The Skeptics Guide to Emergency Medicine

Date: October 2nd, 2019   Reference: Ramgopal et al. Changes in the Management of Children With Brief Resolved Unexplained Events (BRUEs). Pediatrics 2019 Guest Skeptic: Dr. Katie Noorbakhsh is a pediatric emergency physician at the Children’s Hospital of Pittsburgh. This is an SGEM Xtra and it was inspired by the recent publication in Pediatrics on BRUEs. This will not be a traditional nerdy critical appraisal. We wanted to change things up a bit and just have a conversation about this topic. BRUE stand for a Brief Resolved Unexplained Event. It is a diagnosis of exclusion in an asymptomatic infant on presentation (no URI symptoms, no fever). The formal definition of a BRUE is: “A resolved event in an infant (less than one year) as described by an observer lasting less than one minute that includes one or more of the following: Color: Cyanosis or pallor Breathing: Absent, decreased or irregular Muscle Tone: Marked change (hyper or hypotonia) Level of Consciousness: Altered Here is another way to describe BRUEs. It is a diagnosis of exclusion that applies to infants under the age of 12 months. Most of the definition is in the name itself. It is Brief– it lasts less than 60 seconds It is Resolved– the infant is well appearing by the time we evaluate them It is Unexplained– If you think this episode can be explained as a seizure or a choking episode or gastroesophageal reflux, it is not a BRUE The Event includes one or more of the following four things: Change in Color– Specifically cyanosis or pallor Change in Breathing– Breathing is absent, decreased or irregular Change in Tone– Hyper or hypotonia or a Change in Level of Consciousness(LOC) It was previously called an ALTE (Apparent Life-Threatening Event) ALTE was defined in 1986 as “a frightening episode to the caregiver with apnea, choking, gagging, or changes in color, or muscle tone.” (McGovern and Smith). The diagnosis could have caused a great deal of anxiety in parents/caregivers. The name was not reassuring and the definition was vague. The Journal of Pediatrics published a systematic review of literature regarding the Management of ALTE in 2013 and one of the findings was that there was very little agreement in the literature on how to apply the definition. If even the folks who are really expert in the topic are not applying the definition consistently, then perhaps it’s time for a new definition. The change in name took place in 2016. The subcommittee on ALTEs in the AAP published a practice guideline renaming ALTEs to brief resolved unexplained events (BRUEs) in 2016. The New description broke things down into HIGH risk criteria and LOW risk criteria. High Risk Criteria: Prematurity (Gestational age less than 32 weeks and less than 45 weeks post conception) Age less than 60 days (two months) More than one event Low Risk Criteria:  Gestational age at least 32 weeks and post conception age at least 45 weeks Age greater than 60 days (two months) First BRUE Duration of event less than one minute No CPR by trained medical provider *No concerning historical features or physical findings There is an list of concerning historical features or physical findings at the end of this blog. Risk stratifying BRUE patients help direct management. High risk patients require a full evaluation and consideration for admission or observation should be considered. Low risk patients are broken up into four categories: Should do, should not do, may do and need not do. Should: Educate care givers about BRUE, shared decision making to guide management, recommend CPR training, and assess social risk factors to detect child abuse Should Not: CBC, blood cultures, CSF, electrolytes, VBGs or ABGs, ECHO, errors of metabolism, CXR, EEG, GERD study, neuroimaging, home monitoring, overnight sleep study, acid suppression or antiepileptic medication May Do: Pertussis testing, ECG, brief monitor with pulse oximetry and serial observation Not Needed: Viral respiratory tests, urinalysis (bag or catheter), blood glucose, serum lactic acid or bicarbonate, neuroimaging (to detect child abuse) or admit to hospital solely for cardiorespiratory monitoring Here is the flow diagram that was published with the clinical practice guidelines. It can be a great teaching tools and does a nice job of walking through the definitions and recommendations. Here is a table listing the recommendations, level of evidence and the strength of the recommendations. Reference: Ramgopal et al. Changes in the Management of Children With Brief Resolved Unexplained Events (BRUEs). Pediatrics 2019 Again, we are not doing a typical SGEM structured critical review. But we will be going over some of the elements of a review. Clinical Question: What are the changes in the management of BRUE after guideline publication? Patients were included in the study if they were less than or equal to 365 days of age found in a Pediatric Health Information System. This is an administrative database that contains ED, inpatient, ambulatory surgery, and observation data from children’s hospitals in the United States affiliated with the Children’s Hospital Association. They excluded five sites because of insufficient or incomplete data. Comparisons were made between patients diagnosed with ALTE or BRUE between 2015 and 2017. Patients were identified using ICD-9 and ICD-10 codes for the primary or secondary diagnosis or ALTE and BRUE between 2015 and 2017. The primary outcome was rate of admission. The secondary outcomes were rates of revisits and studies performed on index visit. We compared patients admitted in 2015 (before the 2016 guidelines) to those admitted in 2017 (after the 2016 guidelines). The study included 9,501 patients (5,608 in 2015 and 3,893 in 2017). The admission rate decreased from 2015 to 2017. For infants 0 to 60 days the decrease was 5.7% (95% confidence interval, 3.8% to 7.5%). For infants 61 to 365 days the decrease was 18% (95% confidence interval, 15.3% to 20.7%). The rates of testing also changed. Patients in 2017 had lower rates of EEG, brain MRI, chest radiography, laboratory testing, and urinalyses compared with patients in 2015. There were some limitations to the study: Things associated with using an administrative database like coding accuracy Converting ICD-10 to ICD-9 codes Granularity of the data was not complete enough to investigate the changes in management of BRUE after the implementation of the new guidelines A 30% decrease of BRUE from 2015 to 2017 that is unexplained External validity to countries other than the United States of America  Authors' Conclusions: “Compared with patients evaluated in 2015, patients with BRUE or ALTE in 2017 have lower rate of admissions and testing. Findings may be due to changes in the definition of BRUE and guideline recommendations.”  What do you tell the parents or caregivers when discharging a low risk BRUE? Dr. Katie Noorbakhsh "This part is so important. I usually start off by acknowledging the family’s concerns. I will say something like, I know that it was really upsetting and scary when your baby had this episode today, but the good news is that everything you have told me and everything that I see on exam today is very reassuring.  It is not uncommon for young infants to have a concerning episode that goes away on its own and we aren’t really sure what happens. In fact, it’s common enough that we have a name for it. We call it a Brief Resolved Unexplained Event. Now it’s unexplained so we don’t know exactly why your baby had this event, which is challenging to me because I like knowing why things happen, but what we do know what we should look for to tell us that a baby is safe to go home. And your baby has all of the things that we look for, she’s a little bit older, she just had one episode that resolved quickly and on its own, and she looks so well now. I am really glad that you guys came in when you were worried about her. I think you did the right thing. And if anything changes, if you think she is having trouble breathing, if she ever looks blue, if she isn’t eating or peeing well, if she isn’t acting like herself or if you just can’t put your finger on it but something is making you worry, then call your doctor or just come on back in and see us. We will be happy to take care of you." Other FOAMed: Don't Forget the Bubbles (BRUE vs. ALTE: have the new guidelines made a difference? Let me know what you think SGEMers about the way we covered the paper this time. Did you like it or hate it? Should I try this again or stick to the original formula? Send me an email at TheSGEM@gmail.com to let me know your thoughts. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.   Historical Features To Be Considered in the Evaluation of a Potential BRUE Considerations for Possible Child Abuse: Multiple or changing versions of the history/circumstances History/circumstances inconsistent with child’s developmental stage History of unexplained bruising Incongruence between caregiver expectations and child’s developmental stage, including assigning negative attributes to the child History of the Event: General description Who reported the event? Witness of the event? Parent(s), other children, other adults? Reliability of historian(s)? State immediately before the event? Where did it occur (home/elsewhere, room, crib/floor, etc)? Awake or asleep? Position: supine, prone, upright, sitting, moving? Feeding? Anything in the mouth? Availability of item to choke on? Vomiting or spitting up? Objects nearby that could smother or choke? State during the event: Choking or gagging noise?

