Date: June3, 2023 Reference: Kotani et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. Journal of Critical Care April 2023 Guest Skeptic: Dr. Amber Gombash is an emergency physician in Concord, NC. Case: You have a critically ill patient that you are preparing to intubate and wonder if the use of etomidate as your induction agent increases mortality. Missy Carter Background: Intubation is something we have a covered a few times on the SGEM. There was an episode with Physician Assistant (PA) Chip Lange on the use of POCUS to confirm tube placement (SGEM#249). This got some feedback from our friend Scott Weingart over at EMcrit. Our usual go to guest skeptic for airway has been paramedic and PA Missy Carter (SGEM#247, SGEM#271 and SGEM#396). One aspect that has not been well covered on the SGEM is the choice of induction agent when intubating patients. There was an episode 10 years ago looking at the use of etomidate in septic patients (SGEM#44). It was a SRMA reporting an associated increase in adrenal insufficiency and all-cause mortality with the use of etomidate to intubate septic patients. A more recent SGEM episode looked at an unblinded single centre randomized trial comparing etomidate vs ketamine in adult patients requiring emergency endotracheal intubation (SGEM#356). The primary outcome was an 8% absolute increase in all-cause mortality at seven days for patients allocated to the etomidate group. This outcome was no longer statistically different at 28 days. There were multiple issues with this trial including a lack of masking (blinding), selection bias and the primary outcome measure of all-cause mortality at 7 days. Etomidate is often used as the induction agent in critically ill patients due to its fast onset and hemodynamically neutral nature. However, it is hypothesized that etomidate may increase the risk of organ dysfunction and death by the suppression of cortisol production through inhibition of 11-beta-hydroxylase. This goes back to at least 2009 the Ketased study. That trial found that in a critical care setting there was an increase adrenal insufficiency in the group receiving etomidate. There are now multiple randomized trials studying the effect of etomidate as an induction agent on adrenal function and mortality. These studies have reported mixed results—with some finding a statistically significant increase in mortality. There was a SRMA in 2021 that reported an associated increase in adrenal suppression and mortality with etomidate. However, this review combined high-level studies (five randomized controlled trials) with low-level studies (nine post hoc and 15 retrospective studies). Clinical Question: Does etomidate used as an induction agent cause an increased mortality in critically ill adults? Reference: Kotani et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. Journal of Critical Care April 2023 Population: Critically ill adults undergoing emergency endotracheal intubation for critical illness Exclusions: Pediatric patients < 15 years old, etomidate as an infusion (rather than induction/bolus dose), non-randomized trials, systemic reviews, commentaries/editorials and literature reviews, studies not addressing the review question Intervention: Etomidate Comparison: Any other induction agent Ketamine (4 studies), midazolam (4 studies), thiopental (1 study), ketamine + midazolam (1 study), ketamine + propofol admixture (1 study) Outcome: Primary Outcome: Mortality at the main timepoint defined by trial authors Timepoint: Intensive care unit (1 study), Hospital (5 studies), 24 hours (1 study), 7 days (1 study), 28 days (2 studies), 30 days (1 study) Secondary Outcome: Development of adrenal insufficiency

Date: May 10, 2023 Reference: Harhay MO, et al. A bayesian interpretation of a pediatric cardiac arrest trial (THAPCA-OH). NEJM Evidence. 2023. Guest Skeptic: Dr. Kat Priddis is a paediatric emergency medicine consultant and trauma director at Watford General Hospital. She is part of the Don’t Forget the Bubbles team and faculty at Queen Mary University in London where she teaches part of the Paediatric Emergency Medicine MSc. Dr. Kat Priddis Case: You are working at the community emergency department (ED) when you receive a call from the local Emergency Medicine Service (EMS) team that they are bringing a 2-year-old boy who had a cardiac arrest at home. He had been having some upper respiratory symptoms in the previous days. Parents found him in bed that morning blue and unresponsive. They started cardiopulmonary resuscitation (CPR) until EMS arrived.  