The Skeptics Guide to Emergency Medicine

Date: May 14th, 2019 Dr. Michael Brown Guest Skeptic: Dr. Michael Brown is founding chair of the Department of Emergency Medicine at the Michigan State University College of Human Medicine. He is affiliated with multiple hospitals, including Spectrum Health Gerber Memorial and Spectrum Health United Hospital. Dr. Brown received his medical degree from Michigan State University College of Human Medicine and has been in practice for more than 20 years. He has a Masters degree in Epidemiology and currently serves as President for the Association of Academic Chairs of Emergency Medicine. This is an SGEM Xtra that was recorded at the Society of Academic Emergency Medicine 2019 (SAEM) annual meeting in Las Vegas, Nevada. It was SAEMs largest meeting every with over 3,000 attendees. DISCLAIMER: THE VIEWS AND OPINIONS EXPRESSED BY DR. MICHAEL BROWN ON THIS SGEM EPISODE ARE HIS OWN AND DO NOT REPRESENT THE VIEWS OR OPINIONS OF THE COCHRANE COLLABORATION OR ANY OTHER ORGANIZATION. Dr. Archie Cochrane I took this opportunity of being together in Las Vegas for the SAEM meeting to discuss with Mike the following issues: What is the Cochrane Collaboration? Who was Archie Cochrane? What is the Cochrane Mission Statement? How has Cochrane reorganized itself? What was the recent Cochrane controversy? Here is a video from Dr. Damian Rowland from the wonderful DFTB17 Conference. The presentation is called "When we get the wrong answer from the right research". In this talk Damian discusses Cochrane. The SGEM will be back next episode for the start of Season#8. Our goal continues to be to try and cut the knowledge translation window down from over ten years to less than one year using the power of social media (FOAMed). REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

Date: August 9th, 2019 Reference: Daoust et al. Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain. AEM August 2019 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: You are taking care of a 56-year-old woman who presented to the emergency department with a Jones fracture. During your discharge discussion, you offer her a prescription for oxycodone/acetaminophen and she gets a worried look on her face and says: “I try to stay away from those medications…what if I get hooked?” You realize you are unsure what to tell her about the chances of continued opiate use after an initial prescription. Background: Opioid use and misuse have increased greatly in the past 15 years, but opioids remain a mainstay of treatment for acute pain. Some have identified the 2001 Joint Commission making pain the fifth vital sign in an attempt to address the oligoanalgesia issue as part of the opioid misuse problem. ED physicians are among the most frequent prescribers of opioids. (Volkow et al. JAMA 2011). Attempting to decrease a patient’s pain to zero is certainly well-intentioned but you have to ask yourself how many patients are being harmed by such a goal? Another question you need to ask is: Do patients want their pain to be eliminated at the expense of their level of awareness and understanding why they are in pain? We have all had patients who express concern about opioid use like the case presented.  The literature has shown that more educated patients would rather receive less opioids and live with some pain compared to less educated patients. (Platts-Mills TF, et al. Pain 2012). Several studies have looked at opioid use after an initial prescription, but many of them included a large number of patients with prior substance abuse or used prescribing databases to extrapolate recurrent use as a surrogate for misuse. ACEP has a clinical policy regarding prescribing of opioids for adult ED patients that was published in 2012 (Cantrill et al). They suggest that opioid use be carefully individualized and time-limited; that opioids are best left for patients with severe or refractory acute pain; and that exacerbations of chronic pain not be treated with opioids. Clinical Question: What is the incidence of opioid use three months after an initial prescription, and what are the reasons for consumption? Reference: Daoust et al. Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain. AEM August 2019 This episode has a PECO not a PICO. The “I” for intervention is replaced by “E” for exposure because this is a prospective observational study looking at the relationship between an exposure (opioid prescription) and an outcome not a trial of an intervention. You can learn more about study design by going to the Center for Evidence Based Medicine website (CEBM Study Designs). Population: Patients 18 years or older with a painful condition less than two weeks without recent (less than two weeks) opioid use Excluded: Patients who did not speak French or English, were using opioid medication in the past two weeks prior to the ED visit, stayed in the ED for more than 48 hours before discharge home, and patients with cancer pain or who were being treated for chronic pain. Exposure: Discharged from the ED with an opioid prescription Comparison: None Outcome: Opioid use/misuse at three months This is an SGEMHOP episode which means we have the lead author on the show. Dr. Raoul Daoust is a Professor, Université de Montréal Emergency physician Hôpital Sacré-Cœur de Montréal Dr. Raoul Daoust Authors’ Conclusions: “Opioid use at the 3-month follow-up in ED patients discharged with an opioid prescription for an acute pain condition is not necessarily associated with opioid misuse; 91% of those patients consumed opioids to treat pain.