Date: November 13th, 2019 Reference: van der Pol et al. Pregnancy-Adapted YEARS Algorithm forDiagnosis of Suspected Pulmonary Embolism. NEJM 2019 Guest Skeptic: Dr. Theresa Robertson-Chenier is currently an Emergency Physician practicing at the Peterborough Regional Health Centre. She is also an adjunct faculty member with Queen's University, Department of Family Medicine. Case: A 32-year-old female, G1P0, who is 22 weeks pregnant, presents to your local emergency department with the chief complaint of shortness of breath. She states that for the last one week she has had progressive shortness of breath on exertion. She denies any chest pain, fever, cough or leg swelling. She has no history of venous thromboembolic (VTE) disease like deep vein thrombosis (DVT) or pulmonary embolism (PE). But recently she drove seven hours from London, Ontario to Montreal, Quebec. She is worried about the possibility of a PE. She is otherwise healthy, takes only prenatal vitamins and has no allergies. She is terrified about any radiation exposure in pregnancy and has read on google that there is a blood test you can order to rule out PE. Background: We have covered VTE a number of times on the SGEM. This has even included a few of episodes with the PE guru and PERC rule creator Dr. Jeff Kline. However, we have never looked at the YEARS criteria study published by Van der Hulle T et al (The Lancet 2017). SGEM#51: Home (Discharging Patients with Acute Pulmonary Emboli Home from the Emergency Department) SGEM#126: Take me to the Rivaroxaban – Outpatient treatment of VTE SGEM#163: Shuffle off to Buffalo to Talk Thrombolysis for Acute Pulmonary Embolism SGEM#219:Shout, Shout, PERC Rule Them Out The YEARS algorithm starts with the clinician suspecting an acute PE. Then they order a D-dimer and apply the YEARS clinical decision instrument. It has three items with each getting one point: Clinical signs of DVT Hemoptysis PE most likely diagnosis If there are zero YEARS items and the d-dimer is <1,000ng/ml then a PE is excluded. If there are zero YEARS items but the d-dimer is equal to or greater than 1,000ng/ml then a CT pulmonary angiography (CTPA) scan is needed to rule out a PE. If there are one or more YEARS items and the d-dimer is <500ng/ml then a PE is excluded. If there are one or more YEARS items but the d-dimer is equal to or greater than 500ng/ml then a CTPA scan is needed to rule out a PE. While this publication was interesting, it was a prospective observational study from the Netherlands. There was a study by Kabrhel et al (AEM 2018) that was done in 17 hospitals in the USA. They compared usual care for possible PE vs. YEARS criteria. They enrolled 1,789 patients and 84 (4%) had a PE. Using standard d-dimer criteria, 53% would not have been imaged (2 misses). YEARS avoided imaging in 67%, but had 6 misses. Standard care had a sensitivity 97.6% vs, 92.9% for YEARS. It would be better if there was a randomized control trial comparing usual care to YEARS. In addition, the case you presented was of a pregnant woman. In the original YEARS study from 2017 it said pregnancy was an exclusion. Clinically, it can be difficult to diagnosis PE in pregnancy because of the overlap of symptoms due to the physiological changes in pregnancy (tachycardia, shortness of breath and leg swelling) with the signs and symptoms of PE. The incidence of PE is reported to be 1.72 cases per 1,000 deliveries, and it accounts for approximately one death in every 100,000 deliveries. In addition, the diagnostic tests used to diagnosis PE come with their own risks to mom and fetus. The radiation dose to the maternal breast can be potentially carcinogenic owing to the radiosensitive nature of the glandular breast during pregnancy. A CTPA study can increase the risk of breast cancer by 1.5% in a 25-year-old woman (see reference on last page). Clinical Question: Can the YEARS algorithm, which utilizes the D-dimer test, be used in pregnant women to rule out the diagnosis of pulmonary embolism? Reference: van der Pol et al. Pregnancy-Adapted YEARS Algorithm forDiagnosis of Suspected Pulmonary Embolism. NEJM 2019 Population: Pregnant women, 18 years of age and older, with clinically suspected PE (defined as new onset or worsening dyspnea, +/- hemoptysis or tachycardia) referred to the ED or the obstetrical ward. Exclusions: Treatment with a full-dose therapeutic anticoagulant agent, can’t follow-up, allergy to the contrast dye, or a life expectancy of less than three. Intervention: Application of the pregnancy-adapted YEARS algorithm to rule out PE in pregnant women. Comparison: Not using pregnancy-adapted YEARS (Hypothetical situation in which all patients undergo CTA or VQ scan) Outcome: Primary Outcome: The cumulative incidence of symptomatic VTE, with confirmation by objective tests, during a 3-month follow-up period in the subgroup that anticoagulation treatment was withheld. Secondary Outcome: Proportion of patients in whom CTPA was not indicated. The pregnancy-adapted YEARS algorithm is the same as the YEARS algorithm but if the pregnant patient has signs of a DVT you get an ultrasound of the leg. If it shows a DVT you treat for VTE. If it does not show a DVT then you enter the regular YEARS algorithm. Image from MDCalc. Authors’ Conclusions: “Pulmonary embolism was safely ruled out by the pregnancy-adapted YEARS diagnostic algorithm across all trimesters of pregnancy. CT pulmonary angiography was avoided in 32 to 65% of patients”. Quality Checklist for Clinical Decision Tools: The study population included or focused on those in the ED. Unsure The patients were representative of those with the problem. Yes All important predictor variables and outcomes were explicitly specified. Yes This is a prospective, multicenter study including a broad spectrum of patients and clinicians (level II). Yes Clinicians interpret individual predictor variables and score the clinical decision rule reliably and accurately. No This is an impact analysis of a previously validated CDR (level I). No For Level I studies, impact on clinician behavior and patient-centric outcomes is reported. No The follow-up was sufficiently long and complete. Yes The effect was large enough and precise enough to be clinically significant. Unsure Key Results: They recruited 498 consecutive pregnant women with clinically suspected PE into the study. The mean age was 30 years and almost half (46%) were in their third trimester. Half of the patients had no YEARS criteria and half had at least one of the three criteria (19% signs of DVT, 8% hemoptysis and 89% PEs were the most likely diagnosis). Only one symptomatic DVT was diagnosed in follow-up that was not anticoagulated. Primary Outcome:VTE at three months in the subgroup anticoagulation was withheld. 477/498 (96%) VTE was ruled out at baseline Only 1 DVT (0.21%)was identified during follow-up (95% CI; -0.04 to 1.2) Secondary Outcomes: Proportion of patients in whom CTPA was not indicated 195 patients were ruled out based on the adapted YEARS algorithm 12 (6.2%) patients had a CTPA even though not indicated (protocol violation). All 12 were negative for PE. CTPA could safely be avoided in 39% of the patients (95% CI 35-44) 1. Incorporation Bias: This can occur when results of the test under study are actually used to make the final diagnosis. In this study the authors acknowledge that the physician may have been aware of the d-dimer results when assessing the YEARS criteria. This can make the test (diagnostic algorithm) appear more powerful by falsely raising the sensitivity and specificity. 2. Partial Verification Bias (Referral Bias or Work-Up Bias): This can happen when only a certain set of patients who underwent the index test is verified by the reference standard. In YEARS, only those with a positive d-dimer (>1,000 or >500 depending on zero or 1+ criteria) got the definitive test. This could increase sensitivity but decreases specificity. 3. Differential Verification Bias (Double Gold Standard): This is very similar to partial verification bias and could be part of incorporation bias. Differential verification bias can occur when the test results influence the choice of the reference standard. So, a positive index test gets an immediate/gold standard test (CTPA in this case) whereas the patients with a negative index test get clinical follow-up for disease. This can raise or lower sensitivity and specificity. 4. Subjectivity: One of the weaknesses of this study is that it includes the subjective part of the Well’s criteria as part of the YEARS criteria. The part where the clinician needs to use clinical gestalt and decide if a PE is the most likely diagnosis. 5. Spectrum Bias: You made me think of one more potential bias, spectrum bias. Sensitivity depends on the spectrum of disease, while specificity depends on the spectrum of non-disease. So, you could falsely raise the specificity if the YEARS algorithm is used as a screening test. Just because a pregnant patient has some vague chest pain or shortness of breath does not get them into the algorithm. The clinician had to have a clear suspicion of PE. The best paper on these biases was Understanding the Direction of Bias in Studies of Diagnostic Test Accuracy (Kohn et al AEM 2013). Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusion. SGEM Bottom Line: The pregnancy-adapted YEARS algorithm has the potential to safely rule out PE and decrease CTPA studies but requires external validation. Case Resolution: Your clinical gestalt is she does not have a VTE and you do not work her up for a PE.

