Date: April 5th, 2019

Reference: Connolly et al. Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors. NEJM 2019

Guest Skeptic: Dr. Ryan Radecki is an Emergency Physician at Kaiser Permanente NW, co-host of the Annals of Emergency Medicine podcast and Journal Club section editor.

Case: You are caring for a 72-year-old man who comes in after having slipped on the ice.  A routine evaluation finds only minor bumps and bruises, including a rather nasty one on his occiput where he struck a step.  He reports he has been taking apixaban to prevent stroke in the context of atrial fibrillation, which you easily recognize as one of the modern oral anti-Factor Xa inhibitors.  You order a non-contrast CT to rule out hemorrhage. It demonstrates a 7mm subdural hematoma with 3mm of midline shift.  As you are reassessing your patient and treatment plan, the question presents itself – how should we reverse his anticoagulation?

Background: More and more patients are being treated with direct oral anticoagulants (DOACs). This number will probably increase since the AHA/ACC/HRS 2019 updated guidelines for atrial fibrillation guidelines. It now contains the following recommendation:

NOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) are recommended over warfarin in NOAC-eligible patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve). Level A

One of the concerns clinicians had with DOACs was there was no way to reverse these new anti-coagulants when they were introduced. In contrast, protamine could be used for heparin and LMWH reversal and vitamin K, fresh frozen plasma and prothrombinase complex concentrate could be used to reverse coumadin (Hunt and Levi BMJ 2018).

This changed in 2015 when the Food and Drug Administration (FDA) approved idarucizumab for the reversal of dabigatran. Dabigatran is a direct thrombin inhibitor. We covered the interim analysis of 90 patients included in a prospective cohort study by Pollack et al NEJM 2015 on SGEM#139. Our bottom line for that episode was that idarucizumab is here (USA) and probably works but its patient-oriented efficacy and safety are still pending.

The full study cohort of 503 patients has since been published (Pollack et al NEJM 2017) and we are in the same place we were in 2015. Idarucizumab clearly and effectively removes dabigatran from circulation and this ought to be occasionally clinically useful. I would certainly exhaust all potential supportive and expectant management options first, as well as try to definitively confirm dabigatran as the culprit for abnormal hemostasis (EM Lit of Note).

The FDA granted accelerated approval for andexanet alfa (Andexxa) in May of 2018. Andexxa is an antidote for factor Xa inhibitor like rivaroxaban, apixaban and edoxaban. It acts as a decoy and binds to the factor Xa inhibitors.

The American College of Cardiology has published a fact sheet...

Date: March 20th, 2019

Guest Skeptic: Dr.Katie Walker is an emergency physician in Melbourne, Australia. She is a clinical researcher at Cabrini Hospital and an Adjunct Clinical Associate Professor at Monash University.

Case: The emergency department is backing up. You have ambulances ramping and patients queuing at triage. Your medical team is great, but you notice that the busier you all become, the more you see your docs at their computers, rather than at patient bedsides. You are frustrated that whilst you frantically fill in data in the Electronic Medical Record (EMR) from your last consultation, your neighbor is in your waiting room with a dislocated shoulder and you haven’t been able to get to her yet. Is there a better way of working than this way?

Background: One in ten health high-income country consultations are now in Emergency Medicine. Most emergency physicians use some form of electronic medical records (EMRs) when seeing patients.

The EMR tasks we undertake are expanding rapidly, far beyond simply documenting history and physical examination and every implementation slows us down.

Research by Hill et al (1) demonstrated that an ED shift can have 4,000 clicks. Physicians are spending more time on EMRs (40%) than any other activity including direct patient care (30%). SGEM#159 looked at the implementation of an EMR in a tertiary care ED. Median wait times, length of stay, left without being seen, and length of stay for admitted patients all got worse with adding computerized physician order entry (CPOE) as part of their EMR (2).

The implementation of the EMR into clinical practice represents a very large, global, medical productivity loss. It could also have a negative impact on patient care.

