Date: August 14, 2023 Reference: Ma et. al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet 2023 Guest Skeptic: Dr. Mike Pallaci is a Professor of Emergency Medicine (EM) for the Northeast Ohio Medical University, and an Adjunct Clinical Professor of EM for the Ohio University Heritage College of Osteopathic Medicine. He has been program director for two EM residency programs, and is currently a core faculty member for the EM residency at Summa Health System in Akron, OH, where he also serves as the Medical Director of the Virtual Care Simulation Lab. This episode originated because of a thread Mike posted on the social media site formerly known as Twitter.  The tweet said: “I am sick and tired of some non-EM docs/specialists slamming EM when we don’t aggressively lower BP in ICH.” It certainly got a lot of attention. It got a lot of attention both on the positive side (mostly from EM docs who share the frustration) and on the negative side from some neurologists who didn’t seem to particularly care for the premise of the tweet or for the generally positive response. It started out with venting on Twitter about an unpleasant interaction with one of Mike's partners and turned into a week-long discussion that culminated in an invitation to be the guest skeptic on the SGEM to critically appraise INTERACT-3. Mike backed up his position on blood pressure (BP) lowering using evidence. Specifically, he pointed out that the evidence behind the guidelines re BP management in intracranial hemorrhage (ICH) is relatively weak. This received a mixed response on Twitter. Most EM physicians shared the frustration and made positive comments. Some neurologists disagreed with the premise of the tweet and challenged it. I responded by posting the 2013 SGEM episode on INTERACT-2 (SGEM#73) which showed no statistical difference between intensive (<140 mmHg) and guideline directed (<180 mmHg).  In 2017, the SGEM reviewed the ATACH-2 trial (SGEM#172) which showed similar results. A meme was also posted of Charlton Heston from the classic movie the Ten Commandments. It emphasized that GUIDElines are not GODlines. The literature should inform and guide our care, but it should not dictate our care. This is a core principle of evidence-based medicine (EBM). Often the available evidence on a specific medical question is weak. We still need to apply our clinical judgement and ask the patient about their values and preferences. Case: A 67-year-old male presents to the emergency department obtunded with left hemiplegia.  Symptoms began just prior to presentation.  His blood pressure (BP) is 194/110 mmHg.  CT reveals a hemorrhage in the right internal capsule, suggestive of acute hypertensive hemorrhagic stroke.  Should the blood pressure be treated?  If yes, what should the target blood pressure be? How quickly do we want to get there? And are there any other physiologic variables we want to be aggressive about controlling in the early treatment window? Background: We have covered the common issue of elevated BP after ICH on SGEM#73 and SGEM#172. The 2022 AHA/ASA guidelines give several recommendations on this topic. The class (strength) of their recommendation is 2a/2b based upon Level B and Level C quality of evidence.   It is really important to pay attention to the specific language used in the guidelines. First of all, as we’ve already covered, a guideline is something developed by humans giving their best interpretation of the evidence to serve as a guide, not something given to Moses on Mount Sinai. But that point aside, the basis of this discussion was that the strength of the evidence behind these guidelines and the strength of the recommendations in the guidelines themselves are frequently misunderstood and/or misrepresented by our consultants.