Date: November 21st, 2019 Reference: Daley et al. Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs. AEM November 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 caring for a 45-year-old male patient in the emergency department with pleuritic chest pain. You suspect he has a pulmonary embolism (PE), and the CT scanner is currently being used up by a multi-patient multiple-trauma pan-scan which promises to take hours. Your patient has a heart rate of 105 bpm and a systolic blood pressure of 95 mmHg. You pull the department’s ultrasound machine to the bedside and prepare to do a focused cardiac ultrasound to decide if you want to treat for a PE while waiting for the scanner to free up. Background: We have covered the issue of PE many times on the SGEM. This has included outpatient management (SGEM#51 and SGEM#126), catheter directed thrombolysis (SGEM#163) and even discussed the PERC rule with its creator, Dr. Jeff Kline (SGEM#219). We may have covered it so often because PE is commonly suspected in patients presenting the ED with chest pain, shortness of breath, or other symptoms. The current gold standard test is a CT angiogram of the pulmonary arteries (CTA), but this test cannot be performed immediately in some patients due to renal function, availability of the equipment, or contrast allergies. There are concerns about doing CTAs in pregnant patients due to the radiation exposure to both the mother and fetus. We have a show coming up soon looking at a pregnancy adapted YEARS criteria to help minimize the number of CTAs ordered in this patient population. In addition, patients with hemodynamic instability may not be appropriate to take out of the resuscitation bay. Focused cardiac ultrasound (FOCUS) can show findings of right ventricular strain caused by a PE, but in all patients suspected of PE, it is relatively insensitive. However, it has been suggested that in patients with hemodynamic instability, the sensitivity may be higher. Clinical Question: In patients presenting to the ED with suspected PE, who have abnormal vital signs, what is the sensitivity of FOCUS for PE? Reference: Daley et al. Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs. AEM November 2019 Population: Adult patients (>17 years old) undergoing evaluation for PE who are tachycardic (HR >100bpm) and/or hypotensive (systolic BP <90mmHg) Excluded: Prisoners, wards of the state, non–English-speaking patients, and those where investigators could not obtain any ECHO data due to technical challenges. Intervention: Focused cardiac ultrasound (FOCUS) Comparison: CT angiography of the pulmonary arteries Outcome: Primary Outcomes: Sensitivity of FOCUS for PE patient with a HR ≥ 100 beats/min or sBP < 90 mm Hg (n = 136) and those with a HR ≥ 110 beats/min (n = 98). Secondary Outcomes: Specificity and likelihood ratios of FOCUS for PE in each population. Dr. James Daley This is an SGEMHOP episode which means we have the lead author on the show. Dr. James Daley is an emergency physician at Yale New Haven Hospital where he's currently finishing up a fellowship in emergency ultrasound and research. His work centers around the use of point of care echocardiography in the diagnosis of pulmonary embolism and he hopes to branch out to other topics in resuscitation research in the future. Authors’ Conclusions: “A negative FOCUS exam may significantly lower the likelihood of the diagnosis of PE in most patients who are suspected of PE and have abnormal vital signs. This was especially true in those patients with a HR ≥ 110 BPM. Our results suggest that FOCUS can be an important tool in the initial evaluation of ED patients with suspected PE and abnormal vital signs.” 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? Unsure Was the cohort recruited in an acceptable way? No 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? No Was the follow up of subjects complete enough? Yes How precise are the results? Not very 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 Key Results: They screened 143 patients who underwent CTA with 136 subjects enrolled in the study. The mean age was in the mid-50’s, 59% were female, 23% had a previous VTE, 40% had cancer in the previous 6 months and 15% had signs or symptoms of a DVT. FOCUS had a sensitivity of 92% and specificity of 64% for PE Primary Outcomes: Sensitivity of FOCUS for PE in all patient with a HR ≥ 100 beats/min or sBP < 90 mm Hg was 92% (95%CI; 78% to – 98%) Sensitivity of FOCUS for PE in patients with a HR ≥ 110 beats/min (n = 98) was 100% (95%CI; 88% to 100%) Secondary Outcomes: There was substantial interobserver agreement for FOCUS (kappa = 1.0, 95% CI = 0.31 to 1.0) when they were only required to call it positive or negative. You can listen to the podcast on iTunes or Google Play to hear James’ answers to our ten nerdy questions. 1. Convenience Sample: This was a convenience sample. We always like to see consecutive patients recruited but understand the reality of research. Do you think this could have impacted the results in any meaningful way? 2. Spectrum Bias: Sensitivity depends on the spectrum of disease, while specificity depends on the spectrum of non-disease. Because they looked at sicker patients (tachycardic and hypotensive) this could falsely raise the sensitivity of FOCUS. Did you consider doing a multivariable model which could have told us what the association of these vital signs with PE are and not have had to prespecify arbitrary cut points? 3. Blinding: The clinicians obtaining the images (staff, residents and medical students) were not blinded to the hypothesis. There are some subjective aspects to FOCUS when obtaining images. In addition, investigators we unblinded to the results in two cases because the patient were getting a heparin infusion when FOCUS was performed. These things could have biased the operators and made the diagnostic parameters look better than if they did not know the purpose of the study or that the patients had a PE. 4. Primary Outcome: You have what seems to be two primary outcomes, meaning the sensitivity in two patient groups. Can you explain the decision not to define one as the primary and the other as a secondary? 5.Missing Data: How researchers handle missing data is important. There were times when data was missing. Can you explain how that could impact your results? 6. Precision: There were fairly wide 95% confidence intervals around the point estimates for the primary outcome. The lower limits of your sensitivity calculations in patients with HR >100 or BP <90 mmHg are in the 70s. How does this affect your recommendation for using FOCUS to evaluate for PE in these patients? 7. Sensitivity and Specificity: While these statistics provide additional information using likelihood ratios can be more helpful to clinicians. We like to see LR+ more than 10 to confidently rule in a condition and LR- less than 0.1 to rule out a condition. FOCUS did not demonstrate robust enough diagnostic accuracy to help make clinical decisions. 8. Inter-Rater Reliability: Your study had seven ultrasound trained attendings, three EM residents and three medical students. All had different degrees of experience. The inter-rater reliability for FOCUS being positive or negative by two separate sonographers was substantial with a kappa statistic of 1.0 (95% CI = 0.31 to 1.0). How did the attendings compare to the residents and medical students? 9. Resource Poor Facilities: You hypothesized in the discussion that FOCUS could play a role in rural locations that lack access to CTA. I have worked my entire career in locations without a CT scanner. Those locations without a CT do not have a high volume of patients presenting with a suspected PE. Would this not make it difficult to maintain FOCUS skills and lower the diagnostic accuracy of this test? 10. Anything Else: Any other thoughts or comments you think the SGEM audience needs to know about your study? Have you considered a head to head comparison of FOCUS vs. CT for PE? Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions especially since they used the word “may” which can also mean “may not”. SGEM Bottom Line: Focused cardiac ultrasound does not have good enough diagnostic accuracy even in patients with abnormal vital signs to safely rule in or rule out PE. Case Resolution: Your FOCUS exam on your patient shows an essentially normal RV. You delay anticoagulation therapy at this time, choosing to await the CTA results. We face this all the time with patients needing to be transported to another facility for the CTA. This typically takes about three hours. It is my routine not to anticoagulated prior to transportation. Dr. Corey Heitz Clinical Application: In patients with abnormal vital signs, bedside FOCUS may help guide empiric therapy in patients with suspected PE but cannot make a definitive diagnosis to rule in or out a PE. What Do I Tell My Patient? The ultrasound I just performed tells me that you likely do not have a pulmonary embolism, and I think it’s too risky to provide anticoagulation at this time.