Upon arrival at the ED, your team promptly begins high quality CPR and manages to obtain return of spontaneous circulation. As you are mentally running through your checklist for post-arrest care and preparing to transfer the patient, a team member tells you that there are potentially two hospitals in the area who may be able to accept the patient. One of the hospitals has a pediatric intensive care unit (PICU) that has the capability to perform therapeutic hypothermia but it’s further away. Which hospital should you transfer the patient to? Background: Therapeutic hypothermia in cardiac arrest has been covered on the SGEM multiple times, all the way back to SGEM #21 and SGEM #54 and most recently in SGEM #391. Ken and Justin Morgenstern of First10EM provided a very nice summary of the history of therapeutic hypothermia that you can check out, so we won’t belabor the point. Other therapeutic hypothermia trials included Target Temperature Management or TTM trial (SGEM #82), HYPERION (SGEM #275), TTM2 (SGEM #336). However, we have not covered the Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest (OHCA) in Children or THAPCA-OH published in the New England Journal of Medicine in 2015. We’re adding on a second paper looking at the Bayesian interpretation of the original study.  Clinical Question: Does therapeutic hypothermia provide any benefit in neurobehavioral outcomes and survival in out-of-hospital pediatric cardiac arrest? Original trial: Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic hypothermia after out-of-hospital cardiac arrest in children. N Engl J Med. 2015. Reference: Harhay MO, et al. A bayesian interpretation of a pediatric cardiac arrest trial(THAPCA-OH). NEJM Evidence. 2023. Population: 295 pediatric patients (ages greater than two days to less than 18 years) hospitalized in PICUs at 38 children’s hospitals, who were admitted after OHCA.  Excluded: Inability to randomize within 6 hours of ROSC, Glasgow Coma Scale (GCS) motor score of 5 or 6, decision to withhold aggressive treatment by clinical team, traumatic arrest Intervention: Therapeutic hypothermia (target temperature 33°C).  Comparison: Therapeutic normothermia (target temperature 36.8°C) Outcome:  Primary Outcome: Survival with good neurobehavioral outcome at 12 months. Outcome defined by Vineland Adaptive Behavior Scales (VABS-II) of 70 or higher (this is a scale from 20 to 160 with higher scores associated with better function) Secondary Outcomes: Survival at 12 months and change in neurobehavioral function Other Outcomes: Global cognitive score, blood product use, infection, serious arrhythmias through 7 days, 28-day mortality Trial: Multinational unmasked randomized clinical trial  Authors’ Conclusions Original Paper: “In comatose children who survive out-of-hospital cardiac arrest, therapeutic hypothermia, as compared to therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year.”

Date: April 12, 2023 Reference: Edlow et al.Guidelines for Reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. AEM May 2023 Guest Skeptic: Dr. Jonathon Edlow has practiced emergency medicine for nearly 40 years and is a Professor of Emergency Medicine at Harvard Medical School. His academic interest is avoiding the misdiagnosis of patients with neurological emergencies.  This is an SGEM Xtra and #SGEMHOP combined. We have reviewed the previous two GRACE guidelines published by the Society for Academic Emergency Medicine (SAEM). GRACE stands for Guidelines for Reasonable and Appropriate Care in the Emergency Department. This is the third GRACE project. GRACE-1 tackled the common issue of recurrent low risk chest pain (SGEM#337). This contrasts with other guidelines that only looked at a single emergency department presentation for chest pain. And GRACE-2 was about low-risk recurrent abdominal pain (SGEM#367). Now we come to GRACE-3. This time it was not a recurrent condition like chest pain or abdominal pain but rather acute vertigo or dizziness. The objective of the GRACE-3 guideline is to provide an evidence-based framework intended to support patients, clinicians, and other health-care professionals in their decisions about the evaluation and management of adult ED patients with acute dizziness who do not have an obvious central cause with frank neurological findings or an obvious general medical one. The population covered by these guidelines are adult patients presenting to the ED with acute dizziness or vertigo of less than two weeks. Let us clarify some terms because it is often not clear when what people mean by dizziness and vertigo. I tend to describe dizziness as light-headedness, unsteadiness, motion intolerance, imbalance, floating, or a tilting sensation. Dizziness