g IV over 10 minutes and maintenance infusion of 1g IV over 8 hours Comparison: None Outcome: Primary Outcome: In-hospital mortality Safety Outcome: Thromboembolic event within 28 day Dr. Erramousepe This is an SGEMHOP episode and we are pleased to have both the lead author and senior author on the episode. Dr. Joaquin Erramouspe is a medical doctor, who finished medical school in Uruguay, moved to the USA for further training and research, and now, is working as a researcher at Queensland University of Technology while obtaining his mas...

Date: May 19th, 2020 Reference: Yang P et al. Endovascular thrombectomy with or without intravenous alteplase in acute stroke. NJEM 2020. 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. Case: A 53-year-old previously healthy man presents with 1.5 hours of right sided weakness as well as slurred speech. A rapid bedside assessment gives you a National Institute of Health Stroke Score/Scale (NIHSS) of 9 and you are concerned about a large vessel occlusion (LVO) based on the high NIHSS as well as the presence of both an upper extremity drift and the speech abnormality. 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 alteplase. You wonder if you should give the alteplase while waiting for your neurointerventional team? Background: The issue of thrombolytics for stroke has been debated since at least 1995. This is the year that the famous NINDS trial was published. We cover this as an SGEM classic that all EM physicians should know about on SGEM#70. Our bottom line was that we were skeptical thrombolysis has a net patient-oriented benefit for acute ischemic strokes. We have covered this issue of thrombolysis for acute ischemic stroke a number of times on the SGEM SGEM#29: Stroke Me, Stroke Me SGEM Xtra:Thrombolysis for Acute Stroke SGEM#290: Neurologist Led Stroke Teams – Working 9 to 5 You also had the Legend of Emergency Medicine, Dr. Jerome Hoffman on to reflect upon the last 25 years and the thrombolysis for acute ischemic stroke debate (No Retreat, No Surrender) I also invited my EBM friend, Dr. Eddy Lang onto the SGEM to discuss his perspective on the issue (SGEM Xtra). This led to a pro/con publication in the Canadian Journal of Emergency Medicine (CJEM) tPA should be the initial treatment in eligible patients presenting with an acute ischemic stroke (Milne et al CJEM April 2020). The publication of the MR CLEAN trial in January 2015 changed the face of ischemic stroke care. This was the first study demonstrating a benefit to endovascular treatment of a specific subset of ischemic stroke patients: those with LVOpresenting within sixhours of symptom onset. MR CLEAN was followed by a flurry of publications seeking to replicate and refine treatment as well as expand the window for treatment. The REBEL EM team reviewed this literature back in 2018 and, with the help of Dr. Evie Marcolini, created the below workflow: One major component of LVO management is the use of systemic thrombolytics in patients presenting within the current thrombolytic treatment window prior to endovascular intervention. However, it’s unclear if systemic thrombolytic administration results in better outcomes or if it simply exposes the patient to increased risks at a higher cost. Limited evidence questions the utility of the current approach with thrombolytics plus endovascular therapy (Phan 2017, Rai 2018). There is a clear need for further research into systemic thrombolytics dosing and use. Clinical Question: Is endovascular therapy alone non-inferior to endovascular therapy plus systemic thrombolytics in the treatment of patients with large vessel occlusion strokes presenting within 4.5 hours of onset? Reference: Yang P et al. Endovascular thrombectomy with or without intravenous alteplase in acute stroke. NJEM 2020. Population: Adult patients (18 years of age or older) presenting within 4.5 hours of ischemic stroke symptom onset and with cerebral vascular occlusion on CT angiography of the intracrania...