Date: November 6th, 2019 Reference: Lascarrou et al. Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. NEJM Oct 2019 Guest Skeptic: Dr. Laura Melville (@lmelville535) is an emergency physician in Brooklyn, New York, is a part of the New York ACEP Research Committee, ALL NYC EM, and is the NYP-Brooklyn Methodist Resident Research Director. Case: A 59-year-old woman comes is brought into your emergency department (ED) by EMS in cardiac arrest. She had a witnessed arrest, and CPR was initiated by bystanders. Her initial rhythm in the field was reported as pulseless electrical activity (PEA) by EMS.  The patient achieved return of spontaneous circulation (ROSC) on arrival to the ED.  You call your hyperthermia team to initiate targeted temperature management (TTM), which in your hospital means 33C for 24 hours followed by slow rewarming for 24 hours. Your senior resident asks you “should we really be cooling our patient to 33C, doesn’t the data suggest 36C is just as good? And if she was not in a shockable rhythm at arrest, will she be likely to benefit from this treatment?”  The patient’s family has separately mentioned they heard she might have a better chance of being “normal” if she gets cooled down.  What do you say?  Do you continue with the ICE Code? What do you tell the patient’s family? Background: We have covered therapeutic hypothermia many times on the SGEM. This has been or out-of-hospital cardiac arrests (OHCA). Therapeutic hypothermia has not been demonstrated to have benefit in the pre-hospital setting (SGEM#54 and SGEM#183). But two earlier randomized controlled trials (Hypothermia after Cardiac Arrest Study Group 2002 and Bernard et al 2002) showed benefit for good neurologic outcome when TTM was initiated in the hospital after ROSC was achieved.  In those studies, the temperature goal was 32C-34C and 33C respectively. The SGEM covered the targeted temperature management (TTM) trial published in the NEJM. It showed cooling patients to 33C was not superior to 36C for the primary outcome (SGEM#82). The most recent time we have looked at therapeutic hypothermia was SGEM#199. This was a trial looking to see if there was a neuroprotective effect of hypothermia in patients with status epilepticus. Unfortunately, that study failed to demonstrate a benefit of therapeutic hypothermia for adult patients admitted to the ICU with convulsive status epilepticus. It seems like TTM is a good example of an intervention that “makes sense” but doesn’t always work. There are many examples like this in the literature where something makes sense from a pathophysiologic standpoint but is not demonstrated to work when properly tested. Clinical Question: Does therapeutic hypothermia improve survival with good neurologic outcome in patients who achieve ROSC after non-shockable cardiac arrest? Reference: Lascarrou et al. Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. NEJM Oct 2019 Population: Adults (18 years and older) with OHCA or IHCA of any cause, with non-shockable rhythm and a Glasgow Coma Scale (GCS) score of 8 or lower. Exclusion: No flow time of more than 10 minutes (collapse to starting CPR), low-flow time of more than 60 minutes, major hemodynamic instability (continuous vasopressor infusion), time from cardiac arrest to screening >300 minutes, moribund condition, severe hepatic dysfunction, pregnant or breast-feeding, prisoner, lack of health insurance and decide not to participate (by next of kin). Intervention: Targeted temperature management to 33C (+/- 0.5C) was started post arrest and then maintained for 24hrs. Cooling protocol was determined by each of the 25 participating sites. Slow rewarming of 0.25-0.5C/hr to target of 36.5-37.5C, which was maintained for 24hrs. Cooling: Active internal cooling with a specific device, active external cooling with a specific device, or active external cooling without a specific device. Comparison: Targeted normo-therapy to 36.5-37.5C for 48 hours Outcomes: Primary Outcome: Survival to good neurologic outcome at 90 days as defined by Cerebral Performance Category (CPC) scale score of 1 or 2. Secondary Outcomes: clinicaltrials.gov listed 20 outcomes (NCT01994772). The methods section only mentioned six (mortality, mechanical ventilation, length of stay in the ICU and hospital, infection and hematologic adverse events). Authors’ Conclusions: “Among patients with coma who had been resuscitated from cardiac arrest with nonshockable rhythm, moderate therapeutic hypothermia at 33C for 24 hours led to a higher percentage of patients who survived with a favorable neurologic outcome at day 90 than was observed with targeted normothermia.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No 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). Yes The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. No Key Results: The screened 2,723 patients for eligibility and 584 underwent randomizations. The median age was 67 years, two-thirds were male, and three-quarters were OHCAs. Survival with good neurological function was higher in the TTM group Primary Outcome: Survival to discharge with good neurological outcome as measured by a CPC score of 1 or 2 was statistically better in the TTM group compared to the Usual Care group. 10.2% TTM vs. 5.7% Usual Care (absolute difference 4.5%), p=0.047 which gives an NNT of 22 Hazard ratio 4.5 (95% CI; 0.1 to 8.9) and a fragility index of 1 Secondary Outcomes: There was no statistical differences in any of the secondary outcomes Mortality at 90 days 81.3% TTM vs. 83.2% Usual Care (95% CI; −8.0 to 4.4). No statistical difference was reported for mechanical ventilation, length of stay in the ICU and hospital, infection and hematologic adverse events. 1) Statistics: They based their sample size calculation on the assumption that there would be survival with good neurologic function in 23% of the TTM and 14% of the usual care. This would mean they expected a 9% absolute difference. The actual result was only 10.2% for TTM and 5.7% in usual care (4.5% absolute difference). This often happens in research. My EBM mentor Dr. Andrew Worster who taught me also told me if you want to make an outcome rare all you need to do is study that outcome. Here they thought they would have a higher prevalence of the primary outcome and yet in this population it was less than half. Besides basing their sample size on this expected outcome, they also fell a few patients short of their target. The goal was to get 584 participants but three withdrew consent so left them with 581.  Again, because their outcome of interest occurred less often than anticipated, and the difference between the two groups was half what was expected, the study was underpowered. 2) P-Values and Fragility Index: We have discussed the problem with being dichotomous about p-values and the utility of the fragility index. They did report a statistical difference between the two groups for the primary outcome, but the p value was 0.047. That does not mean therapeutic hypothermia works or does not work but rather needs to be interpreted as the probability of false rejecting the null hypothesis and making a type I error. The fragility index is linked mathematically to the p-value and is another way of representing the data. In this study the fragility index was 1. This means that changing the outcome of one participant would have made the results statistically non-significant on a subjective outcome measure susceptible to bias due to lack of blinding and reliability of the CPC score. 3) Lack of Blinding: This is a huge limitation of this study. While the unconscious patients and the outcome assessor were blinded to group allocation, the clinicians were not blinded. This introduces bias that would probably be directed towards treatment. The hypothesis was that TTM would provide a patient-oriented benefit (superior to usual care). Patients could have consciously or unconsciously  been treated differently by the clinicians. These potential subtle differences in management could be responsible for the fragile statistical difference demonstrated. 4) Temperature Management: The true duration of temp control seemed at first like both groups were exposed to temperature management for the same amount of time (48 hours).  However, temperature management was performed between 8-16 hours longer in the 33C group, due to additional time required for re-warming.  In addition, a number of patients had their body temperatures rise above 38C, in particular after the period of TTM. This could have impacted the results and suggests the target should have been 36C for the usual care to prevent hyperthermia. 5) Outcome Assessment: This builds on nerdy point #3. The outcome was done by a single psychologist. They were blinded to the group allocation, but the patient was not. They were being questioned on their neurologic function and could have known if they were or were not in the treatment group thought to be superior. The CPC is a subjective assessment not objective and was done over the telephone.