There are studies showing that EMRs are one of the biggest causes, if not the number one cause of physician burnout (3). Physicians suffering from burnout provide a lower quality and safety of care (4). This means there is an association between EMRs and worse patient care.

If we have to use EMRs, how can we improve our productivity? There haven’t been any large, independent, multi-centre, randomised evaluations of scribe effectiveness and safety, until now.

Scribes are individuals who help physicians by doing the clerical tasks. There is a long list of things that they do including documentation of the clinical encounter, information retrieval, and discharge preparation.

Most physicians (85%) prefer working with scribes (5) and most patients tolerate scribes being involved in the clinical encounter (6). They have been used in US departments for years, but are only now beginning to be used in Canada and Australia.

Clinical Question: What is the impact of scribes on emergency medicine physicians’ productivity and patient throughput.

 Reference: Impact of scribes on emergency medicine doctors’ productivity and patient throughput: multicentre randomised trial, BMJ January 2019

* Population: Five emergency departments in Australia

* Intervention: Scribes rostered to a physician for a shift

* Comparison: Same physicians working shifts without scribes

* Outcomes:

* Primary: Total patients/physician/hour (including medical triage and handovers, where another doctor undertakes the primary/main consultation)

* Secondary: Primary patients/physician/hour, door-to-doctor time, door-to-discharge time, regions of emergency department patients/physician/hour, patient safety events (scribe group only, no comparator) and retrospective cost-benefit analysis

Authors’ Conclusions: “Scribes improved emergency physicians’ productivity,

Date: March 12th, 2019

Reference: Gottlieb, Holladay and Peksa. Ultrasonography for the Confirmation of Endotracheal Tube Intubation: A Systematic Review and Meta-Analysis. Ann Emerg Med 2018.

Guest Skeptic: Chip Lange is an Emergency Medicine Physician Assistant (PA) working primarily in rural Missouri in community hospitals. He hosts a great #FOAMed blog and podcast called TOTAL EM. Chip is also the CEO of a new educational company called Practical POCUS.

Case: A 48-year-old male is in cardiac arrest and is not being successfully oxygenated by bag valve mask or with a supraglottic airway (SGEM#246).  While preparing to intubate the patient, you consider ways of quickly confirming endotracheal tube placement.  You have a colleague in the room who is proficient at ultrasound and asks if there is a role for bedside ultrasound in this situation.

Background: We have talked about ultrasound a number of times on the SGEM:

* SGEM#245: Flash-errrs (POCUS for Retinal Detachments)

* SGEM#177: POCUS – A New Sensation for Diagnosing Pediatric Fractures

* SGEM#153: Simulation for Ultrasound Education

* SGEM#124: Ultrasound for Skull Fractures – Little Bones

* SGEM#119: B-Lines (Diagnosing Acute Heart Failure with Ultrasound)

The SGEM has also discussed endotracheal intubation a number of times:

* SGEM#247: Supraglottic Airways Gonna Save you for an OHCA?

* SGEM#197: Die Trying – Intubation of In-Hospital Cardiac Arrests

* SGEM#186: Apneic and the O, O, O2 for Rapid Sequence Intubations

* SGEM#75: Video Killed Direct Laryngoscopy?

Endotracheal intubation can be challenging and if incorrectly performed can lead to death.  Rapid confirmation of endotracheal tube placement is vital and ACEP has a policy statement on this issue. The various methods to confirm tube placement include:

* Physical exam (auscultation of chest and epigastrium, chest wall movement, and condensation/fogging in the tube)

* Direct visualization or videolaryngoscope of the tube going through the cords

* Pulse oximetry

* Chest x-ray

* Esophageal detector devices

* End-tidal carbon dioxide (CO2) detection (continuous wave form capnography, colorimetric and non-wave form capnography)

There is evidence indicating that commonly used endpoints for rapid confirmation can be inaccurate.  Quantitative waveform capnography, thought to be one of the best methods, correctly confirms tube placement only two-thirds of the time in cardiac arrest (Takeda et al, Tanigawa et al and

Date: March 8th, 2019

Reference: Wiler et al. Continuation of Gender Disparities in Pay Among Academic Emergency Medicine Physicians. AEM March 2019.

