The Skeptics Guide to Emergency Medicine

Date: October 22nd, 2019 Reference: Iyengar R et al. The Effect of Financial Incentives on Patient Decisions to Undergo Low-value Head Computed Tomography Scans. AEM October 2019. Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com Case: A 21-year-old comes into the emergency department after being knocked unconscious while playing rugby. The patient is now feeling great, or as they say in New Zealand “sweet as”. He had no pain, nausea, or neurologic symptoms. His exam is normal. You aren’t worried, but his dad is the coach of the American national rugby team and says that his players always get a CT when this happens. You wonder what factors might influence a patient’s preference for imaging? CT Scanner Background: The CT scan is arguably one of the most important pieces of diagnostic technology that we use in emergency medicine. It allows for incredibly rapid identification of a myriad of life-threatening conditions. However, likely because it is such a valuable tool, there seems to be little doubt that we overuse it. For example, one study that looked retrospectively at all head CTs ordered for trauma concluded that more than 1/3 were unnecessary based on the Canadian CT head rule [1]. Not only does unnecessary testing reduce efficiency and add costs, it also directly harms patients with unnecessary radiation [2]. Many imaging decisions are obvious – the patient either clearly requires or clearly does not require imaging. One way to decrease CT scans of the head is to use a clinical decision instrument like the Canadian CT Head Rule (CCHR). The SGEM covered the classic paper on the CCHR by the Legend of Emergency Medicine Dr. Ian Stiell on SGEM#106. We also recently reviewed a paper that looked at increasing the CCHR age criteria from 65 years of age to 75 years of age (SGEM#266). The bottom line was that this paper opens the door for further research to try to narrow the criteria in the CCHR to further reduce unnecessary head CT imaging in the emergency department. However, further, high quality prospective studies are required prior to clinical application. There is a great deal of uncertainty in emergency medicine, which leaves a sizeable number of patients in a grey zone – where harms and benefits are closely matched, qualitatively different, or just unknown. For these patients, shared decision making is probably the best route forward. Even when it seems clear to the physician that imaging isn’t required, we can be met with resistance from our patients. In addition, if we are working in a zero-miss culture, we may be more likely to order CT scans that are not medically necessary. Thus, it is important to know what factors influence patients’ decision to undergo CT. This study by Iyengar and colleagues examines the impacts of financial incentives, as well as varying levels of risk and benefit, on patient preference for CT imaging in the setting of low risk head injury [3]. Clinical Question: Do financial incentives, together with potential risk and potential benefit information, influence patient preference for diagnostic testing? Reference: Iyengar R et al. The Effect of Financial Incentives on Patient Decisions to Undergo Low-value Head Computed Tomography Scans. AEM October 2019. Population: A convenience sample of adult patients presenting to the University of Michigan emergency department. Exclusions: Patients with chest pain or head trauma (because those were the conditions in the hypothetical cases presented). They also excluded patients with altered mental status, with contact precautions, or in resuscitation bays. Intervention and Comparison: Patients were all presented with a hypothetical low risk head trauma scenario. The scenario was designed such that the Canadian Head CT rule suggests against imaging. Three aspects of the scenario were randomized:

Date: October 17th, 2019 Reference: Driver et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation. A Randomized Clinical Trial. JAMA May 2018 Guest Skeptic: Missy Carter, former City of Bremerton Firefighter/Paramedic, currently a physician assistant practicing in emergency medicine in the Seattle area and an adjunct faculty member with the Tacoma Community College paramedic program. Case: You are preparing for a rapid sequence intubation in a patient suffering from respiratory distress. While doing your airway assessment you notice some difficult airway characteristics (obese patient with a small mouth opening). In the past you’ve had failed first pasts attempts on a similar patient and used a bougie as your back up device. You wonder if this time you would be more successful using the bougie for your first attempt. Background: We have covered airway a number of times on the SGEM. This has included supraglottic airways for OHCA (SGEM#247), POCUS for confirming endotracheal tube placement (SGEM#249) and non-invasive positive pressure ventilation for OCHA (SGEM#96) just to name a few. However, we have never covered the issue of using a bougie for intubation.  