Date: May 18th, 2020 I was asked to participate in a debate regarding the issue of Masks4All in Canada by the people involved in the COVID Information for Canadian Physicians Facebook group. This is a private group ~22,000 physicians, residents, students and nurse practitioners from around the world. Dr. Joe Vipond I was reluctant to participate but was convinced after having a good conversation with the organizers and Dr. Vipond. They assured me it would be respectful, focus on the evidence and be an educational experience for the audience. These are stressful times and we all want the best recommendation for patients, based on the best evidence to ensure community well-being. Arguing for the affirmative position was Dr. Joe Vipond. He is an emergency physician at the Rockyview General Hospital and a clinical assistant professor at the University of Calgary. He has generously made available his notes from the debate that include links to more information. I argued against the resolution. This does not mean I am against wearing a cloth mask in public. Those who know my not so secret identity (BatDoc) know that I am often seen in public wearing a mask. This is not the type of mask Dr. Vipond and I were debating. We were not talking about wearing medical masks, surgical masks, N95 masks or respirators by healthcare providers on the front lines of COVID19. The debate also did not include symptomatic people or those caring for high-risk people. We were only debating the issue of universal cloth Masks4All in public. To be very clear, I am not anti-mask wearing in public. My position is "it all depends" as taught by my evidence-based medicine (EBM) mentor Dr. Andrew Worster from BEEM.  I am just not in favour of a mandatory universal Masks4All in public in Canada. You can watch the Mask4All debate on YouTube. Resolution: Be it resolved that a mandatory universal mask for all to prevent transmission of COVID19 be recommended for Canadians. Dr. Kashif Pirzada We were each given four minutes for an opening statement, three minutes for a rebuttal, four more minutes for a second affirmative statement and finished with three minutes for another rebuttal and closing statement. We had two moderators for this debate. Dr. Kashif Pirzada is an emergency physician in Toronto with an interest in startups and innovation.  He is also a co-founder of Conquer-Covid19, a charity that sources personal protection equipment for frontline health workers. Dr. Jennifer Kwan Dr. Jennifer Kwan is a family physician in Burlington, Ontario. She is known for COVID19 data visualizations on Twitter (@jkwan_md) along with the HowsMyFlattening team, and is an advocate for #Masks4Canada and personal protection equipment donations with Halton Regional Chinese Canadian Association. I am not against wearing a cloth mask in public. My position is that I am not convinced that a mandatory Masks4All in public by people that are practicing physical distancing will prevent transmission of clinical disease (COVID19). This is an important distinction. Dr. Samir Grover Questions on the Facebook feed were moderated by Dr. Samir Grover. He is an associate professor and program director for gastroenterology at the University of Toronto. Kashif and Samir have a podcast about COVID-19 called "The Medicine Club" which can be accessed on Twitter @TheMedClubTO It is important in any discussion to be clear on the terms being used. Mandatory: Required by a law or rule : OBLIGATORY. Universal: Including or covering all or a whole collectively or distributivity without limit or exception. Public: All public places (not to private places) Clinical Disease: There is a difference between a DOO (Disease Oriented Outcome- detection of COVID19 RNA) and a POO (Patient-Oriented Outcome - clinical disease). As a clinician, I am more interested in POOs and less interested in  DOOs.