Date: November 2nd, 2019 Reference: Lee and Yun. Diagnostic Performance of Emergency Physician-Performed Point-of-Care Ultrasonography for Acute Appendicitis: A Meta-Analysis. AJEM 2019. Guest Skeptic: Chip Lange is an Emergency Medicine Physician Assistant (PA) working primarily in rural Missouri in community hospitals. He also hosts a great #FOAMed blog and podcast called TOTAL EM. Chip is the CEO of an ultrasound education company called Practical POCUS which is based in the United States but is expanding into an international market. Case: A 6-year-old boy comes into your emergency department at around midnight with his parents complaining of abdominal pain.  His mother reports that the symptoms began a couple of days ago and he did not eat today.  Now, the patient has been vomiting for the last couple of hours.  Initially, he would point to the periumbilical area, but his father says that now he points to the right lower portion of the abdomen as his area of pain.  You do not have an ultrasound tech available at night and you are thinking of using your point of care ultrasound (POCUS) skills to look for a possible appendicitis, but you are unsure how accurate this test would be especially compared to other modalities such as radiology performed ultrasound. Background: We have reviewed papers on POCUS many times over the years on the SGEM. This has included performing lumbar punctures, diagnosing acute abdominal aneurysms, acute heart failure, pediatric fractures, retinal detachments and endotracheal tube placement. SGEM#41: Ultra Spinal Tap (Ultrasound Guided Lumbar Puncture) SGEM#94: You Better Think Ultrasound for Acute Abdominal Aneurysm SGEM#97: Hippy Hippy Shake – Ultrasound Vs. CT Scan for Diagnosing Renal Colic SGEM#119: B-Lines (Diagnosing Acute Heart Failure with Ultrasound) SGEM#124: Ultrasound for Skull Fractures – Little Bones SGEM#153: Simulation for Ultrasound Education SGEM#177: POCUS –A New Sensation for Diagnosing Pediatric Fractures SGEM#245: Flash-errrs (POCUS for Retinal Detachments) SGEM#249: Ace in the Hole –Confirming Endotracheal Tube Placement with POCUS Ultrasound, especially in the pediatric population, has been a common form of imaging for the diagnosis of appendicitis.  It avoids the concerns for radiation and contrast that is seen with CT.  MRI is not practical in many situations, especially in rural or remote environments. However, ultrasound does have its limitations especially in obese patients or those unable to comply with the exam for reasons such as pain. Clinical Question: What are the diagnostic performance of point of care ultrasonography (EP-POCUS) for diagnosing acute appendicitis? Reference: Lee and Yun. Diagnostic Performance of Emergency Physician-Performed Point-of-Care Ultrasonography for Acute Appendicitis: A Meta-Analysis. AJEM 2019. Population: Patients in original research articles with right-lower quadrant (RLQ) abdominal pain with EP-POCUS being performed as the index test and the use of surgical or pathological findings as the reference standard for acute appendicitis. There had to be sufficient information to reconstruct a 2x2 contingency table regarding sensitivity and specificity. Excluded: Case reports, case series, review articles, guidelines, consensus statements letters, editorials, clinical trial, and conference abstracts. Additionally, studies that did not pertain to the field of interest, insufficient data to create the 2x2 tables, POCUS was not performed by emergency physicians (EPs), and studies that only used the radiologists’ final report. Intervention: EP-POCUS for diagnosing acute appendicitis. Comparison:Radiologist-performed ultrasonography (RADUS) Outcome: Primary Outcome: Diagnostic parameters of EP-POCUS for acute appendicitis (sensitivity, specificity and likelihood ratios). Secondary Outcomes: Subgroup analysis of pediatric patients comparing EP-POCUS to radiologist-performed ultrasonography (RADUS). Authors’ Conclusions: “The diagnostic performances of EP-POCUS and radiologist-performed ultrasonography (RADUS) were excellent for AA, with EP-POCUS having even better performance for pediatric AA.  Accurate diagnoses may be achieved when the attending EP is the initial POCUS operator and uses a 7mm cut-off value.” Quality Checklist for Systematic Review Diagnostic Studies: The diagnostic question is clinically relevant with an established criterion standard. Yes The search for studies was detailed and exhaustive. No The methodological quality of primary studies were assessed for common forms of diagnostic research bias. Yes The assessment of studies were reproducible. Yes There was low heterogeneity for estimates of sensitivity or specificity. No The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision-making models. Unsure Key Results: Their search identified 17 studies involving 2,385 patients. The mean age ranged from 6 to 37 years of age and the mean proportion of male patients were 26% to 61%. EP-POCUS exhibited a pooled sensitivity of 84% and a pooled specificity of 91%, with a positive likelihood ratio of 7.0 and a negative likelihood ratio of 0.22 for diagnosing acute appendicitis. There was better diagnostic performance for pediatric acute appendicitis with a sensitivity of 95% (95% CI: 75%-99%) and specificity of 95% (95% CI: 85%-98%). A direct comparison revealed no statistical differences (p=0.18-0.85) between the diagnostic performances of EP-POCUS (sensitivity: 81%, 95% CI: 61%-90%; specificity: 89%, 95% CI: 77%-95%) and RADUS (sensitivity: 74%, 95% CI: 65%-81%; specificity: 97%, 95% CI: 93%-98%). The meta-regression analyses revealed that study location, acute appendicitis proportion, and mean age were sources of heterogeneity. Higher sensitivity and specificity tended to be associated with an appendix diameter cut-off value of 7 mm and the EP as the initial operator. 1. Wide Range of Cut-Offs:There was a wide range of cut-offs for appendicitis including the diameter and the concurrent findings. This has helped attribute to the heterogeneity of the studies.  We care about this primarily because it makes it more difficult to see if certain parameters are most beneficial for diagnostic cut-offs.  However, from this particular data set, the 7mm cut-off for appendiceal diameter seems to be better than the 6mm cut-off used in other studies. 2. Heterogeneity: There was large heterogeneity as reported by the I2 metric. It was 94% for sensitivity and 89% for specificity. This will affect pooled estimates and we see this all with the wide confidence intervals that were present. It is reasonable to question whether or not these studies should have been meta-analysed given the large heterogeneity. We should be skeptical of these results, especially given the data used. 3. Likelihood Ratios: We like to see LR+ greater than 10 to rule in a diagnosis and LR- less than 0.1 to rule out a diagnosis. Only the RADUS had a LR+ of >10. Neither RADUS nor EP-POCUS had a LR- of less than 0.1. 4. Clinicians: Like most studies regarding POCUS, this used resident and attending physicians in academic centers and does not speak to the abilities of other types of clinicians (such as PAs and NPs or those in rural or remote environments). It would be fantastic to see future studies that addressed these issues specifically to see how much of an impact there is with these groups of clinicians. 5. Pediatric Patients: The evidence for EP-POCUS is strongest for pediatric examinations. This may primarily be related to body habitus. The larger the patient, the harder it is to visualize abdominal organs, especially the appendix.  Also, in small pediatric patients the high-frequency linear probe is frequently used which provides even more detailed visualization of the appendix compared to the more classically use lower-frequency curvilinear or phased array probes. Comment on Authors’Conclusion Compared to SGEM Conclusion:We think that the diagnostic accuracy of EP-POCUS is good but not excellent for diagnosing acute appendicitis. It is better in pediatric populations and that the use of a 7mm cut-off appears to be more accurate.  SGEM Bottom Line: EP-POCUS has the potential to diagnose acute appendicitis especially in pediatric populations and appears to be better at ruling in rather than ruling out. Case Resolution: With consent from the parents and patient, you are able to use your bedside ultrasound and find an 8mm non-compressible and aperistaltic appendix.  You call the pediatric general surgeon who takes the patient to the OR for further management including appendectomy. Chip Lange PA Clinical Application: POCUS continues to play an important role in emergency medicine and is being embraced more over time.  We should consider using ultrasound for a variety of conditions including for the diagnosis of appendicitis. Given the issues of operator experience, study heterogeneity and wide confidence intervals we do not think EP-POCUS should be the sole criteria in diagnosing acute appendicitis. What Do I Tell the Patient? I would tell the parents and patient that we are going to use a special machine that uses sound waves to look into his abdomen to see if his appendix, a small tube in his stomach that can become sick and be causing his symptoms. It is a good test, but it is far from a perfect test. If I see a swollen appendix with the ultrasound machine your son probably has appendicitis. If I do not see his appendix, we probably will need to do more testing. Keener Kontest: Last weeks winner was Dr. Steven Stelts from Auckland, New Zealand. He knew the term that originally used to describe a break in the 4th or 5th metacarpal was “bar room fracture”. Listen to the podcast to hear this weeks’ trivia question.