in GRACE-3 was defined as the sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion (Barany Society). Vertigo in GRACE-3 was defined as the sensation of self-motion (of head or body) when no self-motion is occurring, or the sensation of distorted self-motion during an otherwise normal head movement. The problem is that research shows that patients often use multiple descriptors simultaneously or change their main descriptor if asked again less than 10 minutes later. So, although your concept is exactly what has been taught for decades, data from the last decade and a half show that it’s simply not true. The author group came up with 15 evidence-based recommendations based on the timing and triggers of the dizziness. Let’s go through those recommendations with the first one being an overarching one. 15 Recommendations from GRACE-3 Recommendation 1: Emergency clinicians should receive training in bedside physical examination techniques for patients with the AVS (HINTS) and diagnostic and therapeutic maneuvers for BPPV (Dix-Hallpike test and Epley maneuver), since untrained ED physicians do not reliably apply or accurately interpret results of this bedside eye movement examination. [Ungraded Good Practice Statement] HINTS stands for Head Impulse, Nystagmus, and Test of Skew. It was initially touted as a highly sensitive, specific marker for cerebellar stroke in the ED. However, study results have been mixed and there is ongoing debate about how to train for and utilize this examination in the acute care setting. A 2021 study [1] reported that EM physicians could be trained on the HINTS and it gave a sensitivity of 97% for central vertigo (SGEM#376). However, a SRMA [2] that included EM physicians showed less impressive results with a sensitivity of 83. The authors of the review felt the use of HINTS by EM physicians had “not been shown to be sufficiently accurate to rule out a stroke.” (SGEM#310). There is a clear disconnect between what is possible for emergency physicians to do and what ...

Date: April 25, 2023 Reference: Walsh et al. Revisiting “Excited Delirium”: Does the Diagnosis Reflect and Promote Racial Bias? WJEM 2023 Dr. Brooks Walsh Guest Skeptic: Dr. Brooks Walsh is a former paramedic, and is currently an emergency physician in the Bridgeport Hospital, Yale-New Haven Health in Connecticut. This is an SGEM Xtra episode. Brooks reached out to me recently to see if we could revisit the issue of excited delirium. We had done a show on the topic five years ago on SGEM#218. At that time, we recognized there was no universally accepted definition of excited delirium. Please have a listen to the SGEM podcast to hear Brooks discuss the history of this issue and his recent publication. The American College of Emergency Physicians (ACEP) defined the term in 2009 as “acute delirium (not linked to dementia or preexisting pathologies) associated with extreme physical and psychomotor agitation”. The history of this issue goes back almost 200 years. Dr. Luther Bell described extreme agitation observed while he was the superintendent of the McLean Asylum for the Insane. The condition was named “Bell’s Mania” when published in the American Journal of Insanity (now American Journal of Psychiatry) in October, 1849 [1]. The term excited delirium syndrome (ExDS) was coined in the 1980s, after a flurry of deaths of individuals in custody or during arrests following extreme agitation [2]. ExDS usually involved men in their 30s after cocaine, methamphetamine, or ecstasy abuse [3-5]. Fast forward to 2008 when an ACEP resolution called for a group to study “excited delirium,” and to disseminate the paper to Emergency Medical Services (EMS) and law enforcement. The task force came up with a paper that was presented and accepted by the ACEP board in 2009. It was never published in a peer reviewed journal but it has been widely disseminated and cited. There is increasing awareness of the evidence that black men receive the diagnosis of ExDS more often than White men. Those black men who are labeled as having ExDS have a higher mortality than white men. Most recently, a report released by Physicians for Human Rights in March 2022 highlighted these concerns, attracting coverage from national new media. In emergency medicine, we try to be the physician who will treat anyone for anything at any time (hopefully without judgment). There has been an increased recognition of implicit and explicit biases in the house of medicine. This includes but is not limited to race, gender, age, and socioeconomic status. ACEP has made the equitable treatment of patients a priority, including recognition