Date: May 9th, 2020 Guest Skeptic: Dr. Sean Moore is an Assistant Professor at the Northern Ontario School of Medicine (NOSM), Chief of Emergency Services at Lake of the Woods Hospital in Kenora, Medical director with Ornge, and Associate Medical Director with CritiCall Ontario. CAEP Town Hall We had the pleasure of presenting for the Canadian Association of Emergency Physicians (CAEP) COVID-19 Town Hall this week.  CAEP is the national voice of emergency medicine (EM) in Canada and provides continuing medical education, advocates on behalf of emergency physicians and their patients, supports research and strengthens the EM community. In co-operation with other specialties and committees, CAEP also plays a vital role in the development of national standards and clinical guidelines. Our CAEP COVID-19 Town Hall presentation is available to watch on the CAEP website. It has also been uploaded to CAEP's YouTube channel. All of the the CAEP COVID-19 Town Halls talks are available free open access. Copies of our slides can be downloaded at this link. Dr. Sean Moore Dr. Moore and I were asked to speak about the treatments being used for COVID-19. In this global pandemic, clinicians and researchers have been throwing multiple different treatments at this new corona virus hoping something will work. This includes things like: Azithromycin, Steroids, Famotidine, IL-6 inhibitors, Chloroquine, Hydroxychloroquine, Remdesivir, Vitamin C, and Zinc.   We narrowed our presentation down to five treatments and the evidence behind those treatments. These are listed below with links to the references mentioned in the presentation. Chloroquine / Hydroxychloroquine Dr. Didier Raoult Gautret et al. Clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 COVID-19 patients with at least a six-day follow up: A pilot observational study. Travel Med Infect Dis. April 11th, 2020 Tang et al. Hydroxychloroquine in patients with COVID-19: an open-label, randomized, controlled trial. MedRxIV April 14th, 2020 Chowdhury et al. A Rapid Systematic Review of Clinical Trials Utilizing  Chloroquine and Hydroxychloroquine as a Treatment for COVID‐19. AEM May 2020. We cannot recommend hydroxychloroquine or chloroquine based on the available evidence. Steroids Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. 2020 Mar 28. Steroids Wilson et al. COVID‐19: Interim Guidance on Management Pending Empirical Evidence. From an American Thoracic Society‐led International Task Force. Thoracic April 3rd, 2020 Villar et al. Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial. Lancet Resp Med Feb 7th, 2020 Wu et al. Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Int Med March 13th, 2020 We cannot recommend the use of steroids outside of an RCT. However, steroids should be considered when patients have other indications like COPD or asthma. Remdesivir Grein et al. Compassionate Use of Remdesivir for Patients with Severe Covid-19. NEJM April 10th, 2020 Wang et al. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. The Lancet April 29th, 2020 Fauchi A. Adaptive COVID-19 Treatment Trial (ACTT). Press Conference April 29th, 2020 We cannot recommend the routine use of remdesivir based on the available evidence. Convalescent Plasma Convalescent plasma is being investigated but there is very little information on this treatment modality. Currently the CONCOR Trial is underway in Canada using 200-500 ml of plasma. Researchers from across the country are involved including Drs. Donald Arnold,