For many years the bougie has been considered a back up or “rescue” airway tool and only pulled out after one or even several failed intubation attempts. Many studies have shown that multiple intubation attempts can increase mortality and morbidity, so we are always striving to increase our first pass intubation success rates to improve patient care. Clinical Question: Does using a bougie increase first pass intubation success? Reference: Driver et al. The Bougie and First-Pass Success in the Emergency Department. Annals of Emergency Medicine 2017 Population: Adult patients (age > 17 years) who underwent intubation in the emergency department Excluded: Patients with missing videos that recorded the intubation, cases in which a bougie was used with a hyper angulated video laryngoscope blade (GlideScope) or were intubated before arrival to the emergency department Intervention: Bougie with Macintosh or CMAC laryngoscope Comparison: Intubation with endotracheal tube and stylet Outcome: Primary Outcome: First-pass success rates Secondary: Duration of attempts, hypoxia and esophageal intubations Authors’ Conclusions: “Bougie was associated with increased first-pass intubation success. Bougie use may be helpful in ED intubation.” 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? Yes Was the follow up of subjects complete enough? Yes How precise are the results? Fairly precise given the small sample size 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 Key Results: There were 543 patients included in this cohort. The median age was in the late 40’s and more than two-thirds were male. The vast majority (~95%) of the intubations were performed by a senior resident. First-pass success was greater with than without bougie Primary Outcome: First-pass success 95% with bougie vs. 86% without bougie Absolute difference 9% (95% CI; 2% to 16%) Secondary Outcomes:  Median first-attempt duration was higher with than without bougie (40 seconds vs. 27 seconds) with a difference of 13 seconds (95% CI; 11 to 16). Hypoxia 17% with and 13% without bougie

Date: October 14th, 2019 Reference: CRASH-3 Trial Collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. The Lancet October 2019 Guest Skeptic: Dr. Salim Rezaie currently works as a community emergency physician at Greater San Antonio Emergency Physicians (GSEP), where he is the director of clinical education. He is also the creator and founder of REBEL EM and REBEL Cast, a free, critical appraisal blog and podcast that tries to cut down knowledge translation gaps of research to bedside clinical practice. Case: A 42-year-old man falls off a backyard deck. He arrives at the emergency department via EMS with a Glasgow Coma Scale (GCS) score of 10 and both pupils reactive. He is hemodynamically stable and sent for a STAT head CT. It demonstrates a traumatic intracranial hemorrhage. You wonder if you should give tranexamic acid (TXA) while you wait for neurosurgery to call you back. Background: TXA is a synthetic derivative of lysine that inhibits fibrinolysis and thus stabilizing clots that are formed. We have covered TXA as a treatment for bleeding 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, fails to cause a decrease in all-cause mortality in post-partum hemorrhage, does not demonstrate an improved neurologic outcome in hemorrhagic strokes but does have 1.5% absolute mortality reduction in adult trauma patients. Epistaxis – SGEM#53 and SGEM#210 Post-Partum Hemorrhage – SGEM#214 Stroke due to Intracranial Hemorrhage – SGEM#236 CRASH-2 Trial – SGEM#80 REBEL EM has also looked at TXA for those conditions plus a few others. 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. Zehtabchi et al published a SRMA of TXA for traumatic brain injuries (TBI). They found only two high-quality randomized control trials with 510 patients having TBI that met inclusion criteria. The results were no statistical difference in in-hospital mortality or unfavorable neurologic functional status. However, there was a statistical reduction in intracranial hematoma expansion size with TXA compared to placebo. Clinical Question: Does TXA have mortality benefit in patients with isolated head trauma? Reference: CRASH-3 Trial Collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. The Lancet October 2019 Population: Adult patients 16 years and older with traumatic brain injuries with GCS score of 12 or lower or any intracranial bleed on CT scan and no extracranial bleeding treated within 3 hours of injury Excluded: Age less than 16 years of age, extracranial bleeding, or greater than 8 hours since injury (limited to greater than 3 hours from September, 2016) Intervention: TXA 1g infused over 10 minutes followed by an infusion of another 1g over 8 hours Comparison: Saline placebo Outcome: Primary Outcome: Head injury-related deaths within 28 days Secondary Outcomes: Early head injury deaths (<24hrs), all-cause and cause specific mortality, disability, vascular occlusive events (myocardial infarctions, stroke, venous thromboembolism), seizures, complications, neurosurgery, days in the intensive care unit (ICU), adverse events within 28 days and subgroup analyses. Authors’ Conclusions: “Our results show that tranexamic acid is safe in patients with TBI and that treatment within 3 h of injury reduces head injury-related death. Patients should be treated as soon as possible after injury.”