Guest Skeptic: Dr. Esther Choo. She is an emergency physician and researcher who studies health disparities, substance use disorders, and gender bias. Esther is an Associate Professor at Oregon Health and Sciences University and also is a founding member of the non-profit TIME’S UP Healthcare.

This SGEMHOP was recorded on International Women’s Day. It was the SGEM’s part in the Time’s Up in Healthcare initiative.

The clock has run out on sexual assault, harassment and inequity in the healthcare workplace. It’s time to do something about it.

Here is some more information on Time’s Up in Healthcare:

* Can we put an end to gender inequality and harassment in medicine? BMJ 2019

* Time’s Up Tackles Gender Bias and Harassment in Health Care. Scientific American March 2019

* Men in Medicine Speak Out Against Harassment in Powerful ‘TIME’S UP Healthcare’ Video. Men’s Health March 2019

* Health Organisations Slow to Tackle Inequality. Financial Times March 2019

* Time’s Up Takes on Sexual Abuse and Discrimination in Healthcare. InStyle February 2019

Case: A women colleague is being hired for an emergency department attending job wants to know why her pay is less than that of a man at the same hospital with the same years of training and the same accomplishments?

Background: Salary disparity between men and women has existed forever, and despite efforts such as the Equal Pay Act of 1963, this disparity continues to exist. This gap is seen across numerous professions, including law, marketing, administration and medicine. In the United States, women working full time are typically paid just 80 percent of what men are paid (1-4).

According to one 2010 analysis, the disparity in medicine is one of the highest for any professional industry, trailing only dentistry (5). Women now represent half of medical school graduates and 38% of faculty members in U.S. medical schools (6). After controlling for multiple factors, including specialty, age, faculty rank and metrics of productivity, male physicians earned nearly $20,000 more per year than their female counterparts (7,8). Within emergency medicine, studies have shown female faculty are paid 10% to 13% less than males (9,10).

In Canada, this gender disparity also exists and occurs across specialties and within academia.

* Why are Women Still Earning Less than Men in Medicine? CMAJ 2018

* Why is There a Gender Wage Gap in Canadian Medicine? Healthy Debate 2018

Clinical Question: Is there a difference in compensation for men and women emergency physicians practicing in the United States?

Reference: Wiler et al. Continuation of Gender Disparities in Pay Among Academic Emergency Medicine Physicians.

Date: February 18th, 2019

Guest Skeptic: Dr. Shahriar Zehtabchi is a tenured professor and Vice Chair of Academic Affairs in the Department of Emergency Medicine at SUNY Downstate Medical Center & Kings County Hospital. He has been teaching evidence-base medicine for many years and currently is the editor-in-chief of the EBM website TheNNT.com. Shahriar also serves as an editorial board member and associate editor for Academic Emergency Medicine journal.

Shahriar and I discussed the following:

* The NNT and NNH as a concept

* How to use the NNT/NNH to communicate with patients

* Weaknesses of the NNT

* What topics are covered on TheNNT.com and how they are selected

* Their peer review process for quality control

* Whether or not they have a policy to identify conflicts of interest

* Dr. Zehtabachie’s role as editor-in-chief

Guest Skeptic: Dr. Eddy Lang is a Professor and Department Head for Emergency Medicine Cumming School of Medicine, University of Calgary, Scientific Director Emergency Strategic Clinical Network and BEEM faculty member.

TheNNT.com updated their website January 11th, 2019 changing the recommendation of tPA for acute stroke from RED (no benefit) to GREEN (benefit > harms). Eddy was the lead author of the new recommendation and when it was posted it got the twitterverse very excited.

I reached out to Dr. Hoffman to discuss this change.  Then Eddy was invited to come on the SGEM to discuss why the change was made.

