The Skeptics Guide to Emergency Medicine

Date: November 26th, 2022

Reference: James et al. Emergency Department Condition Acuity, Length of Stay, and Revisits Among Deaf and Hard-of-Hearing Patients: A Retrospective Chart Review. AEM November 2022

Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine.

Click on the LINK for a transcript of the podcast

Case: One night you grab the next patient on the board, and upon entering the room introduce yourself as you normally would. The patient waves at you and gestures to a friend in the room, who explains that the patient is deaf and needs a sign language interpreter. You know from your brief look at the triage report that the patient’s vitals are stable and their chief complaint isn’t likely to be immediately life threatening, so you politely explain you’ll be back, and go find the charge nurse to obtain interpreter services.

Background: The emergency department sees anyone at anytime for anything. This includes some patients who have difficulty accessing the healthcare system due to social determinants of health, race, gender, mental health, substance use disorder, and physical difficulties.

Deaf and hard-of-hearing (DHH) experience disparities in social outcomes as well as health inequities (1), likely due to audism, which creates privilege for non-DHH people in our society (2).

DHH patients are more likely to use the ED than non-DHH patients, but little research has been done to compare ED-focused outcomes for these groups of patients (1, 3-4). DHH patients are heterogenous, with adult-onset DHH patients being less likely to use American Sign Language (ASL) with proficiency (5).

DHH ASL users may have delays due to interpreter availability, potentially resulting in care discrepancies (1, 6).

Clinical Question: How do deaf and hard-of-hearing (DHH) American Sign Language speakers and DHH English speakers utilize the ED, specifically regarding acuity of complaints and pain, what is their ED length of stay and what is the prevalence of acute revisits?

Reference: James et al. Emergency Department Condition Acuity, Length of Stay, and Revisits Among Deaf and Hard-of-Hearing Patients: A Retrospective Chart Review, AEM November 2022

* Population: All DHH-American Sign Language, DHH-English speakers, non-DHH English speakers users who had used a single academic center for care

* Excluded: Patients who had not had an ED visit during the time period

* Intervention: None

* Comparison: Non-DHH English speakers were compared to DHH ASL-users and DHH English speakers

* Outcomes:

* Primary Outcome: Emergency Severity Index (ESI), triage pain score, ED length of stay (LOS), and acute ED revisit (defined as within 9 days)

* Type of Study: Retrospective chart review of a single health care system

This is an SGEMHOP episode which means we have the lead author on the show Dr. Tyler James. Dr. James is a Postdoctoral Research Fellow in the Department of Family Medicine at the University of Michigan Medical School. His research focuses on healthcare access, utilization, and delivery for people with disabilities, with specific interest in working with people with sensory disabilities. He is also a mixed methods research methodologist, and serves as Associate Editor for Media Reviews of the Journal of Mixed Methods Research.

Authors’ Conclusions: Our study identified that DHH ASL-users have longer ED LOS than non-DHH English-speakers. Additional research is needed to further explain the association...

Date: November 19th, 2022

Reference: Khatib N, and Sampsel K. CAEP Position Statement Executive Summary: Where is the love? Intimate partner violence (IPV) in the Emergency Department (ED). CJE.M 2022 Nov

Guest Skeptics: Dr. Nour Khatib is an emergency physician in Toronto working in community sites Markham Stouffville Hospital and Lakeridge health. Dr. Khatib also works in remote Northern communities in the Northwest Territories and Nunavut. She is currently the professional development and education lead at Lakeridge Health and lead preceptor for Lakeridge Health learners. She is the VP of Finance of a not-for-profit emergency education organization creating educational events for community emergency doctors. Prior to her career in medicine, she was a financial analyst for Pratt & Whitney Canada and has a background in Finance and an MBA. Her unique work and life experiences have fueled her passion for leadership, patient education, and quality improvement.

Dr. Kari Sampsel is a staff Emergency Physician and Medical Director of the Sexual Assault and Partner Abuse Care Program at the Ottawa Hospital and an Assistant Professor at the University of Ottawa. She has been active in the fields of forensic medicine and medical education, with multiple international conference presentations, publications and committee work. She has been honored with a number of national awards in recognition of her commitment to education and awareness. She has founded a technology/consultancy company to assist organizations in policy development, staff training, investigation and prevention of sexual harassment and assault. She is also an avid CrossFitter and believes that strength and advocacy are the way to a better world.