Date: August 6th, 2019 Guest Skeptic: Dr. Alyssa Stroud (@TheBlondeMD) is a PGY2 surgery resident who is trying to survive the hardships of residency and dating, one glass of wine at a time. This is an SGEM Xtra episode that was recorded in Algonquin Park where I am volunteering to be the camp doctor at the Taylor Statten Camps. You may hear sounds in the background of nature or campers when listening to the podcast. Dr. Stroud was invited on the SGEM to discuss a recent twitter thread she posted. There was an initial tweet that inspired the thread. Then someone named Bill Ferguson (@billferg1941) sent Dr. Stroud a direct message (DM). Here are the 11 tweets in the twitter thread and a copy of the DM. You can listen to us discuss each one of these tweets on iTunes. We then went on to discuss the good, the bad and the ugly responses to the twitter thread. There was one person named Becky (@BeckylNelson) that really got under Dr. Stroud's skin. The vast majority of the tweets were in support of Dr. Stroud. I asked her why she thought some people seem to get so angry? Some of these negative tweets led Dr. Stroud to step away from twitter for 12 hours. When she logged back onto twitter she found a number of people supporting her by changing their twitter name to include the word "Barbie". Many #FOAMed friends joined included Dr. Esther Choo who has been on the SGEM and Dr. Kirsty Challen who creates the #PaperinaPic infographics for the SGEM. I too changed my twitter name to EBM/Rural EM Barbie and assured Dr. Stroud that she was good enough just the way she was. I learned that from Mr. Rogers on his children's TV show called Mr. Roger’s Neighbourhood. He said: “Love isn’t a state of perfect caring. It is an active noun like struggle. To love someone is to strive to accept that person exactly the way he or she is, here and now”. To be more inclusive in 2019 I would tweak the quote to be gender neutral…but the world needs more love. Dr. Stroud then discusses her twitter name "OR Barbie" and what it means to her. She also explains why being known as a "Barbie" is not degrading to women, it’s not upholding the patriarchy, it’s not negative. It’s about taking back our power and deciding what kind of woman she wants to be. Dr. Alyssa Stroud I hope you enjoyed this SGEM Xtra and finding out more about the amazing person Dr. Alyssa Stroud. The SGEM will be back next episode with a structured critical review of a recent publication. Cutting the knowledge translation window down from over ten years to less than one year with power of social media. The ultimate goal of the SGEM continues to be that patients get best care on best evidence. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Date: July 22nd, 2019 Reference: Yadav et al. A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings. AEM July 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 25-year-old female presents to the urgent care with two days of cough, purulent sputum, fever and myalgias. Vitals signs are within normal limits and her exam is unremarkable. She asks for a prescription for antibiotics to help treat her infection.  Background: Inappropriate antibiotic use exposes patients to opportunistic infections, accelerates the development of antibiotic resistant bacteria and leads to adverse drug events [1]. Acute respiratory infections (ARIs) are a major cause of unnecessary antibiotic use. Emergency departments (EDs) in the United States write 10 million antibiotic prescriptions each year, approximately half of which are inappropriate [2, 3, 4]. Given these risks, strategies to reduce inappropriate antibiotic use in the ED and urgent care centers (UCCs) are needed. Despite recognizing the need for antibiotic stewardship by EDs and emergency providers, this has not led to practice change [5, 6]. Providers in the ED and UCC setting are faced with numerous challenges that may limit change, including: Frequent interruptions, boarding and overcrowding, frequent patient handoffs, and the need to see high volumes of patients [7, 8, 9]. There is evidence in both the medical literature and economic theory to support using a package of feedback, nudges and peer comparisons to improve prescribing outcomes. This has been shown to reduce unnecessary antibiotic prescribing in primary care, and in one study of peer comparisons in outpatient clinics and doctor’s offices, these improvements were sustained for at least 12 months after the interventions were completed [10, 11, 12]. Richard Thaler