Date: October 29th, 2019 Reference: Pellatt et al. Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial. Annals of EM 2019 Bootcamp Buddies Guest Skeptic: Martha Roberts is a critical and emergency care, triple certified nurse practitioner, currently living and working in western Massachusetts. She is the host of EM BOOTCAMP in Las Vegas, as well as a usual speaker and faculty member for The Center for Continuing Medical Education (CCME). She writes a blog called The Procedural Pause for Emergency Medicine News and is the lead content editor and director for the videos series soon to be included in Roberts & Hedges Clinical Procedures in Emergency Medicine. Martha also serves as an adjunct professor for both Georgetown University and Marymount University in the Washington D.C. area. We thought about using Simon and Garfunkel’s song “The Boxer” but  later decided to use “My Buddy” song by Anne Murray. “The Boxer” was one of the most highly produced songs by Simon and Garfunkel. The song is the single of and is featured on the album Bridge over Troubled Water released in May,1969. It was written by Paul Simon as he laments about being criticized by the public.  The song also features a bass harmonica and a Moog synthesizer. The song made it to the Rolling Stones list of top 500 songs of all time as #106. Case: A 26-year-old right-handed male presents to the emergency department on Friday night with a swollen right hand after punching a wall.The x-ray confirms an uncomplicated boxer’s fracture. You explain to him the traditional management which includes adequate pain control, immobilization with a cast and referral to a hand surgeon. He does not want any opioids because a friend was addicted to oxycocet. He is fine with going to see a hand surgeon in clinic, but asks if he really needs a cast. He is concerned that it will interfere with going to work on Monday morning. Background: Boxer’s fractures are common hand injuries. They are usually due to punching a solid object with a closed fist. For clarity, in this SGEM episode: when we say boxer’s fracture, we are referring to a fracture of the neck of the fifth metacarpal. There has been some controversy on the best way to manage an uncomplicated boxer’s fracture. This is typically defined as a minimally displaced closed fracture with angulation up to 70 degrees. Poolman et al (Cochrane 2005) did a SRMA and pooled together five studies with a total of only 252 patients. Most of the studies were of poor quality and functional outcome was not used in any of the studies. Because of the lack of good evidence, no treatment modality could be recommended over another. Another systematic review meta-analysis was done by Dunn et al (Orthopedics 2016). They found that cast immobilization is not superior to soft wrap without reduction in most cases. No study had investigated whether or not buddy taping would be superior to casting for functional outcomes in patients with boxer’s fractures. Clinical Question: Is buddy taping an uncomplicated boxer's fracture just as effective as a plaster cast? Reference: Pellatt et al. Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial. Annals of EM 2019 Population: Adults (18-70 years of age) with uncomplicated fractures of the fifth metacarpal neck (boxer’s fracture). Uncomplicated Fractures: These were defined as fractures confirmed by radiograph with at least two views showing a closed fracture (NOT comminuted, NOT intra-articular) with fracture angulation less than 70 degrees, less than one week old, did not have tendon involvement and with no polytrauma or other significant injury. Excluded: Patients less than 18 years of age or older than 70 years. Fractures that were open, gross rotational deformity, comminuted intra-articular, associated with polytrauma or other significant injuries. Fractures Patients were also excluded if the fracture angulation was greater than 70 decrease and the injury was older than one week. Intervention: Buddy taping of the ring finger and little finger. Comparison: Cast immobilization in an ulnar gutter cast applied in a position of safety. Outcome: Primary Outcome: Hand function at 12 weeks using the QuickDASH QuickDASH is a validated tool to evaluate a patient’s ability to perform certain upper limb activities. DASH stands for Disabilities of the Arm, Shoulder and Hand. The original questionnaire has 30 items while the QuickDASH has only 11. The patient reports their functional ability on a 5-point Likert scale. The patient’s overall disability is rated between 0 and 100. The higher the score, the greater the disability. The minimal detectable change (MDC) is 11% while the minimal clinical important difference (MCID) is 8%. Secondary Outcomes: Pain, satisfaction, return to work, return to sports, and quality of life. Authors’ Conclusions: “We found that patients with boxer’s fractures who were randomized to buddy taping had functional outcomes similar to those of patients randomized to plaster cast at 12 weeks. We advocate a minimal intervention such as buddy taping for uncomplicated boxer’s fractures.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. 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. No All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). No All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. Unsure Key Results: They assessed 506 patients for eligibility with 126 randomized. The mean age was in the mid-twenties, 85% were male and 90% were right hand dominant. No statistical difference in the QuickDASH score between buddy tape and plaster casting. Primary Outcome: Median QuickDASH score at 12 weeks 0 buddy tape vs. 0 plaster cast (95% CI; 0 to 0) Secondary Outcomes:  Pain – Both groups reported absence of pain at 12 weeks Satisfaction – Both groups reported high satisfaction scores with treatment Return to Work – Buddy tape patients missed no days of work while those in a cast missed a median of two days of work Return to Sports – No difference between the two groups Quality of Life - No difference between the two groups  1. Selection Bias: There is a possibility of selection bias. There were 41 eligible patients who were not recruited and 34 who declined to participate. The patients who were missed were because the emergency department was too busy and there were other clinical priorities.  The demographics of the missed patients were similar to the included patients suggesting that selection bias would be unlikely. 2. Loss to Follow-Up: One quality indicator is whether or not there were more than 20% of patients lost to follow-up. They reported 21% of patients being lost to follow-up (18% in the buddy tape group and 23% in the plaster cast group). This threatens the validity of the conclusions. 3. Non-Inferiority Trial: This was designed as a superiority trial. The real question could have been: is buddy taping non-inferior (not worse) that casting. A smaller sample size would be needed to demonstrate non-inferiority. This should help with nerdy point #5 about replication. 4. QuickDASH: We had some questions and concerns about the QuickDASH assessment tool. It's reliability is 0.9 and its validity is 0.7. This could have an impact of the precision of the results. 5. Replication: This study would need to be replicated in other healthcare systems for external validity. The patient population is probably the same, but their expectations may be different. What impact would this have on emergency department length of stay and cost. Would local specialists agree with such a change in management? Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree that they demonstrated buddy taping had similar functional outcomes to plaster casting in patients with a boxer’s fracture. However, we would not advocate for buddy taping uncomplicated boxer’s fractures at this time based on one RCT. SGEM Bottom Line: Consider offering patients with uncomplicated boxer’s fractures buddy taping. Case Resolution: You inform him there is another treatment option called buddy taping and in form him of the limitations of the evidence. He decides to try buddy taping instead of a plaster cast. Ulnar Guttar Clinical Application: This small trial provides some evidence that buddy taping uncomplicated 5th metacarpal fractures is reasonable. It is not enough to change my routine practice of putting patients in an ulnar gutter. The orthopedic surgeon or plastic surgeon can decide how to manage these patients once they see them in clinic. If the patient requests not having a cast, I will bring up the buddy taping idea. We think this type of treatment needs to be validated and confirmed before offering this routinely to patients. Buddy Taping What Do I Tell My Patient? There is another option besides casting. One small study of less than 100 patients done in Australia put half the people in casts and half of them had their 4th and 5th finger buddy taped together.