This is an SGEM Xtra episode. The Canadian Association of Emergency Physicians (CAEP) put out a position statement on intimate partner violence (IPV) on November 2, 2022.  CAEP has several position statements including homelessness, violence in the ED, gender equity, opioid use disorder and other topics. We did an SGEM Xtra episode covering the CAEP position statement on Access to Dental Care. The key message is that CAEP believes that every Canadian should have affordable, timely, and equitable access to dental care.

TRIGGER WARNING:

As a warning to those listening to the podcast or reading the blog post, there may be some things discussed about IPV that could be upsetting. The SGEM is free and open access trying to cut the knowledge translation down to less than one year. It is intended for clinicians providing care to emergency patients, so they get the best care, based on the best evidence. Some of the IPV material we are going to be talking about on the show could trigger some strong emotions. If you are feeling upset by the content, then please stop listening or reading. There will be resources listed at the end of the blog for those looking for assistance.

The rate of women murdered by a current or ex-partner in Canada has increased from 1 in every 6 days, to one in every 36 hours in 2022. Canada’s Emergency Departments are where survivors of violence most often seek care, and where the violence against them is not always recognized. A new position statement from the Canadian Association of Emergency Physicians, published in November 2022, during Domestic Violence Awareness Month, aims to guide Emergency Department staff in the recognition and care of survivors...

Date: November 10th, 2022

Reference: de-Madaria E et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis (WATERFALL). NEJM 2022.

Guest Skeptic: Dr. Salim R. Rezaie completed his medical school training at Texas A&M Health Science Center and continued his medical education with a combined Emergency Medicine/Internal Medicine residency at East Carolina University. Currently, Salim works as a community emergency physician at Greater San Antonio Emergency Physicians (GSEP), where he is the director of clinical education. Salim is also the creator and founder of REBEL EM and REBEL Cast, a free, critical appraisal blog and podcast that try to cut down knowledge translation gaps of research to bedside clinical practice.

Case: A 38-year-old male presents to the emergency department (ED) with acute mid epigastric abdominal pain with nausea and vomiting.  As part of the patient’s workup, he has an elevated lipase, and a CT abdomen and pelvis ultimately shows the patient to have acute pancreatitis. You remember a new trial was just published on whether to use aggressive versus nonaggressive goal-directed fluid resuscitation in the early phase of acute pancreatitis and wonder which would be better for this patient.

Background: It’s interesting to see how fluid resuscitation has been debated over the years. This includes fluid type and rate for things like renal colic (SGEM#32), pediatric diabetic ketoacidosis  (SGEM#255), hyponatremia (SGEM#326), trauma (SGEM#369), and critically ill adults (SGEM#347 and SGEM#368).

Standard management of acute pancreatitis has focused mainly on hydration, analgesia, and investigation for an underlying cause.  Recent evidence has challenged the routine use of aggressive large volume fluid resuscitation with the potential to increase the severity of pancreatitis as well as fluid overload.  High-quality evidence demonstrating harms of aggressive fluid resuscitation in acute pancreatitis have been lacking.

Clinical Question: Does the use of a moderate fluid resuscitation strategy in acute pancreatitis decrease the rate of progression to moderate/severe pancreatitis in comparison to aggressive fluid resuscitation?

Reference: de-Madaria E et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis (WATERFALL). NEJM 2022.

* Population: Adult patients (≥18 years of age) diagnosed with acute pancreatitis based on the Revised Atlanta Classification (Requires 2 of 3: Typical abdominal pain, serum amylase or lipase level higher than three times the upper limit of normal, or signs of acute pancreatitis on imaging) that presented within 24 hours of pain onset

* Exclusions: Patients who met the criteria for moderately severe or severe disease at baseline (shock, respiratory failure, and renal failure) or who had baseline heart failure (NYHA II, III, or IV), uncontrolled arterial hypertension, electrolyte disturbances (hypernatremia, hyponatremia, hyperkalemia, hypercalcemia), an estimated life expectancy of <1 year, chronic pancreatitis, chronic renal failure, or decompensated cirrhosis

* Intervention: Moderate fluid resuscitation (bolus of 10 cc/kg lactated Ringer’s [LR] over two hours in patients with hyp...

Date: October 24, 2022

Guest Skeptic: Dr. Damian Roland is a Consultant at the University of Leicester NHS Trust and Honorary Professor for the University of Leicester’s SAPPHIRE group. He specializes in Pediatric Emergency Medicine and is a passionate believer and advocate of FOAMed. Damian is also part of the Don’t Forget the Bubbles team.