Eddy and I talked about the following:

* My stated position on thrombolysis for acute CVA

* His impression of the twitter storm

* His stated position on thrombosis for acute CVA and synopsis of the evidence

* Why he picked Dire Straights the Walk of Life as the theme music

* The claim that the modified Rankin Scale (mRS) is reliable and validated

* Limitations/weaknesses of the IST-3 Trial

* GRADE Methodology

* Inclusion and exclusion of different thrombolytic molecules in SRMAs

* Various guidelines

* Emberson et al SRMA from the Lancet

* Why they changed the recommendation from RED to GREEN

* The claim that time is brain

* ~1/3 of stroke are determined to be mimics

* Thrombolysing patients without strokes (mimics)

* Need for replication of trials in medicine

* The ethics of replicating the NINDS trial

* What Eddy says to patients/family at the bedside

* The impact of conflicts of interest in the production and interpretation of the literature

Each of us will have different levels of evidence that will convince us to change our practice. I respect that two people can look at the same literature and come to a different conclusion. The burden of proof is on those making the positive claim that tPA results in a net patient-oriented benefit in acute ischemic stroke. In my opinion, the burden of proof has not been met and I remain skeptical. I am happy to change my mind if presented with stronger evidence.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Additional Resources:

* SketchyEBM – Knowing NNT

* Chiong et al. Testing the Presumption of Consent to Emergency Treatment for Acute Ischemic Stroke. JAMA 2014

* Banks and Marotta. Outcomes Validity and Reliability of the Modified Rankin Scale: Implications for Stroke Clinical Trials. A Literature Review and Synthesis.

Date: February 26th, 2019

Reference: Benger et al. Effect of a Strategy of a Supraglottic Airway Device
vs. Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome. The AIRWAYS-2 Randomized Clinical Trial. JAMA 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: EMS arrive to your emergency department with a 68-year-old man post cardiac arrest patient.  They had a difficult time getting a definitive airway pre-hospital. It required multiple attempts which caused several prolonged interruptions in CPR. After the patient is stabilized the medic asks you how he can improve his airway management skills during a cardiac arrest as it was difficult to intubate during compressions. What should you tell him?

Background: We have covered OHCA many times on the SGEM. Key to survival is high-quality CPR and early defibrillation. There is no evidence for a patient-oriented benefit with epinephrine (SGEM#238), other ACLS drugs (SGEM#64), pre-hospital therapeutic hypothermia (SGEM#54, SGEM#183), or mechanical CPR (SGEM#136). One issue we have not discussed is endotracheal intubation.

For many years endotracheal intubation has been the standard of care for airway management in out-of-hospital cardiac arrest (OHCA). Over recent years this practice has been questioned. Endotracheal intubation is a technical skill requiring optimal positioning, proficiency and a technical skill level which may be difficult to obtain in the pre-hospital cardiac arrest setting.

Clinical Question #1: Are superglottic airway devices non-inferior to endotracheal intubation in OHCA with regards to neurologic outcome?

Reference: Benger et al, Effect of a Strategy of a Supraglottic Airway Device
vs. Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome. The AIRWAYS-2 Randomized Clinical Trial. JAMA 2018

* Population: Adults who had a non-traumatic OCHA.

* Exclusions: Prisoners, resuscitation deemed inappropriate, advanced airway already in place, and patient’s mouth opened less than 2cm.

* Intervention: The intervention was the insertion of a second-generation supraglottic airway (SGA) device with a soft non-inflatable cuff (i-gel; Intersurgical).

* Comparison: Endotracheal tube intubation (ETI) with direct laryngoscopy

* Outcomes:

* Primary Outcome: Neurologic outcome at discharge or 30 days using the modified Rankin Scale (mRS score 0-3 = good outcome and mRS score 4-6 = bad outcome).