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: Benefit: This was presented as either 1% or 0.1% Risk: This was presented as either 1% or 0.1% Incentive: Patients were offered either $100 to forgo the CT, or $0. All risk and benefit information were provided in multiple formats, include percentages (0.1%), ratios (1 in 1,000), and in visual depictions. Outcome: Primary Outcome: The percentage of patients that chose to receive a CT scan. Secondary Outcome: They performed multiple regressions to control for potential confounders. Dr. William Meurer This is an SGEMHOP episode which means we have one of the authors on the show. Dr. William Meurer is an emergency physician. His focus is on the treatment of acute neurological emergencies, both as a researcher and clinician. He has been part of the University of Michigan Acute Stroke Team since 2006. In addition, Dr. Meurer has experience enrolling patients in acute trials and has served as a local PI for the CLEAR-ER trial (a trial enrolling acute stroke patients in the ED that tested a reperfusion strategy). He is on the executive team of the Strategies to Innovate EmeRgENcy Care Clinical Trials Network (SIREN). Dr. Meurer has other active or recently completed NIH funded clinical trials involving acute vertigo in the emergency department, hypertension, and therapeutic hypothermia after cardiac arrest. Jessica Winkels Jessica Winkels is the second author on this AEM publication and also joins us on the podcast. She is a fourth-year medical student at the University of Michigan. Jessica is planning on going into emergency medicine after she graduates in the spring. Publishing in AEM should certainly help with her application. Authors’ Conclusions: “Providing financial incentives to forego testing significantly decreased patient preference for testing, even when accounting for test benefit and risk. This work is preliminary, hypothetical, and requires confirmation in larger patient cohorts facing these actual decisions.” Quality Checklist for Randomized Clinical Trials: Although this is an RCT, it is different from our usual RCTs, and some of the questions on our check list aren’t as applicable as when we look at RCTs of therapeutic interventions. Critical appraisal is always complex, and even the two of us had to turn to a true expert in Dr. Chris Carpenter to determine which checklist was the most appropriate to use. The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Unsure The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). No The patients in both groups were similar with respect to prognostic factors. Unsure All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. Yes Key Results: They enrolled 913 patients, with a median age of 45 years of age and 56% of the population was female. The vast majority of this population identified as Caucasian and had attended at least some college. Overall, 54.2% of patients elected to receive a CT scan. Decreased benefit, increased risk, and offering a cash incentive to forgo CT all decreased the desire for CT. Primary Outcome: The percentage of patients that chose to receive a CT scan. If the benefit was reported as 0.1% then 49.6% of people wanted a CT, whereas if it was 1% then 58.9% wanted a CT. (OR 1.48 95% CI 1.13 – 1.92) If the risk was reported as 0.1% then 59.3% of people wanted a CT, whereas if it was 1% then 49.1% wanted a CT. (OR 0.66 95% CI 0.51-0.86) If no cash incentive was offered then 60% of people wanted a CT, whereas if 100$ was offered to forgo the CT then 48.3% of people wanted a CT. (OR 0.64 95% CI 0.49-0.83) Secondary Outcomes: The results remained consistent when adjusted for various potential confounders including age, gender, race, income, level of education, and prior history of health problems. You can listen to the podcast on iTunes or Google Play to hear Will and Jessica answers to our ten nerdy questions. 1. Sample Size: Your sample size was based on the feasibility of medical students being able to complete a summer research project. This would give an approximate power of 85% to 90% to detect a 10% absolute change in the proportion of subjects desiring testing from a baseline test acceptance rate of 50%. Do you think that a 10% difference reflects a real clinically important difference? 2. Statistics: You performed a series of nested regression analyses for your primary statistical analysis. I’ll be honest, we got a little lost in the math. In our relatively simple mind, there were only a couple variables, with a simple yes or no answer regarding CT. It seems like presenting the raw numbers would have been easier to understand than the odds ratios that you ended up using. Can you explain your choice of statistics to me? 3. External Validity: The vast majority of this population was highly educated and white. There was also a very high percentage (24%) that worked in healthcare. How might that affect the external validity of the results? 4. External Validity 2: We was incredibly surprised than half of these patients wanted a CT. In Canada and New Zealand, a CT would not even have been offered to these patients (given that they passed the Canadian CT head rule). We often explain why a CT isn’t needed, and the vast majority are fine with that. We definitely haven’t experienced 50% of my patients asking for a CT.

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 Esophageal intubation 1 with and 1 without bougie 1. External Validity: This is clearly a bougie center of excellence. Of the 543 intubations included in this study, 435 used the bougie as the first-time airway tool. This raises the question of generalizability. If providers in this center are more proficient with the use of a bougie than the average emergency medicine clinician, would we see different results if we put the bougie in the hands of someone who does not use it regularly? In addition, 95% of the intubations were done by residents. Does this have external validity to non-teaching sites where the attending physician is performing the intubations? 2. Missing Data: Although these cases were consecutive; 83 cases had to be excluded due to missing video. The videos in addition to chart review were the primary data collection tools. The authors addressed this limitation with a sensitivity analysis that showed the bougie would still be superior. 3. Associations: The retrospective nature of this study makes it difficult to eliminate bias. The reviewers did their best to mitigate this by using multiple reviewers for the videos looking from multiple angles. Three separate investigators watched all cases from three cameras. They were blinded to the study goals and simply reported information on a standardized form. However, it was not a randomized trial and so we cannot claim causation only association between bougie and first pass success rates. 4. Why Use the Bougie: It is unknown why the bougie was used in each case. The authors’ attempted to identify difficult airway characteristics (obesity, cervical spine immobilization, presence of abnormal anatomy, facial trauma, masses, and body fluids) that could have influenced the operators’ decision. They also screened for hypoxia and esophageal intubations. These characteristics were about the same between groups which suggests the providers used bougie as first line device regardless of difficult airway characteristics. 5. Patient-Oriented Outcomes: They used first pass success rates, duration and hypoxia as surrogate markers. Important patient-oriented outcomes would have been survival and survival with good neurological function. While there was a longer time for ETT insertion with a bougie than without (13 seconds) it is unlikely this was a clinically important difference. Rates of hypoxia among the two groups were similar (13% with bougie and 17% without). Unfortunately, there is missing data on hypoxia in a total of 181 cases (114 missed on video feed and 67 were missed due to poor wave forms). It’s possible that this missing information may have shown a significant increase in hypoxia for our bougie patients. Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusions. SGEM Bottom Line: The use of a bougie is associated with increased first pass success rates for intubations in the emergency department but an RCT is needed to further explore this topic. Clinical Application: But wait there is more. We are going to do two papers today on the SGEM. The second paper is a randomized control trial looking at this issue by the same lead author. 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 Population: Adult patients (>17 years of age) who underwent intubation in the emergency department and the attending emergency physician planned to use a Macintosh laryngoscope blade on the first attempt Exclusions:Prisoners, suspected or known pregnant patients and patients with known distortion of the upper airway or glottic structures Intervention: Bougie with Macintosh or CMAC laryngoscope Comparison: Intubation with endotracheal tube and stylet Outcome: Primary Outcome: First-attempt intubation success Secondary Outcomes: Duration of attempts, hypoxemia (SpO2 <90% or a 10% decrease) and esophageal intubation Authors’ Conclusions: “In this emergency department, use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation. However, these findings should be considered provisional until the generalizability is assessed in other institutions and settings.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Yes The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. No The treatment effect was large enough and precise enough to be clinically significant. Yes Key Results: They enrolled 757 patients that included 380 with a difficult airway characteristic. The mean age was in the mid-40’s with more than two-thirds being male. The vast majority (85%) were intubated by a senior resident or fellow. Only 1% were intubated by emergency medicine faculty. The rest were intubated by junior residents. First-pass success was greater with than without bougie Primary Outcome: First-attempt intubation success 96% with bougie group and 82% without bougie Absolute difference of 14% (95% CI; 8-20) Secondary Outcomes: Median first-attempt duration was similar (38 seconds vs 36 seconds)