and Cass Sunstein wrote a book on the nudge theory. The book is called Nudge: Improving Decisions about Health, Wealth, and Happiness. The authors discuss psychologic and behavioral economics research to support active engineering of choice architecture. It’s a great book to put on your reading list. Clinical Question: Is an enhanced intervention using audit and feedback, peer comparisons, and nudges more effective than a standard intervention in reducing inappropriate antibiotic prescribing for acute respiratory infections by clinicians in an ED/UCC setting? Reference: Yadav et al. A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings. AEM July 2019 Population: Clinicians (general ED physicians, pediatric ED physicians, advanced care practitioners, internists and pediatricians) at five EDs and four UCCs in three academic health systems who prescribed antibiotics for ARIs. Excluded: Resident physicians Intervention: Enhanced intervention: This used all the elements of the adapted intervention, but also included peer comparison feedback via email, comparison to top performing peers, and additional locally tailored public posters demonstrating commitment to judicious antibiotic use. Comparison: Adapted intervention: This incorporated strategies from the Centre for Disease Control and Prevention’s Core Elements for Outpatient Antibiotic Stewardship, including provider and patient education, a physician champion and departmental feedback. This used adapted brochures and other campaign messages for acute care providers. Outcome: Primary Outcome: Rate of inappropriate outpatient antibiotic prescribing for acute respiratory infections diagnosis that were deemed antibiotic-nonresponsive. Secondary Outcome: Difference between the enhanced and adapted intervention g...

Date: July10th, 2019 Reference: O’Riordan W et al. Omadacycline for Acute Bacterial Skin and Skin-Structure Infections. NEJM Feb 2019 Guest Skeptic: Dr. Anand Swaminathan is an assistant professor of Emergency Medicine at the St. Joseph’s Regional Medical Center in Patterson, NJ. He is a deputy editor for EM: RAP and, associate editor for REBEL EM. Case: A 22-year-old woman presents with redness and swelling of her left lower leg from the top of the ankle to about midway up the calf on the medial surface of the leg. Her skin is warm with mild tenderness, no fluctuance and no crepitus. She is well appearing without a fever and she has no prior medical history or allergies. You are about to write her a prescription for cephalexin when you suddenly remember reading about a new antibiotic that recently became available for skin and soft tissue infections called omadacycline Background: We have covered cellulitis and abscesses a number of times on the SGEM (SGEM 13, 131, 156, 164, 209). Often the guest skeptic on these shows is the amazing Physician Assistant, Chip Lange from TOTAL_EM Podcast and the Practical POCUS course. The production and release of new antibiotics is rare and should be celebrated by clinicians. As antibiotic resistance continues to mount, our options narrow and, in turn, our patients suffer. Recently, the NEJM published two articles on a new antibiotic that was recently FDA approved, omadacycline. The articles compared omadacycline to moxifloxacin in the treatment of community acquired pneumonia (CAP) and to linezolid in the treatment of skin and soft tissue infections. Both studies yielded promising results for the new drug which should be cause for excitement. However, significant biases, methodological flaws and poor selection of comparator treatments should temper our excitement. Clinical Question: Is omadacycline non-inferior to linezolid in terms of early clinical response in the treatment of skin and soft tissue infections? Reference: O’Riordan W et al. Omadacycline for Acute Bacterial Skin and Skin-Structure Infections. NEJM Feb 2019 Population: Patients older than 17 years with a skin infection (cellulitis, erysipelas or major abscess) Exclusions: Patients with one or more doses of systemic antibiotics prior to presentation, topical antibacterial agent within 72 hours, infections that would require more than 14 days of treatment, chronic skin lesions, ulcers or wounds and patients with any liver or renal insufficiency or immunocompromise Intervention: Omadacycline 100 mg IV Q12 for two doses then 100 mg Q24 for at least two more days with the option to transition to 300 mg Q24 for 7-14 days total Comparison: Linezolid 600 mg IV Q12 with the option to transition to 600 mg Q12 orally for 7-14 days after at least three days of IV Outcome: Primary: Early clinical response defined as survival with a reduction in lesion size of at least 20% at 48-72 hours after the first dose Secondary: Clinical response post-treatment(at 7-14 days) Authors’ Conclusions: “Omadacycline was noninferior to linezolid for the treatment of acute bacterial skin and skin-structure infections and had a similar safety profile.