* Secondary Outcomes: Initial ventilation success, which was defined as visualizing chest rise. Regurgitation (stomach contents visible in the mouth or nose) or aspiration (stomach contents visible below the vocal cords or inside a correctly placed tracheal tube or airway channel of a SGA device). Any unintended loss of a previously established airway. Sequence of airway interventions delivered. Return of spontaneous circulation (ROSC). Airway management in place when ROSC was achieved, or resuscitation was discontinued. Chest compression fraction. Time to death

Authors’ Conclusions: “Among patients with out-of-hospital cardiac arre...

Date: February 4th, 2019

Guest Skeptic: Dr. Jerome Hoffman is a Professor Emeritus of Medicine and Emergency Medicine, University of California, Los Angeles.

Dr. Hoffman has been a voice of reason for decades and taught a generation of physicians critical appraisal skills. This has been through various peer reviewed publications, doing Emergency Medicine Abstracts (EMA) audio program with Dr. Rick Bukata, teaching at the Emergency Medicine and Acute Care Course among other things.

There was a recent controversy on twitter and I thought Dr. Hoffman needed to join the conversation. Listen to the SGEM podcast to hear the many things we discussed.

The website TheNNT.com has been a good resource to find unbiased critical reviews of the literature. However, Dr. Hoffman did have some concerns about how the concept could be hijacked. It appears his concerns may have come true.

TheNNT updated their page on thrombolytics for acute ischemic stroke on January 11th, 2019. They changed the recommendation from RED (No Benefit) to GREEN (Benefits > Harms). This was very disturbing on multiple levels.

Controversy about thrombolytics and stroke is not new and has existed since at least 1995 with the publication of the NINDS trial. The SGEM has summarized the dozen major RCTs looking at the issue of thrombolytics for acute ischemic strokes (SGEM Xtra). Six trials showed no benefit. Four trials were stopped early due to harm or futility and two trials reported benefit. I do not claim thrombolysis does not work because that would shift the burden of proof. Rather, I state that I am skeptical.

We did not re-hash all the trials in our conversation but instead focused on a couple key publications like NINDS and IST-3. The SGEM did a Classic Episode on NINDS with Anand Swaminathan (SGEM#70). Dr. Hoffman has published a graphic re-analysis of NINDS (Annals EM 2009) and Sayer et al responded in print (Annals EM 2010).

The other major trial that we discussed was the IST-3 study which was covered on SGEM#29. Hoffman and Cooper provided commentary on some of the limitations of IST-3 (EMA 2012).

“using a score that is highly unreliable even when calculated by a neurologist performing an in-person neurologic evaluation. He then acknowledges that this problem was enormously exacerbated in IST-3 because the scoring was done by a layperson; to make matters even worse, this was a layperson who, like the patient himself, was unblinded to treatment group.” Hoffman and Cooper

Another issue we discussed was the outcome measure of mRS or in the case of IST-3, the Oxford Handicap Score (OHS) which is very similar to the mRS. Previous research has shown the mRS to have poor inter-rater reliability (Wilson et al Stroke 2005) and issues with validity (Zhao et al Cerebrovasc Dis 2010).

The methodology was changed in IST-3 when they did not reach...

Date: February 22nd, 2019

Reference: Lane et al. Association Between Early Intravenous Fluids Provided by Paramedics and Subsequent In-Hospital Mortality Among Patients With Sepsis. JAMA 2018

Guest Skeptics: Jay Loosley is the Superintendent of Education at Middlesex-London Paramedic Service. Jenn Doyle is a paramedic educator at Middlesex-London Paramedic Service.

Case: A 77-year-old man’s partner calls 911 because he has a fever, cough, shortness of breath and lethargy. The patient is known to have hypertension and dyslipidemia. Paramedics arrive quickly and find a man in bed with a temperature of 39.5C, heart rate of 111 beats per minute, respiratory rate of 24 breaths per minute, oxygen saturation of 91% and a blood pressure of 98/56. They suspect a respiratory infection, provided supplemental oxygen with a target of 94-96% (SGEM#243), establish IV access and begin a 500cc normal saline bolus.