I sent Damian a message on Twitter after he posted about his pre-print paper, “Concomitant infection of COVID19 & Serious Bacterial infection in Infants <90 Days Old during Omicron Surge.”  It was a rapid evaluation under the remit of the Public Health/Disease Control so did not require review by a Research Ethics Committee (REC). Unfortunately, journals, do not typically accept this and want to see ethics derogation. This led to a conversation about research ethics and governance.

It is important to acknowledge that historically, the medical community has not always conducted research ethically. We took advantage of vulnerable and minority populations as evidenced by Nazi medical experimentation in the concentration camps, the Tuskegee Syphilis Study, or the HeLa cells of Henrietta Lacks. We recognize the importance of research oversight and ethical research, but our world is changing…

How have emerging pandemics, technology, and social media impacted the way we conduct and disseminate research?

We covered five topics:

* Ethics of Research in Pandemics

* Maintaining Research Quality

* Deferred Consent

* Big Data

* Sharing Research on Social Media

Ethics of Research in Pandemics

Many processes that govern research were scaled back to enable rapid translation of ideas. Some of this was good (ex. steroids in Covid, vaccines) but some had some potentially detrimental consequences (think pre-prints) [1].

It was much easier (in the UK) to access national data sets, and this enabled real-time research to take place. During pandemics, we need to be nimble but governed when conducting research. For example, when a new disease process (ex. PIMS TS or MIS-C) is of such a public health importance that we need to understand it as fast as possible, it is difficult to do so under stringent ethics and governance practices. For the next pandemic, we need to have systems in place for research studies to be pre-approved and ready to go as soon as a pandemic hits.

Maintaining Research Quality

At one point there were over 100 articles being published per day about COVID-19 [2]. Not all of them were useful or high quality. Keep in mind the words of Professor Altman, “we need less research, better research, and research done for the right reasons.”[3]

It is possible to have well-governed research that is poor quality but finds itself through poor review, disseminated widely in a high-quality journal. Conversely, there can be well-governed research that is high-quality, but journals disagree, and that research has less impact because it is not perceived by journals to be good.

The issue of ethical review should be separate from quality and governance. Does ethical review encompass the standard or quality of research or the mechanism of ensuring that the research is ethically performed? A randomized control trial is always going to have ethical review whereas an observational study may not. Should research that is well thought out and robust but lacking ethical approval be excluded from journals because editors perceive it does not meet the standard for high-quality research?

We separated 1) the governance of conducting research 2) the process of research, and 3) the publication of research and 4) the application of research findings.

There are many factors that come into in play when making clinical decisions while ...

Date: October 27th, 2022

Reference: Hayashi et al. Comparative efficacy of sedation or analgesia methods for reduction of anterior shoulder dislocation: A systematic review and network meta-analysis. AEM October 2022

Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com  

Case: A 19-year-old man presents to the emergency department (ED) with his first time anterior should dislocation after trying to recreate one of his favourite scenes in the movie Lethal Weapon. He is in significant pain, but your charge nurse informs us that, like most days since the pandemic started, the department is completely full of admitted patients, and there is nowhere safe to perform a procedural sedation, let alone have the staff to do it. The patient asks, through clenched teeth, whether there are any other options to get his shoulder back in.

Background: We have covered shoulder issues a few times on the SGEM. There was an episode looking at diagnosing rotator cuff injuries (SGEM#74), the best position post-dislocation immobilization (SGEM#121) and using point of care ultrasound (POCUS) to diagnose shoulder dislocations (SGEM#288).

The shoulder joint has the widest range of motion of any joint in the human body. This makes it very useful and very susceptible being dislocated. The vast majority of shoulder dislocations are anterior. Young active men are at greatest risk for dislocating their shoulder.

There is also a wide range of options to diagnose shoulder dislocations (clinically, POCUS, x-ray) and dozens of reduction techniques. Some clinicians perform reductions without any analgesics at all, while others choose from a variety of options, including peripheral nerve blocks, intra-articular anesthesia, and full procedural sedation.

Procedural sedation might represent one of the greatest advancements for the practice of emergency medicine, allowing us to perform a large variety of necessary but painful procedures without causing our patients pain. Although minor adverse events, such as brief apnea or hypoxia, are common, significant adverse events are very rare, and the benefits are clear (Bellolio 2016). However, for most departments, procedural sedation represents a logistical challenge that can increase a patient’s length of stay.