of the role that implicit bias exerts in EM [6]. A statement from ACEP described the death of George Floyd as a manifestation of a “public health emergency,” [7] and affirmed that “ACEP’s mission includes the promotion of health equity within the communities we serve.” Revisiting “Excited Delirium”: Does the Diagnosis Reflect and Promote Racial Bias? This brings us to the 2022 article called Revisiting "Excited Delirium": Does the Diagnosis Reflect and Promote Racial Bias? WJEM 2023 There were five key points raised in the article: Continuing lack of a clear definition for excited delirium Excited delirium is a health issue Excited delirium Is a health equity issue Racialized criteria for diagnosis “Just semantics?” Four actions were suggested in the article: Emergency medicine should avoid the concept of “excited delirium” Clinicians Should Use Established Medical Diagnoses ACEP Should “Retire” the 2009 Report Consider Greater Professional and Racial Diversity in Future Panels ACEP Task Force Report on Hyperactive Delirium with Severe Agitation in Emergency Settings 2021 ACEP published a task force report in April 2021 on Hyperactive Delirium with Severe Agitation in Emergency Settings. It said that “explicit discussion of ‘Excited Delirium Syndrome’ will only o...

Date: April 26, 2023 Reference: Han et al. The effect of telemental versus in-person mental health consults in the emergency department on 30-day utilization and processes of care. AEM April 2023 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 moonlighting at the Veterans Administration emergency department (ED) and are caring for an Iraq veteran complaining of post-traumatic stress disorder (PTSD) and severe anxiety. You desire a psychiatric consult and learn that you don’t have in-person consult availability at this facility, but instead use telehealth services. You wonder about how this compares to an in-person consult. Background: Mental health and behavioral complaints are common in the ED, but a shortage of mental health providers results in high numbers of patients requiring transfer, some of whom may have been appropriate for discharge. Telemental health (TMH) has been shown in settings outside the Veterans Administration (VA) to increase access to mental health providers, increase the proportion of patients discharged home, and decrease the number of patients transferred. However, what’s not well studied is the effect of TMH on post-evaluation utilization and processes of care such as medication changes, disposition, length of stay, involuntary holds, and use of chemical or physical restraints. Clinical Question: What is the effect of TMH, versus in-person consult, on 30-day outcomes and processes of care during the visit? Reference: Han et al. The effect of telemental versus in-person mental health consults in the emergency department on 30-day utilization and processes of care. AEM April 2023 Population: Veterans presenting to VA medical center (VAMC) EDs and urgent care centers (UCC) Intervention: Telemental health consult administered via iPad and Apple FaceTime software Comparison: In-person mental health consultation Outcome: Primary Outcome: Composite of 30- day return ED visits, 30-day return hospitalization after the index ED visit, and death from any cause. Secondary Outcomes: Number of medications changed, disposition, length of stay, involuntary hold, use of parenteral benzodiazepines or haloperidol, and use of physical restraints or seclusion Type of Study: Exploratory retrospective cohort study Dr. Jin Han This is an SGEMHOP episode which means we have the lead author on the show.  Dr. Jin Han is an emergency physician with Vanderbilt University Medical Center in Nashville TN, and a researcher with the Geriatric Research, Education, and Clinical Center at the Tennessee Valley VA Healthcare System. Authors’ Conclusions: “TMH was not significantly associated with the 30-day composite outcome of return ED/UCC visits, rehospitalizations, and death compared with traditional in-person mental health evaluations. TMH was significantly associated with increased ED/UCC length of stay and decreased odds of placing an involuntary psychiatric hold. Future studies are required to confirm these findings and, if confirmed, explore the potential mechanisms for these associations.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results/is the estimate of risk? Fairly narrow CIs Do you believe the results? Yes Can the results be applied to the local population? No Do the results of this study fit with other available evidence? Yes Funding/COI: Grant from the Office of Rural Health of the V...