Reference: Easter JS et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Annals of Emergency Medicine 2014. Date: July 10, 2023 Guest Skeptic: Dr. Joe Mullally is a paediatric trainee in the Welsh paediatric training program and interested in Paediatric Emergency Medicine. He is a student in the Paediatric Emergency Medicine Masters Program through Queen Mary University in London in collaboration with the Don’t Forget the Bubbles team. Dr. Joe Mullally Background: Children have big heads proportionally to their body compared to adults which makes them more at risk of traumatic brain injury (TBI). Computerized tomography (CT) is commonly used in the emergency department in the diagnosis of TBI. But we’re always trying to balance the potential harms and potential benefits in medicine. A CT scan does mean radiation to the pediatric brain which can increase the risk of leukemia or brain cancer later [1]. Thankfully, clinically important intracranial injuries are rare in children [2]. So, should we CT scan children with minor head injury? The SGEM covered pediatric concussions and head imaging in SGEM #112 and the NEXUS II Pediatric Head CT Decision Instrument in SGEM #225. Today we’re talking about three other popular clinical decision rules (PECARN, CATCH, and CHALICE). But we also want to know, how do those rules compare to physician judgement? Clinical Question: What is the diagnostic accuracy of clinical decision rules and physician judgment in identifying clinically important traumatic brain injuries (TBI) in children with minor head injury? Reference: Easter JS et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Annals of Emergency Medicine 2014. Population: Children less than 18 years of age presenting with head injury to a level 2 pediatric trauma center in the United States between 2012-2013. These children have to have 1) history of signs of blunt injury to the head 2) GCS scores ≥13, 3) injury within the previous 24 hours prior to presentation, 4) physician concern for potential TBI Excluded: Heightened TBI risk (GCS<13, brain tumors, ventricular shunts, on anticoagulants, or had bleeding disorders), or if they presented >24 hours after injury Intervention: CT vs no CT Comparison: Comparison of PECARN, CHALICE, CATCH, physician judgement, and physician practice Outcomes: Primary Outcome: “Clinically important TBI” defined as death from TBI, need for neurosurgery, need for intubation >24hrs for TBI, or hospital admission >2 nights for TBI. Secondary Outcomes: TBI on scan TBI requiring neurosurgery (craniotomy, elevation of skull fracture, monitoring of intracranial pressure, or intubation for elevated intracranial pressure) Type of Study: Single center prospective cohort study Authors’ Conclusions: “Of the 5 modalities described (PECARN, CATCH, CHALICE, physician judgment and physician practice), only physician practice and PECARN identified all clinically important TBIs, with PECARN being slightly more specific. CHALICE was incompletely sensitive but the most specific of all rules. CATCH was incompletely sensitive and had the poorest specificity of all modalities.” 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? Unsure  Was the outcome accurately measured to minimize bias? Unsure  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 Do you believe the results? Yes Can the results be applied to the local population? Unsure

Join emergency medicine physician Dr. Chris Bond and paramedic Neil MacDonald as they dissect the evolving practices in spinal motion restriction following a workplace injury case. They discuss the shift away from traditional cervical immobilization techniques and the impact of paramedic perceptions on patient care. Delve into the intricacies of statistical methodologies in spinal care research and the debate over cervical collar effectiveness, all while advocating for more personalized and evidence-based approaches in emergency medical protocols.

In this discussion, Dr. Jeff Jarvis, Chief Medical Officer at MedStar and seasoned emergency medicine expert, weighs in on the evolving techniques for intubation, focusing on the debate between video and direct laryngoscopy. He highlights the vital role of first-pass success in emergency settings and shares insights from recent research. The conversation also touches on ethical dilemmas in clinical trials and the challenges of informed consent, particularly in pre-hospital environments. Jarvis's engaging take combines humor with crucial medical insights.

Date: 15 June 2023 Guest Skeptic: Dr. Samina Ali is a pediatric emergency medicine physician, clinician scientist, and Professor of Pediatrics and Emergency Medicine at the University of Alberta in Edmonton. Her research focuses on improving assessment and treatment of pain in children. She is an executive member of Pediatric Emergency Research Canada (PERC), pain content advisor for TREKK and faculty member of BEEM. Dr. Samina Ali Background: Pain, a common acute and chronic complaint that we see a lot in the emergency department. Whether it is a broken bone, a laceration, abdominal pain, sickle cell vaso-occlusive pain episode, emergency department physicians are familiar with patients experiencing pain, but do we always do a good job at addressing it? The answer is no, especially in vulnerable groups like the seniors [1], certain ethnicities [2], patients with mental health issues [3], and pediatric patients [4,5]. While addressing pain, we sometimes must perform medical procedures which lead to…more pain. This issue is magnified in children where even placement of an IV can be traumatic and painful for a child who does not understand why they’re getting poked. The emergency department can be a painful place to be… We have covered pediatric pain management on the SGEM multiple times. Peds EM superhero, Dr. Anthony Crocco from McMaster University, did one of his rants on pediatric pain. SGEM#78: Sunny Days (Pediatric Pain Control) SGEM#123: Intranasal Fentanyl – Oh What a Feeling SGEM#242: Pain, Pain, Go Away – IN Ketamine vs. IN Fentanyl for Pediatric Pain Management SGEM#378: Keepin’ It REaL when Treating Pediatric Migraine Patients SGEM Xtra: RANThony#3 - Paediatric Pain It is estimated that 1 in 5 children develop chronic pain before childhood. Pediatric pain is one of the costliest chronic conditions, even more so than asthma and obesity [6]. When admitted, children experience an average of 6.3 painful procedures per day and this goes up to 12 in the ICUs! Although evidence-based best practices for addressing pain in children have been published all over the world, we still often fall short. Some of the most serious consequences of untreated pain in children occur much later than the procedure itself. For example, a child who is scared to get an IV: One might think we can hold the child down, bundle them up, and just quickly get it over with, as they need their antibiotics/iv fluids. On that day, we might hear crying and stress from the child, but they will likely settle down and we have successfully delivered out treatment. But there are consequences to this. Poor pain management contributes to avoiding medical care in the future and even vaccine hesitancy [8,9]. This same child, if unvaccinated, may present with serious vaccine-preventable illnesses, require more time and resources for every fever. There is also psychological trauma for the patient, their families, and the healthcare workers who care for them.  Sometimes, healthcare workers think that treating children’s procedural pain takes up precious ED time, like waiting for a topical anesthetic to work. In fact, using pain relief for procedural pain leads to less repeat procedures, better ED flow and shorter lengths of stay. Importantly, children who experience chronic pain are more likely to have mental illness, opioid use, and socioeconomic disparities in adulthood. Canada creates 15% of the world’s pediatric pain research, so it made sense that we would be the first country in the world to create a national standard.  This new standard is divided up into four main themes. Make pain matter: creating a framework to provide better pain care and employing continuous Quality Improvement (QI) Make pain understood: education and knowledge sharing Make pain visible: pain assessment Make pain better: individualized care plans & multi-modal pain strategies Tune into the podcast to hear Dr.