Background: Sepsis is a serious condition with high morbidity and mortality. It has been covered on the SGEM many times over the last seven seasons (SGEM# 69, 90, 92, 113, and 168).

Recently we covered a paper looking at whether or not pre-hospital antibiotics could provide a benefit to patients with varying degrees of sepsis (SGEM #207).  The study by Alam et al took adult patients with a diagnosis of suspected infection and randomized them to ceftriaxone 2g IV started pre-hospital or usual care with a primary outcome of all-cause mortality at 28 days.

The bottom line from that episode pre-hospital antibiotics in the ambulance do not appear to have a mortality benefit in patients with varying degrees of sepsis in an optimized EMS system.

The Surviving Sepsis Campaign makes a number of recommendations in their 2016 guideline. One recommendation that they make is the rapid administration of 30ml/kg of crystalloid for hypotension. This is a strong recommendation from SSC based on low quality evidence. This was updated in 2018 with the 3-hour and 6-hour bundles combined into a single 1-hour bundle. This led to a petition requesting the SSC retract their 2018 guidelines (SGEM Xtra). For more information see PulmCrit recent post.

Clinical Question: Is IV fluid administration by Paramedics for patients with suspected sepsis associated with reduced in hospital mortality rates?

Reference: Lane et al. Association Between Early Intravenous Fluids Provided by Paramedics and Subsequent In-Hospital Mortality Among Patients With Sepsis. JAMA 2018

* Population: Patients with sepsis identified using the international Statistical Classification of Disease and Related Health Problems, Tenth Revision (ICD-10CA) coding that was modified to be consisten...

Date: February 15th, 2019

Reference: Gottileb, Holladay and Peksa. Point-of-Care Ocular Ultrasound for the Diagnosis of Retinal Detachment: A Systematic Review and Meta-Analysis. AEM January 2019.

Guest Skeptic: Dr. Daniel Theodoro is an Assistant Professor of Emergency Medicine at Washington University School of Medicine in St. Louis and the Emergency Medicine Point of Care Ultrasound Section Chief.

Case: A 54-year-old diabetic female presents to your emergency department (ED) complaining of floaters of flashing lights and blurry vision. She has no pain and no history of trauma. She noticed that she couldn’t read her newspaper, like there was a wall of light between her left eye and the words on paper. She presents to the ED looking for answers.

The vision in her right eye is 20/40 and vision in the left eye is 20/50. The left eye field of vision is significant for floaters and decreased capacity to see medially. She has no afferent pupillary deficit and she has no obvious cranial nerve deficits. Her eye is not red, and her cornea is not hazy. The rest of her examination is unremarkable.

Background: Ocular complaints account for 3-4% of all ED visits but the cause for the vast majority of these are benign. One in five of patients with eye complaints, however, will require an ED work up and referral for vision preservation. This group of pathology includes diagnoses such as uveitis, macular degeneration, occipital lobe disorders (amaurosis fugax), and posterior chamber pathology such as vitreous hemorrhage, vitreous detachment and retinal detachment.

Retinal detachment is important because, in some cases, there is an intervention that will prevent and possibly restore vision. Since the preservation of vision and quality of life are closely related, cases with retinal detachment deserve proper follow up and referral to a retina specialist.

Traditionally posterior chamber pathologies are diagnosed with direct and indirect ophthalmoscopy. However, few doctors other than ophthalmologists are sufficiently expert enough to do this examination. So, in the majority of ocular cases in the ED the examination is skipped entirely.

In the FOTO-ED study, ED physicians only did fundoscopy in 14% of appropriate cases. In the study trained nurse practitioners took photos of patient’s funduscopic examination and the photos were reviewed by retina specialists in 24 hours. They enrolled 350 patients, but ED physicians only examined 33 patients whose findings were unknown and in whom fundoscopy may have had a role. In all 33 the diagnosis was missed. Granted that in two-thirds the findings were not in the posterior chamber (e.g. retinopathy and optic nerve pallor) but still, this observational study showed ED physicians haven’t developed or maintained fundoscopic skills.