Date: October 9th, 2019 Guest Skeptic: Dr. Hasan Sheikh is an emergency and addictions physician in downtown Toronto and a graduate student studying public policy at the Harvard Kennedy School of Government. This is an SGEM Xtra and the result of Dr. Sheikh's recent Canadian Association of Emergency Physicians (CAEP) Position Statement on Dental Care in Canada. It calls for the expansion of publicly funded and publicly delivered dental care in Canada. The Canadian Association of Emergency Physicians believes that every Canadian should have affordable, timely, and equitable access to dental care. You can down load a PDF of the CAEP Position Statement on Dental Care in Canada. For other positions statements from CAEP click on this LINK. You can also listen to the SGEM Xtra podcast on iTunes to hear us discuss the following: Dr. Sheikh's elevator pitch summarizing the position statement The Association between oral health and overall health How the current dental care system in Canada is inconsistent with the principles of the Canada Health Act A brief description on the history of dental care in Canada and the current situation How the current dental system impacts the individual How the current dental system impacts the emergency department What are the organizations that support public dental care in Canada What are the barriers to adopting a public dental care system How CAEP thinks the goal of affordable, timely and equitable access to dental care will be achieved CAEP Position Statement on Dental Care in Canada Executive Summary: Oral health is an important part of an individual’s overall health; however, dental care is not included in the Canadian public health care system. Many Canadians struggle to access dental care, and six million Canadians avoid visiting the dentist each year due to cost (1). The most vulnerable groups include children from low income families, low income adults, seniors, indigenous communities, and those with disabilities (1–5). The lack of affordable, equitable, and accessible dental care puts undue strain on Emergency Departments across the country, as patients desperately seek the care of a physician when they actually need the care of a dental professional(6). Emergency physicians do not have the same expertise or equipment as dentists, and in most cases are only able to provide temporary symptom relief. This results in an increased reliance on prescription opioids that would otherwise be unnecessary if patients could access the dental care they required. The Canadian Association of Emergency Physicians supports the expansion of publicly funded dental care in Canada, starting with the most vulnerable groups including children, low-income adults, and seniors. The Canadian Association of Emergency Physicians also supports the expansion of publicly delivered dental care in Canada via Community Health Centres, Aboriginal Health Access Centres, and Public Health Units, given the failures of the private sector model and the preferences of those who currently have the most difficulty accessing care (1,7). Oral Health and Overall Health Oral health is a critical component of an individual’s overall health. There are a number of associations between poor oral health and poor general health, including cardiovascular disease, diabetes, having a low birth weight infant, erectile dysfunction, osteoporosis, metabolic syndrome, and stroke (8–15). There is increasing evidence, however, that poor oral health can actually cause or worsen other general medical conditions due to chronic inflammation (16). Treating periodontal disease in diabetics has been shown to improve blood sugar control to a similar degree as adding another oral diabetes medication (17). Providing oral care in long-term care settings has been shown to reduce the risk of developing aspiration pneumonia (18).