Peripheral nerve blocks (PNBs) can be very effective at controlling pain, but require a degree of practitioner skill. The use of ultrasound to guide these procedures has increased their popularity in recent years. There have been a few randomized control trials (RCTs) of peripheral nerve blocks for shoulder dislocation, but without definitive results (Raeyat Doost 2017; Blaivas 2011).

Intra-articular anesthetic (IAA) injections are another option, and seem like they should be incredibly easy, considering that the humeral head is not sitting in the glenoid fossa, and so the joint is wide open and supposedly easy to access. Intra-articular injection has been compared with procedural sedation (PS) for shoulder dislocation, with some potential benefits (Wakai 2011).  However, in one study, emergency physicians missed the joint space almost half the time when performing landmark-based shoulder injections (Omer 2021).

Therefore, uncertainty remains about the ideal technique to provide analgesia and/or sedation for the reduction of anterior shoulder dislocations.

Date: October 18th, 2022

Reference: Moore et al. Head and thorax elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival. Resuscitation 2022

Guest Skeptic: Clay Odell is a Paramedic, Firefighter, and registered nurse (RN).

Case: You are the Chief of your local Fire and EMS Department, and an individual contacts you saying he saw a piece on TV about a “Heads Up” CPR device, and he wants to donate half the cost and has his checkbook out.

Background: We have covered Out of Hospital Cardiac Arrests (OHCAs) many, many times on the SGEM. This includes epinephrine for OHCA, target temperature management, mechanical CPR, supraglottic airways, steroids, hands on defibrillation and many more topics.

* SGEM#50: Under Pressure Journal Club: Vasopressin, Steroids and Epinephrine in Cardiac Arrest

* SGEM#54: Baby It’s Cold Outside: Pre-hospital Therapeutic Hypothermia in Out of Hospital Cardiac Arrest

* SGEM#59: Can I Get a Witness: Family Members Present During CPR

* SGEM#64: Classic EM Paper: OPALS Study

* SGEM#107: Can’t Touch This: Hands on Defibrillation

* SGEM#136: CPR – Man or Machine?

* SGEM#143: Call Me Maybe for Bystander CPR

* SGEM#152: Movin’ on Up – Higher Floors, Lower Survival for OHCA

* SGEM#162: Not Stayin’ Alive More Often with Amiodarone or Lidocaine in OHCA

* SGEM#189: Bring Me To Life in OHCA

* SGEM#238: The Epi Don’t Work for OHCA

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

* SGEM#275: 10th Avenue Freeze Out – Therapeutic Hypothermia after Non-Shockable Cardiac Arrest

* SGEM#306: Fire Brigade and the Staying Alive APP for OHCAs in Paris

* SGEM#314: OHCA – Should you Take ‘em on the Run Baby if you Don’t get ROSC?

* SGEM#329: Will Corticosteroids Help if…I Will Survive a Cardiac Arrest?

* SGEM#336: You Can’t Always Get What You Want – TTM2 Trial

* SGEM#344: We Will…We Will Cath You – But should We After An OHCA Without ST ...

Date: October 5th, 2022

Reference: Top Gun 1986

Guest Skeptic: Dr. Chris Carpenter is Professor of Emergency Medicine in the Department of Emergency Medicine at Washington University in St. Louis and co-wrote the book on “Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules”.  Chris will be moving to Rochester, Minnesota soon to become the Vice Chair of Implementation and Innovation at the Mayo Clinic.

This is an SGEM Xtra episode about what we learned from the 1986 movie Top Gun. It is similar to the episode with kindness guru, Dr. Brian Goldman, on how Star Trek made us better physicians.

When Top Gun Maverick was released on Memorial Day Weekend May 27th, 2022, I hosted a weekend extravaganza. This involved watching the original movie, playing beach volleyball and then seeing Top Gun Maverick. It was an epic weekend with friends from around the world. Chris Bond from Standing on the Corner Minding My Own Business (SOCMOB) and I even stood up and sang She’s Lost that Lovin’ Feeling at the local movie theatre. You can click on this LINK to see the performance.

Chris Carpenter was booked to attend the Top Gun long weekend but COVID had other ideas. He tested positive a few days before the extravaganza. Chris did not want to become a  citizen of Canada for two-weeks in isolation, so he stayed home and missed the fun.