Date: April 24th, 2020 Reference: Watanabe et al. Is Use of Warning Lights and Sirens Associated With Increased Risk of Ambulance Crashes? A Contemporary Analysis Using National EMS Information System (NEMSIS) Data. Annals of Emergency Medicine. July 2019 Guest Skeptic: Dr. Robert Edmonds is an emergency physician in the US Air Force in Virginia.  This is Bob’s eleventh visit to the SGEM. Disclaimer: The views and opinions of this podcast do not represent the United States Government or the US Air Force. Case:You are visiting with your father, a 64-year-old overweight man with hypertension.  He describes significant pain in his chest upon awakening and tells you to call an ambulance.  The EMS crew arrives and performs a 3 lead EKG that does not show an ST elevated myocardial infarction. They prepare to load your father into the ambulance, and since you’re his only child and he’s a talker, he mentions you’re an emergency physician.  The crew then asks if you want them to transport your father Code 3 with full lights and sirens. Background: The use of warning lights and sirens in ambulances is fairly widespread. Their use is associated with marginally faster response and transport times (7). Several studies have found ambulance crashes occurring while lights and sirens are used to have a higher injury rate, and a majority of fatal ambulance crashes involve their use (12-15). EMS agencies have varying guidelines on when to use lights and sirens, and the amount of time saved with lights and sirens is approximately 1-3 minutes (REF).  This means the intervention is likely unhelpful for the patient in many transports. Clinical Question: What is the association between warning lights and sirens use by EMS and crash-related delays? Reference: Watanabe et al. Is Use of Warning Lights and Sirens Associated With Increased Risk of Ambulance Crashes? A Contemporary Analysis Using National EMS Information System (NEMSIS) Data. Annals of Emergency Medicine. July 2019 Population: All dispatches of a transport-capable ground EMS vehicle to a 911 emergency scene from the 2016 National EMS Information System, both the response to the scene and the transport from the scene. Excluded: Interfacility transfers, intercepts, medical transports, and standbys; responses by nontransport or rescue vehicles, mutual aid activations, and supervisor responses; and events documented as responses or transports by rotor-wing or fixed-wing air-medical services. Intervention: Use of lights and sirens Comparison: No lights and sirens Outcome: Crash-related delay (proxy for EMS vehicle crash) Authors’ Conclusions: “Ambulance use of lights and sirens is associated with increased risk of ambulance crashes. The association is greatest during the transport phase. EMS providers should weigh these risks against any potential time savings associated with lights and sirens use.” 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? Yes Was the outcome accurately measured to minimize bias? Yes/No Have the authors identified all-important confounding factors? Yes Was the follow up of subjects complete enough? Yes How precise are the results/estimate of risk? Adequate Do you believe the results? Yes Can the results be applied to the local population? Yes Do the results of this study fit with other available evidence? Yes Results: The 2016 NEMSIS database contained 20.4 million 911 dispatches of ground EMS. There was a total of 2,539 crash-related delays. Key Result: There was a greater odds ratio of crashing with the use of lights and sirens. 1) Reporting Bias: The authors mention how the study is entirely dependent on crash related...