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Unsure The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Unsure The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. Yes All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes

Date: June 28th, 2019 Reference: Cardona et al. Prospective Validation of a Checklist to Predict Short-term Death in Older Patients After Emergency Department Admission in Australia and Ireland. AEM June 2019. Guest Skeptic:Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com Case: An 83-year-old man with early dementia, congestive heart failure (CHF), prior myocardial infarction (MI) with three stents, chronic obstructive pulmonary disease (COPD), and atrial fibrillation is transferred to the hospital because the nursing home thinks he might have a urinary tract infection (UTI). On arrival he is febrile, confused, with an alternating level of consciousness, tachycardia, and a rapid respiratory rate. According to the family with him, he had never had an end of life conversation with his physicians. You think such a conversation is important to guide your care in the next few hours, but you wonder if there is a tool to help you predict this gentleman’s chance of dying during this visit or shortly after. Background: Discussion about goals of care at the end of life are an essential component of emergency medicine. Such discussions are aided by accurate prognosis, so that life-saving interventions can be provided to those in need, but hopefully without providing overly aggressive management in patients with little hope of recovering. Such prognosis is difficult, especially in the chaotic and time-limited environment of an emergency department. An accurate decision tool would be welcomed. Unfortunately, available tools are only modestly accurate and have not been rigorously validated.1,2 Basic demographic data alone are insufficient to predict individual patient risk.3 Therefore, the purpose of this study was to validate a personalized risk score – the Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL) – in older patients presenting to the emergency department.4 CrisTAL Tool - BMJ 2015 Clinical Question: To establish the predictive ability of individual and combined parameters in the CriSTAL tool to predict short-term post-discharge death in an elderly population. Reference: Cardona et al. Prospective Validation of a Checklist to Predict Short-term Death in Older Patients After Emergency Department Admission in Australia and Ireland. AEM June 2019. Population: Patients over the age of 65 who stayed overnight in the emergency department or were admitted to hospital. The derivation population was from five hospitals in Australia, while the validation population was from a single hospital in Ireland. Exclusions: Patients with severe cognitive impairment, the critically ill, or those unable to communicate in English were all declared ineligible to participate unless they had a surrogate. Intervention:The CriSTAL score, and its various components. Comparison:None Outcome: Primary Outcome(s): Death within three months and CriSTAL’s predictive ability. Secondary Outcome: Predictive ability for in-hospital death This is an SGEMHOP episode and usually we have the lead author on the show. Unfortunately, we were not able to coordinate the recording times with being in three different countries. Our hope is the authors can respond to our nerdy questions on the blog. Authors’ Conclusions: The modified CriSTAL tool (with CFS instead of Fried’s frailty instrument) had good discriminant power to improve certainty of short-term mortality prediction in both health systems. The predictive ability of models is anticipated to help clinicians gain confidence in initiating earlier end-of-life discussions. The practicalities of embedding screening for risk of death in routine practice warrant further investigation. Quality Checklist for Clinical Decision Tools: The study population included or focused on those in the ED. Yes The patients were representative of those with the problem.