In a thought-provoking discussion, Dr. Anand Swaminathan, an Assistant Professor of Emergency Medicine, dives into the controversial use of Tamiflu for influenza treatment. He shares insights from a systematic review that questions the drug's efficacy and reveals its side effects, including gastrointestinal issues. The podcast also examines historical safety concerns and emphasizes the need for a shift in clinical practices regarding Tamiflu's routine use, urging practitioners to reconsider treatment strategies for flu patients. It's a must-listen for those navigating influenza care!

Dr. Salim Rezaie, a community emergency physician and founder of the critical appraisal blog REBEL EM, dives deep into the impact of tranexamic acid (TXA) in trauma care. He explores a striking motor vehicle collision case, debating TXA’s effectiveness versus traditional treatments. The discussion highlights key studies like CRASH-2 and scrutinizes research methodologies, showing how they influence patient outcomes. Engagingly, they weigh the survival benefits against potential long-term issues, all while adding a splash of humor to the serious topic of emergency medicine.

Date: June 16, 2023 Reference: Reed et al. Pilot Testing Fentanyl Test Strip Distribution in an Emergency Department Setting: Experiences, Lessons Learned, and Suggestions from Staff. AEM June 2023 Guest Skeptic: Dr. Lauren Westafer is an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the cofounder of FOAMcast and a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and a research methodology editor for Annals of Emergency Medicine. Case: A 27-year-old right hand dominant patient presents to the emergency department (ED) with a 2.5 cm left forearm abscess. They have no fever, chills, or signs of compartment syndrome. You perform an incision and drainage of the abscess with significant improvement in pain. The patient reports injection use of opioids, last use was a few hours ago. The patient currently has no signs of withdrawal and is interested in potentially starting on methadone; however, the patient is not ready to start the medication right now. Background: We have addressed the issue of substance use disorder a few times on the SGEM. This included looking at alcohol misuse and opioid misuse. SGEM#55: Drugs in My Pocket (Opioids in the Emergency Department) SGEM#241: Wake Me Up Before You Go, Go – Using the HOUR Rule SGEM#264: Hooked on a Feeling - Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain SGEM#313: Here Comes a Regular to the ED SGEM#374: Bad Habits – Medications for Opioid Use Disorder in the Emergency Department Rises in opioid overdose deaths have been attributed, at least in part, due to increases in fentanyl contaminating the illicit opioids in the United States. EDs are an important touch point for individuals with opioid use disorder (OUD), given the number of encounters for overdose and complications associated with drug use. Although some patients may be ready for medication such as buprenorphine or methadone, which can be initiated in the ED, some patients may not be ready for either medication. In these cases, harm reduction practices, strategies that mitigate complications from drug use, are critical. Fentanyl test strips (FTS) have been suggested as one harm reduction strategy to reduce opioid overdose deaths. The American College of Emergency Physicians (ACEP) endorses greater harm reduction education for emergency physician . Fentanyl test strips can be used by people who use drugs (PWUD), prior to use, to detect the presence of fentanyl. Individuals can then use that information to decide if or how much of the drug to use. Clinical Question: What are the perspectives of clinicians and other staff distributing fentanyl test strips to people who use drugs in an ED setting? Reference: Reed et al. Pilot Testing Fentanyl Test Strip Distribution in an Emergency Department Setting: Experiences, Lessons Learned, and Suggestions from Staff. AEM June 2023 Study design: This was a qualitative study assessing staff perceptions of a pilot of distribution of fentanyl test strips. Staff meeting inclusion criteria (below) were invited to participate and rec Population: English speaking ED clinician (physician, nurse, advanced practice provider, technician, social worker, certified recovery specialist) distributing fentanyl test strips through the pilot program. Intervention: Interviews at two points in time, three weeks and three months after distribution of FTSs began Comparison: Not applicable Megan Reed PhD This is an SGEMHOP episode, and it is my pleasure to introduce Dr. Megan Reed. She is a PhD with a Master’s in Public Health. Megan currently works at the College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA. Authors’ Conclusions: “Implementing FTS distribution may improve patient rapport while providing patients with tools to avoid a fentan...