Date: April 21st, 2020 Reference: Juergens et al. Effectiveness of emergency physician determinations of the need for thrombolytic therapy in acute stroke. Proc Baylor Univ Med Center Oct 2019 Guest Skeptic: Dr. Chuck Sheppard is an attending Emergency Department Physician at Mercy Hospital in Springfield, Missouri and the medical director for Mercy Life Line air medical service.  He has been practicing in Emergency Medicine for over 40 years and involved in EMS services for over 30 years. Case: 56-year-old female with sudden onset of left arm and leg weakness with slurred speech presents to the emergency department (ED). She was last seen well two hours prior. Her past medical history includes hypertension and type II diabetes. She is not on any anticoagulation except ASA. There is no previous history of stroke. The neurology led stroke team is not available and you wonder if that will affect her outcome. Background: Treatment for acute ischemic stroke has been debated between neurologists and emergency physicians for years now. A recent PRO/CON debate on the subject was published in CJEM April 2020 with Dr. Eddy Lang and myself. It was the legend of emergency medicine, Dr. Jerome Hoffman that really raised the concern about the lack of evidence for using thrombolytics in acute ischemic stroke. He was interviewed on an SGEM Xtra segment called No Retreat, No Surrender. We have covered acute ischemic stroke many times on the SGEM. SGEM#29: Stroke Me, Stroke Me SGEM#70: The Secret of NINDS SGEM Xtra:Thrombolysis for Acute Stroke SGEM Xtra: Walk of Life SGEM#269: Pre-Hospital Nitroglycerin for Acute Stroke Patients? Clinical Question: Does the presence of a neurologist led stroke team affect the likelihood of receiving tPA and does that improve a patient-oriented outcome? Reference: Juergens et al. Effectiveness of emergency physician determinations of the need for thrombolytic therapy in acute stroke. Proc Baylor Univ Med Center Oct 2019 Population: All patients presenting to the ED meeting stroke activation criteria Intervention: Neurologist led stroke team Comparison: No neurologist led stroke team Outcomes: Primary Outcome: Rate of tPA administration Secondary Outcomes: Door-to-needle times, modified Rankin Scale (mRS) at discharge, change in National Institutes of Health Stroke Scale (NIHSS), and discharge disposition Authors’ Conclusions: “Emergency physicians administered significantly less thrombolytics than did neurologists. No significant difference was observed in outcomes, including mRS and admission-to-discharge change in NIHSS. 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? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Precise Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Results: There were 415 stroke activations during the study period (Jan 1, 2015 to June 30, 2016). Of those activations, 153 (37%) were managed by the neurologist led team and 262 (63%) were treated by emergency physicians. The median age was early 60’s with slightly more female patients in the cohort. Three-quarters arrived by EMS and the median NIHSS score was 7 for the EM physicians and 6 for the neurologists. The diagnosis was hemorrhagic stroke (~10%), ischemic stroke (~70%), neurological/psychiatric (~15%) and other (~5%). Key Result: Neurologists gave tPA 13% more often than EM physicians

Date: April 9th, 2020 Reference: Kline et al. Randomized trial of therapy dogs versus deliberative coloring (art therapy) to reduce stress in emergency medicine providers. AEM April 2020 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com Case: It has been a hard shift. You wish you could say “uncharacteristically”, but recently all your shifts in the emergency department have felt a little hard. The increased workload due to COVID-19 hasn’t been helping. You sit down to chart after a difficult resuscitation, and the charge nurse, seeing that you look a little stressed, asks if you would like to take a break to play with a dog. Background: Medicine is an incredibly rewarding profession. However, it is undeniably marked by significant levels of stress. Reports of burnout are high across medicine, and even higher in emergency medicine (1,2). A study of USA physicians showed that they had more than  50% with at least one symptom of burnout. Emergency physicians reported the highest prevalence of burnout at around 70% (3). Burnout is associated with a loss of empathy and compassion towards patients, decreased job satisfaction, and shorter careers in medicine (4,5). It has also been associated with negative impacts on patient care including self-perceived medical error (6), risk of medical errors (7), and quality of care (8,9). We have covered burnout a few times on the SGEM including my own personal experience of being on the edge of burnout: Five Tips: To Avoid Emergency Medicine Burnout SGEM#178:Mindfulness – It’s not Better to Burnout than it is to Rust SGEM Xtra: On the Edge of Burnout ACEM18 SGEM Xtra: CAEP Wellness Week 2019 YouTube: Being on the Edge of Burnout One Year Later There is some prior literature that exposure to animals decreases stress (10,11). Theoretically, time spent deliberately coloring as a mindfulness practice could also decrease stress (12). Therefore, these authors designed a prospective, randomized trial comparing the effects of dog therapy, deliberate coloring, and control on stress levels for emergency department providers (13). Clinical Question: Does dog therapy result in lower perceived stress than deliberate coloring or control when applied as a break during an emergency medicine shift? Reference: Kline et al. Randomized trial of therapy dogs versus deliberative coloring (art therapy) to reduce stress in emergency medicine providers. AEM April 2020 Population: Emergency care providers, including nurses, residents, and physicians, from a single center emergency department. Exclusions: Dislike, allergy, fear, or other reason not to interact with a therapy dog. Intervention: There were two interventions, which occurred approximately midway through the provider’s shift. Dog therapy consisted of an interaction with a therapy dog, which providers could pet or touch if they wished. The coloring group was provided with three mandalas to choose to color and a complete set of coloring pencils. Both of these activities occurred in a quiet room, physically separated from the clinical care area, with no electronic devices, telephone, window, or overhead speaker. Comparison: A convenience sample of providers that were not offered any break. Outcomes: Primary Outcomes: There were two primary outcomes. The first was a self-assessment of stress using a visual analogue scale. The second was a 10-item validated perceived stress scores, altered to focus providers on the past several hours rather than months, as it was originally designed. These were both measured at the beginning of the shift, about 30 minutes after the intervention, and near the end of the shift. Secondary Outcomes: They looked also looked at a FACES scales as a measure of stress, and provider cortisol levels. Dr. Jeff Kline This is an SGEMHOP episode which means we have t...