We were back together again at ACEP22 in San Francisco. Each year we co-present at the Rural Section meeting. This year we reviewed ten recent publications, provided some critical appraisal of the studies and then discussed if the evidence would be applied differently in a rural or critical access hospital compared to a tertiary or urban centre. You can download a copy of our slides at this LINK.

Being together again for the first time since 2019 was a great opportunity to record the Top Gun SGEM Xtra episode. There are so many different lessons/takeaways from the movie and we covered eleven (my second favourite number).

Lessons Learned from Top Gun

1) Be Prepared To Fail: Lieutenant Pete Mitchell (Maverick) takes risks and sometimes they work and sometimes they do not work. He dropped below the hard deck to get the kill shot during a training session but was reprimanded. Maverick also took a chance in the bar and tried to sing She’s Lost that Loving Feeling.

Lieutenant Commander Rick Heatherly (Jester): “That was some of the best flying I’ve seen to date — right up to the part where you got killed.

Date: September 15, 2022

Reference:  Ramnarayan P et al. Effect of high-flow nasal cannula therapy vs continuous positive airway pressure therapy on liberation from respiratory support in acutely ill children admitted to pediatric critical care units: a randomized clinical trial. JAMA July 2022

Guest Skeptic: Dr. Spyridon Karageorgos is a Pediatric Resident at Aghia Sophia Childrens’ Hospital, Athens, Greece and a MSc student in Pediatric Emergency Medicine at Queen Mary University London.

Case: A 10-month-old male infant presents to the emergency department (ED) with a low-grade fever, rhinorrhea and reduced feeding during the last two days. On exam, you notice increased work of breathing, nasal flaring, grunting with subcostal and intercostal retractions. He’s breathing at a rate of 75 per minute with oxygen saturations of 86% on room air. You make a clinical diagnosis of severe bronchiolitis. You start with low-flow O2 therapy but there is no clinical improvement. You discuss with the family the possibility that the child may need to be admitted in the pediatric intensive care unit (PICU) and require escalation of respiratory support with another modality of non-invasive ventilation. Parents look worried and ask you what kind of non-invasive support are you planning to start?

Background: The use of High-Flow Nasal Cannula (HFNC) has increased in both PICU and in the Pediatric ED, especially for infants presenting acutely ill with respiratory distress requiring non-invasive ventilation (NIV). Despite the rise in popularity, there is a lack of high-quality evidence surrounding the use of high flow nasal cannula.

Most studies are observational studies rather than randomized control trials (RCTs) [1-3]. Randomized control trials performed demonstrated that the early initiation of high flow nasal cannula led to lower rates of treatment failure/escalation…to high flow nasal cannula[4]. Even results from meta-analyses are mixed [5-6].

The SGEM covered the use of high flow nasal oxygen for bronchiolitis with Dr. Ben Lawton on SGEM #228.

The bottom line for that episode was:

“High flow oxygen therapy is not required for every child in hospital with bronchiolitis. It will continue to have a role in supporting those with more severe disease, but the potential benefits and harms will need to be considered within the context of where it is being used.”

There are a few proposed mechanisms for HFNC:

* Positive pressure

* Reduced upper airway resistance

* Washout of dead space in the nasopharynx

* More comfort from humidified air

However, data regarding the clinical effectiveness of HFNC compared to continuous positive airway pressure (CPAP) is limited.

In 2018, Ramnarayan et al. performed a multicentre pilot randomised controlled trial of HFNC vs CPAP in paediatric critical care that confirmed the feasibility of performing a large multicenter trial on HFNC vs CPAP in PICU [7].

The FIRST-ABC master protocol included two RCTs, one in acutely ill children requiring respiratory support (Step-Up RCT) and one in children requiring respiratory support after extubation from invasive ventilation (Step-Down RCT), with the aim of assessing the clinical and cost-effectiveness of HFNC as the first-line mode of non-invasive respiratory support in critically ill children.

We’re focusing on the Step-Up RCT for today’s episode.

Clinical Question: In acutely ill pediatric patients requiring non-invasive ventilation in the PICU, is High Flow Nasal Cannula (HFNC) noninferior to Continuous Positive Airway Pressure (CPAP) in terms of time to liberation from all forms of respiratory support?

Date: September 28th, 2022

Reference: Hartford et al. Disparities in the emergency department management of pediatric migraine by race, ethnicity, and language preference. AEM September 2022.

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 is a pulmonary embolism and implementation science researcher.