Date: September 25th, 2019 Reference: Bath PM et al. Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomized, sham-controlled, blinded, phase 3 trial. The Lancet March 2019. Guest Skeptic: Clay Odell is a Paramedic/RN for New London Hospital EMS in New Hampshire, USA which provides 9-1-1 coverage and Mobile Integrated Healthcare for seven rural communities. He’s been involved in EMS for over 30 years in a variety of roles and is a strong advocate for evidence-based EMS protocols. Case: Your ambulance responds to a 9-1-1 call for a 75-year-old male experiencing abrupt onset of left sided weakness. You arrive to find the patient awake and alert, with a facial droop, slurred speech and left-sided arm drift (FAST-ED score = 3). He has a history of hypertension. His vital signs are heart rate 90 beats per minute, blood pressure 162/96 mmHg, respiratory rate 14 breaths per minute, SpO2 96% on room air, capillary blood glucose 120 mg/dl (6.7 mmol/L). His 12-lead ECG shows a normal sinus rhythm without ST abnormality or ectopy. While preparing for transport you contemplate administering nitroglycerin due to the likelihood of stroke. Background: We have covered 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: No Retreat, No Surrender; and SGEM Xtra: The Walk of Life). This episode will not debate the use of tPA for acute ischemic stroke. Rather we will be discussing whether lowering the blood pressure of a patient suspected of having a stroke in the pre-hospital setting will have a net beneficial patient-oriented outcome (POO). Hypertension is common in acute stroke and is a predictor of poor outcome [1]. There is still some controversy on whether or not it is beneficial to lower the blood pressure in these cases [2]. Previous studies suggested that Nitric Oxide (NO) donors, such as transdermal glyceryl trinitrate (GTN – also known as nitroglycerin), reduced blood pressure, improved cerebral blood flow and reduced stroke lesion size if administered early [3 and 4]. There have been five randomized trials looking at nitroglycerin with four not showing superiority for functional outcome. One phase 2 trial done in the pre-hospital setting (RIGHT: Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial) did suggest a benefit to nitroglycerine [5]. The RIGHT study was a subgroup analysis of the ENOS (Efficacy of Nitric Oxide in Stroke) that looked at nitroglycerin within 6 hours of stroke. It too failed to demonstrate a statistical benefit [6]. However, a SRMA of individual patient data in these five trials suggested that earlier administration of nitroglycerin was associated with better outcomes in both ischemic and intracerebral hemorrhage stroke. It also was associated with lower mortality, disability, cognitive impairment, mood disturbance and poor quality of life (QOL) [7]. The conclusion to the RIGHT study was that a larger trial is needed to determine if nitroglycerin improves survival with good neurologic outcome. Clinical Question: Does early administration of glyceryl trinitrate (nitroglycerin) by paramedics in the pre-hospital setting improve neurologic outcome in patients with presumed acute stroke? Reference: Bath PM et al. Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomized, sham-controlled, blinded, phase 3 trial. The Lancet March 2019. Population: Adult patients who called emergency services for presumed stroke within 4 hours of onset of symptoms and a FAST score of 2 or 3, systolic blood pressure of equal or greater than 120 mmHg Exclusions: Nursing home patients, Glasgow Coma Scale <8, hypoglycemia or witnessed seizure, life expectancy < 6 months, known to have taken PDE5 inhibitor in the previous days and sens...