Date: April 4th, 2020 It has been just over a year since Dr. Salim Razaie (REBEL EM) and I stepped into the ring for a boxing matched theme debate in Sydney, Australia. It was the EBM rumble down under for SMACC 2019. How the world has changed with COVID19. You can see the original SGEM Xtra post from March 2019. It has more details about each issue we discussed and our slides. This is being posted now because a high-definition video is available on YOUTUBE for those who could not attend or for those who want to watch this epic match again.  It is an example of mixing education and entertainment for some great knowledge translation. You can also listen to an edited version on the SGEM iTunes feed. We went four rounds punching and counter punching arguments about critical care controversies. The REBEL took the fight to the Skeptic. He supported his position with a flurry of publications.. The skeptic responded with his own citations. As with boxing, the champion must be beat, the challenger cannot win with a draw and there were no knockouts in the match. The skeptic fell back on the burden of proof and asserted he had not been convinced to accept any of the REBELs claims. The ultimate winner was the patient. We both agree that the patient deserves the best care, based on the best evidence. Four Critical Care Controversies: Round#1: Mechanical CPR - SGEM#136 Round#2: Epinephrine in Out-of-Hospital Cardiac Arrest (OHCA) - SGEM#238 Round#3: Stroke Ambulances with CT Scanners Round#4: Bougie for First Pass Intubation - SGEM#271 Conclusion/Winner - Use EBM and the winner is the patient We appreciate Dr. Justin Morgenstern (First10EM) being the impartial referee for this contest.  He ensured it was a good clean fight about the evidence and did not allow us to punch each other below the belt (in the p-value). We encourage you to read the primary literature yourself. There are multiple links provided to the relevant studies in the original post. The literature should guide your care but it should not dictate your care. You will still need to apply your good clinical judgment and ask the patient what they value and prefer. Thank you to all the students who supported me in the skeptical corner of the ring. I hope it encouraged their critical thinking skills. Not just to accept anything because their supervisor/attending told them. They also made sure I had plenty of maple syrup between the rounds. The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. The ultimate goal is for patients get the best care, based on the best evidence.  REMEMBER TO BE SKEPTICAL ABOUT ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

Date: March 27th, 2020 Reference: Secko et al. Musculoskeletal Ultrasonography to Diagnose Dislocated Shoulders: A ProspectiveCohort. Ann Emerg Med Feb 2020 Guest Skeptic: Dr. Tony Zitek is an Emergency Medicine physician in Miami, Florida. He is an Assistant Professor of Emergency Medicine for Florida International University and Nova Southeastern University, and Tony is the Research Director for the Emergency Medicine residency program at Kendall Regional Medical Center. DISCLAIMER: THIS IS NOT AN EPISODE ON COVID19 Here are five websites to get up-to-date information about COVID19: Centre for Disease Control and Prevention Health Canada Public Health Ontario World Health Organization Food and Drug Administration Case: An 18-year-old, previously healthy male presents to the emergency department after sustaining an injury to his right shoulder after colliding with another player during a football game.  On examination, there is a loss of the normal rounded appearance of the shoulder.  You suspect the patient may have a shoulder dislocation.  He has no history of shoulder dislocations in the past.  Will you order an x-ray or perform a point-of-care ultrasound to confirm the diagnosis? Background: Despite shoulder dislocations being a very common injury presenting to the ED, it has only been covered once on SGEM#121. This episode tried to answer whether it was better for the shoulder to be immobilized in an external or internal rotation post-reduction. We still don’t know if one position is superior to another. Emergency physicians frequently perform pre- and post-reduction x-rays for patients with shoulder dislocations.  However, some prior studies suggest that the routine performance of these x-rays may not be necessary, especially in patients with recurrent dislocations who have not sustained any direct trauma [1-2]. Point-of-care ultrasound (POCUS) has previously been studied for the use of the diagnosis of shoulder dislocations with most prior data suggesting that POCUS is highly sensitive and specific for the diagnosis of shoulder dislocations [3-4]. As with other applications of POCUS, the use of ultrasound for shoulder dislocations has the potential to reduce the time to diagnosis, reduce radiation exposure, and lower cost.  However, prior studies about the use of POCUS for shoulder dislocations have used a variety of scanning techniques and some have utilized as few as 2 sonographers [4].  One study found only a 54% sensitivity for identifying persistent dislocation after a reduction attempt [5]. Clinical Question: What is the diagnostic accuracy of point-of-care ultrasound for the diagnosis of shoulder dislocations as compared with x-ray? Reference: Secko et al. Musculoskeletal Ultrasonography to Diagnose Dislocated Shoulders: A Prospective Cohort. Ann Emerg Med Feb 2020 Population: Adult patients with suspected shoulder dislocations who presented to one of two EDs when a study investigator was present. Exclusion: Patients with multiple traumatic injuries, decreased level of consciousness, or hemodynamic instability. Intervention: Pre- and post-reduction POCUS utilizing a posterior approach in which they traced the scapular spine towards the glenohumeral joint. The POCUS technique they used is basically as follows --- the sonographer palpates the spine of the scapula, and then places the ultrasound probe directly over the scapular spine. The study protocol allowed the sonographer to choose either a linear or curvilinear probe. The sonographer then follows the scapular spine laterally until the glenoid and humerus are identified. Using this technique, the glenoid and humeral head both look like hyperechoic semicircles. They should be very close to each other, and if not, that indicates a shoulder dislocation. After assessing for dislocation, the sonographer can assess for fracture by fanning the probe from a cephalic...