Dr. Amy Drendel, a pediatric emergency medicine physician and researcher at Children’s Wisconsin, discusses an intriguing case of a 14-year-old boy with sickle cell disease facing a painful vaso-occlusive episode. She highlights the promising role of intranasal fentanyl in improving pain management and expediting discharge from emergency departments. The conversation dives into the challenges of opioid administration, the potential efficiencies of intranasal versus intravenous methods, and the need for further research to enhance care for pediatric patients.

Date: June 6th, 2023 Reference: Pines, Raja, Bellollo and Carpenter. Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules 3rd Edition Dr. Jesse Pines Guest Skeptic: Dr. Jesse Pines is the Chief Clinical Innovation at US Acute Care Solutions and a Clinical Professor and George Washington University and Professor of Emergency Medicine at Drexel University. In this role, he focuses on developing and implementing new care models including telemedicine, alternative payment models, and clinical programs involving new technology at USACS.  Jesse has been on the SGEM before including these two episodes: SGEM#308: Taking Care of Patients Everyday with Physician Assistants and Nurse Practitioners SGEM#316: What A Difference An A.P.P. Makes? Diagnostic Testing Differences Between A.P.P.s and Physicians Please consider listening to the SGEM Xtra podcast with Jesse discussing the 3rd edition of Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules. I was honoured to be asked to write the foreword to this latest edition. Foreword Emergency physicians are many things but one of the most important things we try to be is great diagnosticians. Every shift we use limited information in a busy, chaotic environment to make decisions. Sometimes those decisions can mean life or death and need to be made quickly. We strive to be the best at exercising this important responsibility. This is the book that can help clinicians achieve that goal. The first and second edition of Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules is a resource I have used regularly through my career. It has made me a better diagnostician and better physician. Questions come up on every shift as to what evidence supports our actions. This fantastic book provides answers to those questions in a brief and helpful way. I am often accessing it for my own needs and as an educational resource for students. The third edition contains the foundational elements of providing excellent evidence-based medicine (EBM) care. The authors start by discussing diagnostic testing in the emergency department (ED). They explain the epidemiology and statistics behind diagnostic testing. They appropriately emphasize that clinical decision instruments are tools to guide care, not rules to dictate care. They touch upon the additional responsibility of being good stewards given the realities of limited resources. They also provide a chapter to help clinicians understand the direction of bias in diagnostic research. The third edition covers dozens of common and deadly conditions clinicians are faced with in the ED. This includes chapters on pediatrics, geriatrics, cardiac, neurological, surgical, trauma, infectious disease, and other conditions. There are four new chapters in the latest edition of the book: Skin and Soft Tissue Infection, Shared Decision Making, Cognitive Bias and Telemedicine Diagnosis. There are all wonderful additions to the book. My favourite new chapter is the one discussing Shared Decision Making (SDM). SDM goes beyond informed consent and recognizes the autonomy and agency of patients. We are making important decisions that must consider patients values and preferences. This is one of the three pillars of EBM. While we may be the experts at clinical medicine, patients are experts of their own personal experience. There are many examples of where SDM can be utilized in the ED with my clinical experience to enrich the therapeutic patient-physician alliance. If you want to provide patients the best care, based on contemporary evidence then this is your book. Previous Books Highlighted on the SGEM SGEM Xtra: Message in a Book by the SGU SGEM Xtra: Don’t Give Up – The Power of Kindness with Brian Goldman SGEM Xtra: The Danger Within Us SGEM Xtra: Relax – Damm It! SGEM Xtra: Season 1 to 10 PDF Books