Date: June 20th, 2019 Reference: Pluymaeker et al. Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation. NEJM 2019 Guest Skeptic: Dr. David Glaser, emergency physician from a community teaching hospital in Denver and faculty member for the annual Emergency Medicine and Acute Care course series. Dave is also residency-trained and boarded in internal medicine. Case: A 62-year-old woman with a history of hypertension presents with four hours of palpitations, described as a racing heart. Her vital signs: BP 148/90, HR 135, RR 16, T 37oC, O2 Sat 96%. Lungs are clear and cardiac exam shows a tachycardic and irregularly irregular rhythm without murmur. The ECG shows atrial fibrillation without ischemic changes. How do you proceed? Background: New-onset atrial fibrillation is a common occurrence in the emergency department, and practitioners differ on whether to take a primary rate-control approach versus a rhythm-control approach utilizing either electrical or pharmacological cardioversion. We are not going to settle this debate on this podcast. In the United States especially, these patients are often admitted to the hospital with rate control and cardiology decides on cardioversion. Dr. Ian Stiell In Canada, these patients are often cardioverted and discharged home. We covered the Ottawa Aggressive Protocol on SGEM#88. That episode reviewed a 2010 cohort study done by the Legend of Emergency Medicine, Dr. Ian Stiell. The results from this observational study was 92% of patients were electrically cardioverted, 97% discharged home with 93% in sinus rhythm at discharge. Things are starting to change in the US. A study published in AEM showed that implementing a new atrial fibrillation algorithm decreased hospital admissions from 80% to 67% and cardioversion increased from 17% to 21% (SGEM#222). Clearly there is a difference in the management of patients with recent onset of rapid atrial fibrillation depending on your practice location. Clinical Question: In adult patients who present with hemodynamically stable, symptomatic, recent-onset atrial fibrillation without signs of myocardial ischemia, is a wait-and-see approach, inferior to an immediate cardioversion strategy. Reference: Pluymaeker et al. Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation. NEJM 2019 Population: Adults(18 years and older) who presented to the emergency department of 15 hospitals in the Netherlands (3 academic, 8 non-academic teaching, and 4 non-teaching hospitals) with hemodynamically stable, symptomatic, recent-onset (< 36 hours), first-detected or recurrent atrial fibrillation, without signs of myocardial ischemia or a history of persistent atrial fibrillation (defined as lasting > 48 hours). Exclusions: Signs of myocardial infarction on ECG, hemodynamically unstable, presence of pre-excitation syndrome, history of sick sinus syndrome, history of unexplained syncope, history of persistent AF (episode of AF lasting more than 48 hours), acute heart failure or deemed unsuitable for participation by attending physician. Intervention: Delayed cardioversion (“wait-and-see” approach). This was defined as administration of a rate-control medication, including intravenous or oral beta-blockers, nondihydropyridine calcium-channel blockers, or digoxin, given in increasing doses to obtain relief of symptoms and a HR of 110 BPM or less. Patients were discharged when their condition was judged to be clinically stable. A cardiology out-patient clinic visit was planned for the next day, as close as possible to 48 hours after the onset of symptoms. If atrial fibrillation was still present at this visit, patients were referred back to the emergency department for delayed cardioversion. Comparison: Early cardioversion. This was performed at the initial emergency department visit, either pharmacologically (and preferentially with flecainide) or electrically in those with contraindications to ...