Date: April 20, 2023 Reference:  Franklin D, et al. Effect of early high-flow nasal oxygen vs standard oxygen therapy on length of hospital stay in hospitalized children with acute hypoxemic respiratory failure: the PARIS-2 randomized clinical trial. JAMA 2023 Guest Skeptic: Dr. Michael Falk is a Pediatric Emergency Medicine attending at Mount Sinai Medical Center and Associate Professor of Emergency Medicine at the Icahn School of Medicine in New York. He is interested in simulation and medical education. Dr. Michael Falk Case: A 14-month-old boy presents to the emergency department (ED) with two days of upper respiratory symptoms and respiratory distress.  He has a cough, fever of 38.5°C, runny nose and increased work of breathing that started today.  He is breathing at rate of 48 breaths per minutes with intercostal retractions and oxygen saturation of 88%.  His lung exam reveals bilateral wheezing, rhonchi but no focal findings. He is drinking well, and parents report normal urine output.  He is suctioned and given trial of Beta agonist because has a history of eczema and a sibling with asthma with no change.  Despite your interventions, he continues to breathe rapidly with an oxygen saturation of 89% on room air.   You are working with an eager medical student, and she asks, “Should we start high flow nasal cannula (HFNC) at 2L/kg/min and admit the patient?” Background: Respiratory illnesses remain one of the most frequent causes of admission for children less than 5 years.  Some of these illnesses result in acute hypoxemic respiratory failure. Historically, there were not many treatments for these children, and they were admitted for observation or intubated and started on mechanical ventilation. High flow nasal cannula (HFNC) started gaining popularity in the early 2000s as an option of noninvasive ventilation.   We have covered the use of HFNC in pediatrics a few times on the SGEM including SGEM #228 and SGEM #379. Previous research has shown that HFNC can lower the rate of escalation of care but showed no impact on admission to the intensive care unit (ICU) or length of stay [1].  Clinical Question:  Does the early use of HFNC reduce the length of hospital stay in pediatric patients with acute hypoxemic respiratory failure compared with standard oxygen therapy? Reference:  Franklin D, et al. Effect of early high-flow nasal oxygen vs standard oxygen therapy on length of hospital stay in hospitalized children with acute hypoxemic respiratory failure: the PARIS-2 randomized clinical trial. JAMA 2023 Population: Children aged 1 to 4 years of age who presented across 14 emergency departments in Australia and New Zealand requiring hospital admission for acute hypoxemic respiratory failure Exclusion: There was a long list of exclusion criteria that you can find in the supplemental material, but these included craniofacial abnormalities, upper airway obstruction, cyanotic heart disease, tracheostomies, apneas, immediate high-level care in the ICU or required noninvasive or invasive mechanical ventilation. Intervention: HFNC at differing rates depending on weight Comparison: Oxygen via nasal cannula at 2L/min or by face mask up to 8L/min  Outcome:  Primary Outcome: Length of hospital stay defined as time from randomization to time of hospital discharge/death. Secondary Outcomes: Length of oxygen therapy from the time of randomization Length of hospital stay starting from arrival in the ED Proportion of children requiring a change in therapy on the general ward Proportion of children that required ICU admission or transfer to hospital with a pediatric ICU Proportion of children that required escalation of care to noninvasive or invasive ventilation Adverse events Tolerance of intervention Clinical triggers that warranted a change in that child’s care Type of Study: Multicenter, randomized clinical trial

Dr. Susanne DeMeester, an Emergency Physician and cardiovascular section editor, delves into the critical issues surrounding women's heart health in sports. She discusses the alarming incidence of sudden cardiac arrest among female athletes and highlights gaps in research and representation. The conversation emphasizes unique risk factors like estrogen influence and the prevalence of conditions like Takotsubo syndrome. Dr. DeMeester calls for targeted cardiovascular screening and enhanced awareness to better protect women in high-intensity sports.