Date: September 11th, 2019 Reference: Putzu et al. The Effect of Vitamin C on Clinical Outcome in Critically Ill Patients: A Systematic Review with Meta-Analysis of Randomized Controlled Trials. Critical Care Medicine. June 2019. Guest Skeptics: Dr. Erin Willard is a PGY-3 Emergency Medicine Resident, Department of Emergency Medicine, University of Arkansas for Medical Sciences. Dr. Carly Eastin is an Associate Professor, Division of Research and Evidence Based Medicine, Department of Emergency Medicine, University of Arkansas for Medical Sciences. Case: A 45-year-old female in the emergency department is being admitted to the intensive care unit (ICU) for septic shock secondary to urinary tract infection (UTI). She has been given fluids, antibiotics, and is currently maintaining adequate mean arterial pressure (MAP) on low-dose vasopressors. You are ready to call the ICU and get her admitted. But you remember seeing in the news there was a study claiming vitamin C could cure sepsis. You wonder if giving vitamin C will affect her outcome? Background: There was a huge buzz in the media a few years ago about a vitamin C cocktail (vitamin C, hydrocortisone and thiamine) as a possible cure for sepsis. This was because of a well-known critical care physician Dr. Paul Marik. Dr. Paul Marik Dr. Marik published a retrospective before and after study that included a vitamin C cocktail reporting an impressive number needed to treat of 3 to prevent one death due to sepsis. For the scientific rationale why vitamin C therapy may help septic patients check out Dr. Josh Farkas’ post on PulmCrit. We reviewed Dr. Marik’s observational study on SGEM#174. A dozen skeptics commented about the validity of the study including my EBM mentor Dr. Andrew Worster who started BEEM and Legend of Emergency Medicine Dr. Jerome Hoffman. The SGEM Bottom Line was that Vitamin C, hydrocortisone and thiamine was associated with lower mortality in severe septic and septic shock patients in this one small, single centred retrospective before-after study but causation has yet to be demonstrated. A number of clinical trials are currently underway in an attempt to replicated Dr. Marik’s findings. The existing evidence to support vitamin C use in patients with septic shock is weak and has been summarized in a systematic review meta-analysis.  Clinical Question: Does the administration of vitamin C to an adult critically ill ICU patient or cardiac surgery patients decrease mortality? Reference: Putzu et al. The Effect of Vitamin C on Clinical Outcome in Critically Ill Patients: A Systematic Review with Meta-Analysis of Randomized Controlled Trials. Critical Care Medicine. June 2019. Population: Randomized trials examining critically ill adult ICU or cardiac surgery patients Exclusions: Inappropriate setting (cardiac or ICU) or study design (RCT), pediatrics, non-critically ill Intervention: Any type of vitamin C formulation or regimen Comparison: Placebo or no therapy Outcome: Primary outcome: Mortality at the longest follow-up available Secondary outcomes: Acute kidney injury, supraventricular tachycardia, ventricular arrhythmia, stroke, ICU and hospital length of stay. Authors’ Conclusions:“In a mixed population of ICU patients, vitamin C administration is associated with no significant effect on survival, length of ICU or hospital stay. In cardiac surgery, beneficial effects on postoperative atrial fibrillation, ICU or hospital length of stay remain unclear. However, the quality and quantity of evidence is still insufficient to draw firm conclusions, not supporting neither discouraging the systematic administration of vitamin C in these populations. Vitamin C remains an attractive intervention for future investigations aimed to improve clinical outcome.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes

Date: September 18th, 2019 Reference: Scheuermeyer et al. A Multicenter Randomized Trial to Evaluate a Chemical-first Cardioversion Strategy for Patients with Uncomplicated Acute Atrial Fibrillation. AEM Sept 2019 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and clinical lecturer in Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Case: A 55-year-old male presents to the emergency department with sudden onset of palpitations and pre-syncope starting one hour ago. He has no chest pain or shortness of breath and aside from a heart rate of 140 beats per minute, the rest of his vital signs appear within normal limits. His past medical history is significant for hypertension for which he takes perindopril. His ECG shows atrial fibrillation with a rapid ventricular response. Background: Atrial fibrillation is the most commonly encountered significant dysrhythmia in the emergency department (1). We have covered this topic a number of times on the SGEM. SGEM#88: Shock Through the Heart (Ottawa Aggressive Atrial Fibrillation Protocol) SGEM#133: Just Beat It (Atrial Fibrillation) with Diltiazem or Metoprolol? SGEM#222: Rhythm is Gonna Get You – Into an Atrial Fibrillation Pathway SGEM#260: Quit Playing Games with My Heart – Early or Delayed Cardioversion for Recent Onset Atrial Fibrillation? The