Date: March 18th, 2020 Reference: Ebell et al. Accuracy of Biomarkers for the Diagnosis of Adult Community-Acquired Pneumonia: A Meta-analysis. AEM March 2020 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. Disclaimer: This is Not an Episode on COVID19 Things are changing quickly with the COVID19 pandemic.  Here are five basic things you can do to help flatten the curve as of this blogpost: Wash your hands well and often (at least 20 seconds with soap and water) Try not to touch your face Physically isolate yourself from large gatherings but stay socially connected electronically Cough into your elbow or use a tissue, throw the tissue out and go to #1 Disinfect objects or surfaces with a regular household cleaning wipe or spray If you are unsure of what to do or for more information, here are five websites to get up-to-date information about COVID19: COVID19 Centre for Disease Control and Prevention Health Canada Public Health Ontario World Health Organization Food and Drug Administration   Case: A 47-year-old healthy, non-smoker, presents to the emergency department (ED) with a productive cough, fever and says it has been difficult to breathe for the past four days. He appears well, with a temperature of 38.7 Celsius, heart rate of 90 beats per minute, respiratory rate of 20 breaths per minute and room air oxygen saturation of 91%. On auscultation you hear some fine crackles at the bases. You wonder if there is value in ordering any bloodwork, particularly a biomarker such as C-reactive protein (CRP), procalcitonin (PCT) or a complete blood count for white blood cell count (WBC) in addition to doing a chest x-ray (CXR). Background: Community-acquired pneumonia (CAP) is a significant source of morbidity and mortality in adults (1,2).  We have covered this issue a couple of times on the SGEM. One episode looked at β-Lactam monotherapy vs. β-Lactam plus macrolide combination therapy in adult patients admitted to hospital with moderately severe CAP (SGEM#120). This study supported the combination therapy in these patients. More recently, we looked at the question of whether steroids improve morbidity and mortality in patients admitted to hospital with CAP (SGEM#216). The bottom line was that corticosteroids appear to improve mortality and/or morbidity in patients admitted to hospital with CAP. There is evidence that an accurate diagnosis of CAP may lead to earlier treatment while avoiding unnecessary antibiotics for patients who do not have CAP. Pervious research has demonstrated that individual signs and symptoms have limited accuracy in the diagnosis of CAP. The diagnosis of CAP is usually based on an abnormal chest x-ray in a patient with signs and symptoms of a lower respiratory tract infection (3,4). White blood cell count (WBC), C-reactive protein (CRP), and procalcitonin are biomarkers associated with an increased likelihood of CAP. There are also clinical prediction rules that include CRP for the diagnosis of CAP (5,6). Procalcitonin is another potential biomarker that may help in the diagnosis of bacterial pneumonia (7).  Guidelines such as the National Institute for Health and Care Excellence (NICE) recommend the use of CRP at the point of care to reduce inappropriate antibiotic when diagnosing CAP (8) These various biomarkers are readily available in the ED setting in the US, as well as in the primary care setting in other countries in Europe. The study we are reviewing on this SGEM episode performs an updated systematic review and meta-analysis (SRMA) of the diagnostic accuracy of biomarkers for CAP. Clinical Question: What is the accuracy of biomarkers for the diagnosis of community acquired pneumonia? Reference: Ebell et al.