Further complicating matters is that one study in California demonstrated that fewer than 50% of rural EDs and only 75% of urban EDs have ophthalmology coverage. There are currently some tele-ophthalmology services going up online. They require a photograph taken of the fundus by the practitioner that is remotely reviewed. These are known as 45-degree non-mydriatic ocular fundus photographs and one such company is known as Topcon.

To make matters worse direct ophthalmoscopy has poor test characteristics and even indirect ophthalmoscopy has limits until it’s in the hands of experienced and skilled ophthalmologists. In the hands of experienced operators, indirect ophthalmoscopy has an LR+ 44 and LR- of 0.23. Remember, you need a LR- of less than 0.01 to rule out a condition.

If you are repeatedly performing a skill or procedure, receiving feedback, and working to improve you are engaged in Ericsson’s “deliberate practice,”  the key to becoming an expert.

Date: February 7th, 2019

Reference: Bouida et al. LOw dose MAGnesium sulfate versus HIgh dose in the early management of rapid atrial fibrillation: randomised controlled double-blind study. AEM February 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 working in your local freestanding emergency department (ED). This is an ED not physically attached to a hospital, for the non-American listeners. A 64-year-old male patient presents with a feeling of “palpitations” for about one week. His heart rate is 130-140 beats per minute, irregular, and his EKG shows atrial fibrillation with rapid ventricular response (RVR). You want to control his rate and have recently heard some of your colleagues talking about using intravenous magnesium in addition to their typical rate control agents.

Background: Atrial fibrillation is the most frequent cardiac arrhythmia. Patients often present to the ED with increased heart rates, chest pain and weakness among other presentations.

Rate control vs. rhythm control is a debate that has gone on for many years. The management in the USA tends to be rate control while in Canada they tend to do more rhythm control.

In Canada, we tend to cardiovert patients with recent onset of atrial fibrillation (less than 48 hours). There is an aggressive protocol out of Ottawa using procainamide and electricity to rapidly cardiovert and discharge patients with these arrhythmias. A study by Stiell et al showed that the vast majority of patients (97%) were discharged home from the ED with 93% in normal sinus rhythm using this protocol (SGEM#88).

In patients with chronic atrial fibrillation or unknown time of onset and a rapid ventricular response (RVR), rate control and consideration of anticoagulation therapy are the standard ED approach.

Dr. Anand Swaminathan and I reviewed a RCT comparing diltiazem vs. metoprolol in the management of atrial fibrillation or flutter with rapid ventricular rate in the ED (SGEM#133). The SGEM bottom line was that the best available evidence shows that diltiazem will achieve more rapid rate control in patients with atrial fibrillation than metoprolol (NNT 2).

Magnesium has been investigated as an alternative or adjunct for to rate control patients with rapid atrial fibrillation. Prior analyses have suggested that it is a safe and effective alternative strategy, however it has not been well studied in the ED, and the best dosing has been unclear.

Clinical Question: Can IV magnesium sulfate reduce the ventricular rate safely and effectively in ED patients with rapid atrial fibrillation?

Reference:Bouida et al. LOw dose MAGnesium sulfate versus HIgh dose in the early management of rapid atrial fibrillation: randomised controlled double-blind study. AEM February 2019.

* Population: Emergency department patients older than 18 years of age with rapid atrial fibrillation (>120 bpm).

* Exclusions: Hypotension (SBP < 90 mm Hg), impaired consciousness, renal failure (serum creatinine > 180 mmol/L), wide-complex ventricular response, or contraindication to MgSO4, acute myocardial infarction, acute congestive heart failure (New York Heart Association functional class 3 or 4), sick sinus syndrome, or rhythm other than atrial fibrillation.

* Intervention: 9g IV Magnesium sulfate (MgS) infused over 30 minutes.

* Comparison: 5g IV Magnesium sulfate or placebo infused over 30 mi...