most recent episode looked at whether late cardioversion is non-inferior to early cardioversion (SGEM#260) in acute atrial fibrillation. The SGEM bottom line from that episode was that the late approach was non-inferior to early approach and that both strategies achieve high rates of sinus rhythm at the 4-week follow up (>90%). In uncomplicated patients with symptoms less than 48 hours and no stroke or TIA in the past six months, the 2018 Canadian Cardiovascular Society (CCS) guidelines permit rate or rhythm control (2). There is significant variability in the management of patients with acute atrial fibrillation, with the proportion undergoing rhythm control ranging from 42-85% in Canadian academic centres (3). The rhythm control strategies typically employed are chemical cardioversion with procainamide infusion or electrical cardioversion with electrical countershock (3-6). Both of these strategies appear safe from prior studies, but comparative effectiveness data is lacking. Thus, Canadian management varies, with 56% of patients receiving a chemical-first approach and 44% an electrical-first approach (3). Clinical Question: In emergency department patients with atrial fibrillation, is sinus rhythm achieved more rapidly with electrical-first rhythm control when compared with chemical-first rhythm control? Reference: Scheuermeyer et al. A Multicenter Randomized Trial to Evaluate a Chemical-first Cardioversion Strategy for Patients with Uncomplicated Acute Atrial Fibrillation. AEM Sept 2019 Population: Adults between 18 and 75 years of age with atrial fibrillation less than 48 hours duration and a CHADS2 score less than two. Excluded: Hemodynamic instability, atrial flutter, CHADS2 score greater than or equal to two, patients with an acute underlying medical illness, recent cardiac procedure, acute intoxication or withdrawal from alcohol or illicit substances. They also excluded those who attended the emergency department for other reasons (eg. trauma, gout) who were incidentally found to be in atrial fibrillation. Intervention: Chemical cardioversion with procainamide (a dose of 17mg/kg up to a maximum of 1500mg infused over one hour was recommended). This was followed by electrical cardioversion if chemical cardioversion was unsuccessful. Comparison: Electrical cardioversion using a synchronized biphasic waveform sequence of 100J to 150J to 200J to a maximum of three shocks were allowed. Patients were sedated at the physicians’ discretion. The study recommended an initial propofol bolus of 0.

Date: September 18th, 2019 I had the honour of presenting at FIX19 conference in New York City. Thank you to Dr. Dara Kass and the organizing committee for giving me the opportunity to present at this amazing conference. FIX stands for FeminEM Idea Exchange and is part of FeminEM. While attending FIX19, I had the opportunity to interview a couple of fantastic women. One of them was Dara Kass. She is an Assistant Professor, Emergency Medicine, Columbia University Medical Center. Dara has been on the SGEM before (FIX You Up and FeminEM-Stronger Together). Barb Lubell, Jen Gunter and Ken Milne I also interview Dr. Jennifer Gunter who is a super hero of science wielding the lasso of truth. When she was back in London, Ontario for Western's Homecoming she too made an appearance on the SGEM (Super Hero of Science). Dr. Gunter has written a new book called The Vagina Bible that has been on the New York Times bestseller list. She also has her own TV show on CBC called Jensplaining. You can listen to the brief conversation with Drs. Kass and Gunter on iTunes. From Evidence-Based Medicine to Feminist-Based Medicine. My talk at FIX19 was called from Evidence-Based Medicine to Feminist-Based Medicine. Over the last few years Dara and others have opened my eyes to some of the other limitations to EBM. You can get copies of my slides at this LINK. Evidence-based medicine was originally defined by Dr. David Sackett over 20 years ago. He defined EBM as: “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”   I would add the word SHARED to this definition.  The modified version would be “The conscientious, explicit and judicious use of current best evidence in making SHARED decisions about the care of individual patients.”  There is a Venn diagram used to represents the EBM definition. Many people think that EBM is just about the scientific literature. This is not true. The evidence informs and guides our care but it should not dictate our care. EBM also needs your clinical judgement based on your experience. We also need to engage with patients and ask them about their preferences and values. These three components make up EBM: The literature, our clinical judgement and the patient's values. If you do that, you will be giving patients the best care, based on the best evidence and engaging in a shared decision making model, or so I thought. My eyes have been opened to the inequities in medicine by Dara Kass and other. I cannot look away any longer or stay silent These are the inequities I see in EBM. The Medical Literature: Who gets most of the grant money in medicine? Men