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.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. 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 All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. Unsure Key Results: The CRASH-3 investigators randomly allocated 12,737 patients with TBI to receive either TXA or placebo. There were 9,202 (72%) who were enrolled within 3 hours of injury. The mean age was 42 years, 80% were male, 80% had both pupils reactive and about 2/3 had a GCS less than 12. No statistical difference in head-injury related mortality with TXA compared to placebo Primary Outcome: Death due to head injury 18.5% TXA vs. 19.8% placebo, RR 0.94 (95% CI 0.86 to 1.02) Secondary Outcomes: The two statistically significant results were less head injuries deaths within the first 24 hours and in the subgroup of patients with milder injuries (GCS 9-15). Disability was similar between both groups. There was no evidence of increased vascular events, seizures, complications or adverse events. We could not find the data on neurosurgery or days in the ICU. This was a large multinational study looking at a very important question. The CRASH-3 Trial Collaborators need to be commended for successfully completing this study.  All studies will have some limitations that need to be considered when interpreting the results. Here are five that we identified and wanted to discuss: 1. Selection Bias: We are unsure if there was any selection bias in CRASH-3. Patients were eligible if the recruiting clinician was uncertain as to the appropriateness of TXA. No denominator was provided for how many people were screened. They state that “almost all patients with TBI who met inclusion criteria were recruited” but do not provide the actual number. Because of the subjective nature of the inclusion and exclusion (based on recruiting clinicians’ uncertainty) this could have introduced selection bias into the study. 2. Wide-Confidence Intervals: The confidence intervals were wide for point estimate of the primary outcome (relative risk head injury related death). It ranged from a large effect size (0.86) but also crossed the line of no difference (1.02). That does not mean we can conclude TXA does not work but rather it did not demonstrate a statistical benefit. The point estimate did favour TXA over placebo (RR 0.94). The width of the 95% confidence interval and the upper limit crossing the 1.0 decreases the certainty of any conclusion that can be made. 3. All-Cause vs. Head Injury Mortality: The authors considered many patient-oriented outcomes. While their primary outcome was head-injury related mortality, a more important POO would be overall mortality. The patient and their family usually do not care what they died from but whether or not they did die. We saw this in the WOMAN trial where the overall mortality was not decreased but the paper highlighted the statistically significant decrease in post-partum hemorrhage related deaths. 4. External Validity: The study was done in 29 countries with the majority being middle to low income countries. Canada had one centre and the USA had no participating centres. They did do an analysis based on income that was not pre-specified. This did not show a statistical difference. However, the question remains on whether TXA would have a clinically important impact in the USA healthcare setting. 5. Subgroup Analysis: While the subgroup analyses were pre-specified, they are underpowered to draw any strong conclusions. We should be cautious not to over-interpret these results. Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree that TXA does appear to be safe but think the claim about decreased head-injury related death is misleading. This is because it was only for a subgroup of patients. If TXA is given, then giving it as soon as possible seems reasonable. SGEM Bottom Line: We cannot recommend the routine use of TXA for patients with isolated traumatic brain injuries at this time. Case Resolution: You decide not to give TXA and decide to leave it up to the neurosurgeon. Clinical Application: Clinicians will have different thresholds of evidence that will convince them to change practice. The effect size of TXA in patients with TBI was small, the confidence intervals were wide and the upper end of the 95% confidence interval crossed the line of no statistical difference. The evidence was even less convincing when looking at the more patient-oriented outcome of all-cause mortality. While the subgroup analyses showing efficacy in certain cohorts was interesting, the groups were underpowered to provide a clear answer on how to apply this information. We have a number of concerns how this trial will be interpreted and applied. One aspect is the “spin” on the article. People may highlight the “significant” relative reduction of death in a subgroup rather than focusing on the lack of statistical difference of an absolute reduction in overall mortality. This was seen in the WOMAN trial and we need to be cautious not to do this with CRASH-3 by over hyping the results. Dr. Salim Rezaie It is also well recognized that the efficacy of treatment decreases when applied outside the strict environment of a research trial.

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). Periodontal therapy has been shown to reduce patients’ cardiovascular risk category (19). Integrated comprehensive oral health care has been shown to increase completion of substance use disorder treatment, increase employment, increase drug abstinence, and reduce homelessness (20). Poor oral health also has a negative impact on a person’s self-esteem, social interactions, and employability (21). Given the important relationship between oral health and overall health, our current dental care system is inconsistent with the principles of the Canada Health Act: “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.” The History of Dental Care in Canada Canada began adopting community water fluoridation in the 1950s, around the same time as the genesis of Medicare, Canada’s single payer public health care system. This led to a sharp decline in dental caries, and a false reassurance that the solutions to oral health concerns would be non-provider based (1). The 1964 Commission on Health Services did not include dental care in its recommendation of publicly financed services, believing oral health care to be a personal responsibility. At the same time, tax incentives for employers and employees led to an expansion of employment-based dental insurance, which further reduced public investments in times of economic hardship (1). In fact, in the early 1980s, approximately 20 percent of all spending on oral health care was public, compared to approximately 5 percent currently (22). This ranks Canada amongst the lowest in public spending for dental care of all OECD countries, second only to Spain. In fact, public spending on dental care in Canada is less than the United States, where 10 percent of all dental care is publicly financed (23). Furthermore, Canada has been reducing its proportion of public dental expenditures, while the United States and most other OECD countries have been increasing their public share of dental spending (2). Currently, dental care in Canada is almost entirely funded through the private sector. Approximately 51 percent of dental spending is paid for by employment-based insurance, and 44 percent through direct out-of- pocket payments( 22). The remaining 5 percent that is funded publicly is delivered through a patchwork of policies targeting marginalized groups (1). Public per capita spending on dental care is approximately $24, compared to $337 on drugs, and $999 on physician services (24,25). Consequences for the Individual The lack of a robust, publicly funded dental care system in Canada has led to significant barriers for many Canadians to access care. Approximately six million Canadians avoid visiting a dentist each year due to the cost (1). The people who experience the most difficulty accessing oral health care are also the ones who experience the highest burden of dental disease, including children, low income adults, seniors, indigenous communities, refugees, people with disabilities, and people living in rural areas (1–5). Overall, approximately 20 percent of people cite cost as a barrier for seeing a dentist (4). Studies show that 42 percent of low income. Canadians avoid seeing a dentist when they need to due to cost, compared to only 15 percent of high income Canadians (2). This is in stark contrast to physician services, where the only 9 percent of low income Canadians and 5 percent of high income Canadians avoid seeing a physician due to cost (2). Despite having higher needs, seniors are 40 percent less likely to have private dental insurance compared to the general population (26). In Canada’s largest province, Ontario, 3.5 percent of the population avoids social interactions, including conversation, laughing, and smiling, due to a dental condition; this proportion increases to 8.5 percent amongst those in lower income groups (4). Consequences for the Emergency Department People who are suffering with an oral ailment and cannot access affordable, timely dental care often turn to the Emergency Department (ED) in desperation. In fact, approximately 1 percent of all visits to the ED are for dental complaints (6,27). The majority of patients presenting to the ED for dental complaints are low-income adults, and these visits in Ontario alone are estimated to cost the health care system in the range of 16 to 31 million dollars annually (5,28). Both patients and providers often know that the patient needs to see a dentist, but patients turn to the ED when they have nowhere else to go. Most of these patients receive either no intervention, or pharmacotherapy for temporary symptom relief (6). This is expected, as emergency physicians do not possess the training or equipment to deal with most dental complaints in a definitive way (29). Emergency physicians often end up prescribing antibiotics, anti-inflammatories, or opioids to try and provide some relief – medications that would otherwise be unnecessary if patients could access dental care. Opioids are prescribed in more than 50 percent of non-traumatic dental condition visits to the ED, and emergency physicians are five times more likely to provide an opiate prescription for a dental complaint compared to a dentist (30–32). In the midst of an opioid epidemic, it is important that we take steps to reduce our reliance on these potentially harmful medications. This is particularly true in cases like these, where opioids are not the optimal therapy for the presenting problem. Organizations Supporting Public Dental Care in Canada Canadian Association of Public Health Dentistry: "All Canadians should have equitable access to oral health care, regardless of their employment, health, gender, race, marital status, place of residence, age or socio- economic status." (33)