Date: June 11th, 2019 Reference: Huybrechts et al. Association of Maternal First-Trimester Ondansetron Use With Cardiac Malformations and Oral Clefts in Offspring. JAMA Dec 2018. Guest Skeptic: Dr. Nick Papalia completed his MD at Western University. He is currently completing an Obstetrics and Gynecology residency at the University of Calgary. Case: A 24-year-old woman G2T1P1A0L1 who presents with nausea and vomiting of pregnancy at nine weeks gestational age. She has stopped her iron pills, taken ginger, used acupressure, tried vitamin B6 with doxylamine and dimenhydrinate. She is frustrated nothing is working and wants to try something else. Her friend got little wafers that dissolved under her tongue (ondansetron). She is worried because her google search said it could cause a birth defect like a cleft lip. Background: Many women suffer from nausea and vomiting when pregnant. These symptoms can become clinically significant in over 30% of woman. Hyperemesis gravidarum is the most common reason for hospitalization in early pregnancy and impacts a small percentage of these pregnancies. The Society of Obstetricians and Gynecologists of Canada (SOGC) published a guideline for the management of nausea and vomiting of pregnancy in 2016 (Campbell et al 2016). They make 13 recommendations: Women experiencing nausea and vomiting of pregnancy may discontinue iron-containing prenatal vitamins during the first trimester and substitute them with folic acid or adult or children’s vitamins low in iron. (II-2A) Women should be counselled to eat whatever pregnancy-safe food appeals to them and lifestyle changes should be liberally encouraged. (III-C) Ginger may be beneficial in ameliorating the symptoms of nausea and vomiting of pregnancy. (I-A) Acupressure may help some women in the management of nausea and vomiting of pregnancy. (I-B) Mindfulness-based cognitive therapy as an adjunct to pyridoxine therapy may be beneficial. (I-B) Pyridoxine monotherapy or doxylamine/pyridoxine combination therapy is recommended as first line in treating nausea and vom- iting of pregnancy due to their efficacy and safety. (I-A) Women with high risk for nausea and vomiting of pregnancy may benefit from preemptive doxylamine/pyridoxine treatment at the onset of pregnancy. (I-A) H1 receptor antagonists should be considered in the management of acute or chronic episodes of nausea and vomiting of pregnancy. (I-A) Metoclopramide can be safely used as an adjuvant therapy for the management of nausea and vomiting of pregnancy. (II-2B) Phenothiazines are safe and effective as an adjunctive therapy for severe nausea and vomiting of pregnancy. (I-A) Despite potential safety concerns of ondansetron use in pregnancy, ondansetron can be used as an adjunctive therapy for the management of severe nausea and vomiting of pregnancy when other antiemetic combinations have failed. (II-1C) Corticosteroids should be avoided during the first trimester because of possible increased risk of oral clefting and should be restricted to refractory cases. (I-B) When nausea and vomiting of pregnancy is refractory to initial pharmacotherapy, investigation of other potential causes should be undertaken. (III-A) The primary literature used to support the acupressure recommendation is very weak. A review by Roscoe and Matteson 2002 showed conflicting results from seven methodologically flawed trials. The conclusion was that acupressure might (might not) be beneficial. The American College of Obstetricians and Gynecologists (AGOC) has published a practice Bulletin (January 2018) on nausea and vomiting of pregnancy. It starts with non-pharmacologic options. Pharmacologic options include Vitamin B6 alone or in combination with doxylamine. The next step is adding dimenhydrinate or prochlorperazine or promethazine. The algorithm then dichotomizes into no dehydration or dehydration with persistent symptoms.