Who rises to the top academic positions at universities? Men Who rises to the top academic positions in medicine? Men Who rises to the top academic positions in Emergency Medicine? Men Who is most likely the first author on a medical publication? Men Who is most likely the first author on a emergency medicine publication? Men Who is most likely to be the first author on a Pediatric Emergency Medicine (PEM) Paper? Men 62% of PEM  are women but only 42% are lead authors in the four high impact pediatric journals. Who are often excluded from being subjects in medical research? Women The Clinicians: Who historically has been the clinician in the room? Men Who is most likely to rises to top leadership positions within the hospital structure? Men. Only 3% of healthcare CEOs are women, 6% are Department Chairs, 9% are Division Chiefs, and 3% are serving as Chief Medical Officers. This is despite women comprising 80% of the healthcare workforce. Who gets paid more in medicine? Men ($20,000/year) Who gets paid more in academic medicine? Men ($17,000/year) Who gets paid more in academic Emergency medicine? Men ($12,000/year) Who is more likely to be introduced with their professional title at grand rounds...

Date: September 10th, 2019 Reference: Fournier et al. Adapting the Canadian CT head rule age criteria for mild traumatic brain injury. Emergency Medicine Journal 2019. Guest Skeptics: Dr. Sarah Berg is a PGY-3 resident in Emergency Medicine at Washington University School of Medicine in St. Louis. She is interested in social determinants of health in the emergency department and health policy. Dr. Ian Holley is also a PGY-3 resident in Emergency Medicine at Washington University School of Medicine in St. Louis.  He is interested in ultrasound and international emergency medicine. Case: It’s a busy night in the emergency department, your next patient is a well appearing 70-year-old man, presenting after a mechanical fall from standing with loss of consciousness.  He is neurologically intact with a Glasgow Coma Scale (GCS) of 15 one hour after the fall.  There are no other external signs of trauma on your exam. He is not on anticoagulation and there is no history of seizures. Background:  Head trauma is an exceedingly common presenting complaint in the emergency department, with approximately 2.5 million emergency department visits in the US in 2014 [1], with the most significant proportion of visits occurring in the elderly ≥75 (1,682/100,000) [1]. Head trauma can result in a spectrum of brain Injuries varying from mild to severe.  In cases of severe injury, the decision to obtain head CT imaging is straight forward.  In mild traumatic brain injury (mTBI), this decision is can be more difficult, as there may be no or minimal evidence of injury on exam.  Traditionally CT imaging was obtained for fear of missing intracranial pathology. In an attempt to improve resource utilization, emergency department length of stay, limit cost and improve outcomes, there have been multiple Clinical Decision Rules (CDRs) created to help guide clinicians in their decision-making process.  Two of the most commonly used rules include the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC); other rules include NEXUS-II, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies, the National Institute of Clinical Excellence guidelines, and the Scandinavian Neurotrauma Committee guideline. We have covered the CCHR on the SGEM with the EM Swami and Dr. Emily Junck back on SGEM#106. It was a classic EM paper published in the Lancet back in 2001 by the Legend of Emergency Medicine, Dr. Ian Stiell. We also discussed three studies that compared CCHR to the NOC. The bottom line was while both rules are highly sensitive for positive CT findings and clinically important brain injuries, the CCHR had higher specificity and may be more clinically applicable given it is designed to predict clinically important brain injuries. The Canadian CT Head Rule [2] is a clinical decision instrument to help you decide if a patient with a mild head injury requires a CT head. Minor head injury was defined as blunt head trauma, resulting in amnesia, loss of consciousness or an altered mental state (confusion or disorientation) with a GCS score ≥13. The CCHR only applies to those patients with minor head injury and is not applicable to non-traumatic cases, GCS less than 13, age less than 16 years, coumadin or bleeding disorder or obvious open skull fractures. The CCHR is the most researched CDR in mTBI [3] and has shown sensitivities and specificities from 99-100% and 48-77% [3].  The use of CDRs such as CCHR, have the ability to reduce the amount of unnecessary head CT imaging obtained in the emergency department [4]. Unfortunately, the CCHR uses age ≥ 65 as a high-risk criterion for obtaining head CT imaging in mTBI.  This is based on the initial validation study which demonstrated an odds ratio (OR) of 4.1 for risk of clinically important brain injury (CIBI) [2].  CIBI is defined, per the CCHR, as “any acute brain finding revealed on CT and which would normally require admission to hospital and neurologi...