Case: A 15-year-old patient presents to the Emergency Department with a unilateral pounding headache. The headache is similar to prior migraine headaches. They have photophobia but no vision changes, weakness, numbness, tingling, or neurologic deficits. They took 400 mg ibuprofen at home without relief. The patient and their mother ask what the next steps will be and what type of medication will be administered.

Background: We have looked at migraine treatment a few times on the SGEM. That includes an episode on steroids to prevent bounce back visits to the ED (SGEM#28), ketorolac for acute treatment (SGEM#66), acupuncture for prophylaxis (SGEM#211) and a calcitonin gene-related peptide antagonist (SGEM#279).

Patients with migraines often present to the ED looking for pain relief. There are many therapeutic options available to clinicians to address their pain. Unfortunately, poor pain control persists despite the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) making pain “the fifth vital sign” in 2001 to raise the awareness of oligoanalgesia in the ED.

Despite the limitation of having a subjective measure as a vital sign, the problem of oligoanalgesia (poor pain management) persists (Motov and Khan). Some groups of patients who are at greater risk than others (elderly, women, mentally ill, certain ethnic groups, and insurance status).

Children represent one group that is less likely to receive adequate analgesia. (Brown et al, Selbst and Clark). It is not well documented, whether gaps in pain assessment and treatment exist in conditions in which opioids are not indicated, such as migraine headaches. It is hypothesized that race, ethnicity and language (REaL) could also be independently associated with pain control.

Clinical Question: Is there an association between patient demographics (race, ethnicity, and language) and pain management among pediatric ED patients presenting with migraine headaches?

Reference: Hartford et al. Disparities in the emergency department management of pediatric migraine by race, ethnicity, and language preference. AEM September 2022.

* Population: All patients treated in a single pediatric ED with at least one migraine-relevant medication using an ED migraine pathway from pathway inception (October 14, 2016) through February 28, 2020.

* Excluded: Repeat encounters

* Intervention: Intravenous (IV) medications +/- oral (...

Date: September 20th, 2022

Reference: Menon et al. Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial. The Lancet 2022

Guest Skeptic: Professor Daniel Fatovich is an emergency physician and clinical researcher based at Royal Perth Hospital, Western Australia. He is Head of the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research; Professor of Emergency Medicine, University of Western Australia; and Director of Research for East Metropolitan Health Service.

Case: A 74-year-old man arrives from home by private vehicle complaining of right-sided weakness and dysarthria beginning two hours prior to arrival. Advance neuroimaging demonstrates no bleed and no large vessel occlusion. His NIHSS score is calculated to be 10 and he has no absolute contra-indications for systemic thrombolysis.

Background: A lot has happened since you were on the SGEM last time discussing stroke (SGEM#325). This includes the CADTH report on thrombolysis by Alteplase for acute ischemic stroke in less than 4.5 hours with a letter to the editor from some neurologists representing CSC expressing their serious concerns about the report.

Neurologist Dr. Ravi Garg was on an SGEM Xtra discussing his publication analysing the 1995 NINDS study. He showed the study had a high risk of selection bias. Dr. Garg concluded that the baseline imbalances observed in the NINDS study were more likely due to randomization errors than random chance. His advice was treatment decisions and guideline recommendations based on the original treatment effect reported in the NINDS tPA study should be done cautiously.

We also had stroke neurologist Dr. Jeff Saver on an SGEM Xtra discussing his SRMA using the fragility index. He holds a much different interpretation of the stroke literature than Dr. Garg. The conclusion to Dr. Saver’s publication was that intravenous alteplase given within three hours of symptom onset for acute ischemic stroke is one of the most robustly proven therapies in medicine.

Besides the disagreement about the strength of the evidence for tPA, there are challenges with administering this medication. It involves giving an infusion of 0.9mg/kg IV to a maximum dose of 90mg. The infusion starts with 10% of the total dose given as a bolus administered in one minute. The remaining amount is infused over 60 minutes.  Tenecteplase (TNK) is a genetically modified variant of alteplase with greater fibrin specificity (15-fold higher) and longer plasma half-life (22 min vs 3.5 min). Because of its ease of use as a single bolus and more favourable benefit-to-risk profile, it is preferred over alteplase as the fibrinolytic agent of choice for acute myocardial infarction.

Clinical Question: Is tenecteplase non-inferior to alteplase in treating acute ischemic stroke?

Reference: Menon et al. Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial. The Lancet 2022

* Population: Adult patients aged 18 years and older with ischemic stroke...