The Skeptics Guide to Emergency Medicine

Dr. Samina Ali, a pediatric emergency medicine physician and researcher, dives into the complexities of managing pain in children. She discusses the pressing need for better pain assessment and treatment protocols in emergency settings. The conversation emphasizes a collaborative approach to create comprehensive pain management standards in Canada. Dr. Ali also highlights the significance of family involvement and innovative distraction techniques to ease children's fears during medical procedures, paving the way for more compassionate healthcare.

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

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.”

Join Dr. Jonathon Edlow, a Harvard emergency medicine professor, and Dr. Peter Johns, a seasoned emergency physician with a passion for vertigo education. They discuss the GRACE-3 guidelines, emphasizing the complexities of diagnosing acute dizziness and the importance of comprehensive history-taking. The duo critiques traditional methods and advocates for an algorithmic approach to enhance diagnostic accuracy. They delve into vital techniques for managing Benign Paroxysmal Positional Vertigo and highlight the necessity of ongoing training for emergency physicians in effectively evaluating vestibular disorders.

Dr. Brooks Walsh, an emergency physician and former paramedic, delves into the complex topic of excited delirium, revealing its historical roots dating back nearly 200 years. He critiques the term's racial biases and calls for a re-evaluation of its application in emergency medicine. Walsh emphasizes the need for diversity in decision-making to improve patient outcomes and discusses the challenges in translating research into practice. He advocates for better communication strategies in high-stress situations, aiming to foster equity in medical care.