Date: September 5th, 2019 Reference: Dalziel et al. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial. The Lancet May 2019 Guest Skeptic: Dr. Tessa Davis is a Paediatrician specializing in Paediatric Emergency Medicine and currently practicing at the Royal London Hospitals. She is also the co-founder of Don’t Forget the Bubbles and on the FeminEM Speaker Bureau. Case: Julia is a 4-year-old girl with a history of seizures and developmental delay. She presents the emergency department with another seizure for more than five minutes and has not been aborted with two doses of midazolam intramuscularly.You know the guidelines recommend phenytoin as a second line agent, but the junior doctor asks you if levetiracetam would work faster with less side effects. Background: Convulsive status epilepticus can be defined as a single seizure lasting greater than 20 to 30 minutes, or recurrent shorter seizures without recovery of consciousness between seizures. Status epilepticus is a common paediatric emergency with significant consequences for the patients. Our focus on management of status is to stop the seizures quickly to avoid any complications. Guidelines recommend benzodiazepines as the first line treatment, and we have plenty of evidence to back this up. Most guidelines recommend phenytoin or fosphenytoin as a second-line treatment, but the evidence base for its use is much weaker. CPS - Emergency management of the paediatric patient with generalized convulsive status epilepticus APLS - Advanced Life Support Group. Advanced paediatric life support: a practical approach to emergencies, 6th edn. Hoboken: Wiley-Blackwell, 2016. NICE - Epilepsies: diagnosis and management. London: National Institute for Health and Care Excellence, 2012. AES - Glauser T, Shinnar S, Gloss D, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr 2016 Phenytoin is linked to many adverse events including liver damage, Steven-Johnson syndrome, extravastion, pancytopenia, hypotension, arrhythmias, and death due to dosing errors. Levetiracetam is an alternative to phenytoin for second line treatment of convulsive status epilepticus. It can be given more quickly, is more compatible with intravenous fluids, has less drug interactions, and has a lower risk of adverse events. Although small studies suggest that levetiracetam is effective, there have been no comparison studies until now. Clinical Question: Is levetiracetam superior to phenytoin as a second-line treatment for convulsive status epilepticus in children? Reference: Dalziel et al. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial. The Lancet May 2019 Population: Children aged three months to 16 years of age presenting to 13 emergency departments in Australia and New Zealand in status epilepticus. Convulsive status epilepticus was defined as having a seizure for more than five minutes or two or more recurrent seizures without recovery of consciousness between seizures. Or three or more seizures within the preceding hour and a current seizure. They also had to have received two doses of benzodiazepines. Exclusions: Being on regular phenytoin or levetiracetam; having already had a second-line treatment; known to be refractory to the medication; allergy; seizures secondary to a head injury; or seizure due to eclampsia in late pregnancy. Intervention: Levetiracetam 40mg/kg (max 3g) IV or IO over five minutes. Five minutes after the infusion finished, patients were assessed to see if the seizures had stopped. If the patient was still convulsing, then the other drug was given.