Date: May 15th, 2019 Guest Skeptic: Dr. Dara Kass is an Assistant Professor, Emergency Medicine, Columbia University Medical Center. This is an SGEM Xtra that was recorded at the Society of Academic Emergency Medicine 2019 (SAEM) annual meeting. Dr. Kass received the SAEM Award for the Advancement of Women in Academic Emergency Medicine at the meeting in Las Vegas. This award recognizes an SAEM member who has made significant contributions to the advancement of women in academic emergency medicine. All of the SAEM 2019 winners can be found at this LINK. Dr. Kass and I sat down at SAEM19 for a little chat about a variety of things. You can listen to our discussion on iTunes or Google Play. Here are of few of the things we talked about on the SGEM Xtra podcast: SGEM Xtra: FeminEM - Stronger Together SGEM Xtra: I Am Woman Gender Equity in Medicine Research Foundation (GEMRF) Period. End of Sentence Revive: A FeminEM Development Retreat TamponGate ACOG19: Mother with baby escorted out of exhibit hall FeminEM Idea Exchange 2019 (FIX19) Dr. Diane Birnbaumer - Legend of Emergency Medicine Dr. Jen Gunter - Super Hero of Science The SGEM will be back next episode trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media (FOAMed). Remember to be skeptical of anything you learn, even if you heard it on the Skeptics' Guide to Emergency Medicine.

Date: May 23rd, 2019 Reference: Joseph et al. Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma. JAMA Surgery March 2019. Guest Skeptic: Dr. Robert Edmonds is an emergency physician in the US Air Force in Virginia. This is Bob’s tenth 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 working at a Level 1 Trauma Center and are alerted to an incoming Type A trauma. After donning your PPE (personal protective equipment) and greeting the trauma surgeon in your resuscitation bay, nursing delivers report that you are about to receive a 24-year-old male that was involved in an explosion that knocked the patient from their vehicle. They have an unstable pelvis and were intubated in the field for airway protection due to a low Glasgow Coma Scale (GCS) score.  Vitals are heart rate 112 bpm, blood pressure 110/60 mmHg, respiratory rate 16 bpm (intubated), oxygen saturation 94%, afebrile and the patient is four minutes from arrival.  You have a brief conversation with your trauma surgeon regarding these findings, and upon arrival of the patient, you note an intubated airway, equal bilateral breath sounds, and a rapid regular heart rate.  The patient’s eyes are closed and makes minimal movements with his extremities. Your surgeon rapidly asks for the REBOA kit and begins catheterization of the femoral artery while you have a professional yet rapid debate about the need to complete the primary survey and roll the patient to examine their back. Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) was first used 50 years ago in the Korean War but was not mentioned in emergency medicine literature until 1986.  Its use declined in the 1990s and early 2000s, but during the past decade, it has gained the attention of trauma surgeons in military and civilian settings, potentially due to advances in the technology and smaller catheter sizes. The evidence for REBOA is conflicting.  Animal studies have shown REBOA to temporize exsanguinating hemorrhage and to restore perfusion.  Some human studies [1,2] have shown benefit but a recent registry study from Japan [3] showed the use of REBOA associated with higher mortality.  The authors noted a lack of multi-institutional data at a national level regarding efficacy and safety of REBOA in the United States, which prompted their study. The American College of Emergency Physicians (ACEP) and American College of Surgeons Committee on Trauma (ACS COT) in 2018 put out a joint statement for the use of REBOA [4]. They discuss some general observations, indication for REBOA, and guidelines for REBOA use and implementation. ACEP and ACS COT also discuss the transfer, management, special circumstances (deployed military settings), training, credentialing and quality assurance of REBOA. Clinical Question: What are the outcomes of trauma patients after REBOA placement? Reference: Joseph et al. Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma. JAMA Surgery March 2019. Population: All adult (over 18 years of age) patients in the ACS-TQIP database from 2015-2016. Exclusions: Patients who were dead on arrival, were transferred from other facilities, had missing physiological parameters, or who underwent resuscitative thoracotomy were excluded. Intervention: Patients who received REBOA within one hour of presentation to the emergency department Comparison: Patients who did not receive REBOA (matched in a 1:2 intervention to comparison group) Outcome: Primary Outcomes: Emergency department mortality, 24-hour mortality, and mortality after 24 hours Secondary Outcomes: Transfusion requirements at four hours and 24 hours after injury, in hospital complications (DVT, PE, CVA, MI, extremity compartment syndrome,