Date: April 4th, 2023 Reference: Vaughan and Browne. Reconfiguring emergency and acute services: time to pause and reflect. BMJ Qual Saf. 2023 Apr Guest Skeptics: Dr. Louella Vaugh is an internist practising as a hospitalist physician at an academic centre in London, UK with a special interest in smaller, rural and remote healthcare. Her main job is working for a think tank. John Brown PhD is a Professor of Health Services Research in Ireland who has been studying rural healthcare issues since 2012. This is an SGEM Xtra episode. There have been many “temporary” rural emergency department closures during the past last year. In Ontario alone there have been approximately 160 emergency departments (ED) temporarily closed since the beginning of 2022. This is something that has only happened once since 2006 (Ottawa Citizen March 28, 2023) The study referred to in the editorial looks at the experience in Denmark with a reconfiguration of their emergency healthcare services (Flojstrup et al 2023). The objective of that study was the following: To investigate how the’ natural experiment’ of reconfiguring the emergency healthcare system in Denmark affected in-hospital and 30-day mortality on a national level. The reconfiguration included the centralisation of hospitals and the establishment of emergency departments with specialists present around the clock. It was a stepped-wedge reconfiguration of the entire Danish emergency healthcare system. The main outcome was the adjusted odds ratio for in-hospital mortality and hazard ratio for 30-day mortality with some pre-specified subgroups. They found no statistical difference for in-hospital mortality but slightly increased 30-day mortality. The pre-specified subgroup analyses showed a decrease in in-hospital or 30-day mortality for myocardial infarction, stroke, aortic aneurysm, and major trauma but not for pneumonia, bowel perforation or hip fractures. This was not the only study to come out of the Danish reconfiguration initiative. The dataset also reported increasing admissions, mixed results on length of stay, increasing readmission rates, increasing COPD deaths if transported by ambulance, and expected productivity benefits were not realized. The SGEM advocated for having the evidence to inform/guide our decisions. Here is what the evidence say about the centralization of emergency healthcare services from the Danish study: some possible benefits for small groups of patients (myocardial infarction, stroke, aortic aneurysm, major trauma), there was no overall improvement in the in-hospital mortality trend and a slight worsening of the 30-day mortality trend. Five Assumptions Made about Emergency Healthcare Centralization Listen to the SGEM podcast to hear Louella and John discuss the five assumptions. Listed are the assumptions and some of the points we touched upon. Assumption#1: There is a problem with the quality of EM care that needs to be fixed Boarded patients length of stay (LOS) in the ED increases mortality Canary in the coal mine (fix the mine not the canary) COVID19 and staffing It’s about a system problem not a small hospital problem Assumption#2: Smaller hospitals provide worse care than their larger counterparts Myocardial infarction, stroke, and major trauma account for 1% of ED attendance Other skilled time-sensitive interventions (abdominal, vascular, obstetrical, and intracranial surgeries) still only amount to a total of 5% of ED attendance Little or no evidence that care in small hospitals is worse for 95% of cases Assumption#3: Reconfiguration produces better outcomes While studies of centralisation of care for individual services show better outcomes for specific patient groups, the population-level evidence for whole-scale reconfiguration through changes to ED services tells a different story.

In this discussion, Dr. Justin Morgenstern, an emergency physician and creator of First10EM.com, joins Lauren Fowler, a neuroscience professor focusing on fatigue, and Dr. Emily Hirsh, an associate professor dedicated to faculty wellbeing. They dive into the critical issue of fatigue in emergency medicine, revealing its ties to shift work and how it impairs performance and patient care. Insights into managing burnout, recent research findings on fatigue assessment, and the importance of systemic changes highlight the necessity for a healthier work environment in this demanding field.

Dr. Casey Parker, a Rural Generalist specializing in emergency medicine and ultrasound, shares insights from his work between remote and urban hospitals in Australia. He discusses the effectiveness of point-of-care ultrasound (POCUS) in diagnosing biliary diseases, revealing its advantages over traditional methods. The real clinical case of a woman with abdominal pain highlights the importance of ultrasound training in emergency settings. Casey emphasizes the impact on surgical decision-making and the need for better research methods to enhance diagnostic accuracy.