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Date: November 27th, 2017

Reference: Legriel et al. Hypothermia for Neuroprotection in Convulsive Status Epilepticus. NEJM Dec 2016

Guest Skeptic: Dr. Neal Little is an Emergency Physician who works at Chelsea Hospital in Chelsea, Michigan. He is also a Faculty member of the Emergency Medicine and Acute Care Series 1986 to present.

Case: Johnny is a 22-year-old male patient who presents to the emergency department via EMS with a seizure. He is known to have poorly controlled epilepsy. It was a witnessed clonic-tonic seizure that stopped but he did not wake up. The paramedics report another seizure on route to the hospital. He arrives with normal vital signs, normal finger stick blood glucose and a Glasgow Coma Scale of 3. He then has another seizure in the department. You quickly assess him in the resuscitation room, the team attempts intravenous (IV) access and collects labs while you give 10mg of midazolam intramuscularly and the seizures seem to stop. His oxygen saturation begins to drop and you decide to intubate and mechanically ventilate. He is now stabilized, fosphenytoin is being infused, you are getting ready to ship him to the neuro-ICU and wonder if cooling him down would help.

Background: We have covered hypothermia a number of times on the SGEM. This has been for out-of-hospital cardiac arrests (OHCA). Therapeutic hypothermia has not been demonstrated to have benefit in the pre-hospital setting (SGEM#54 and SGEM#183)

The TTM trial provided evidence that it was not necessary to drive the temperature down to 32C. There was no statistical difference in the primary outcome between 33C vs. 36C (SGEM#82).

Status epilepticus used to be defined as a seizure lasting 30 minutes or more. This definition has been changed to a single seizure lasting more than five minutes or two or more seizures within a five-minute period without the person returning to normal between them (Al-Mufti and Claassen Neurocritical Care Oct 2014).

The American Epilepsy Society has guidelines on the acute management of convulsive status epilepticus (Glauser et al Epilepsy Currents 2016). They recommend in adults without IV access to use midazolam IM. There is no significant difference in effectiveness between IV lorazepam and IV diazepam in adults. See the proposed treatment algorithm for status epilepticus from the guidelines for details.

The hypothesis would be that cooling down the seizing brain could protect it from further injury. However, there is not good evidence that therapeutic hypothermia is neuroprotective in ischemic or hemorrhagic stroke, IHCA or traumatic brain injury.

Clinical Question: Does induced therapeutic hypothermia improve neurologic outcomes in patients with convulsive status epilepticus?

Reference: Legriel et al. Hypothermia for Neuroprotection in Convulsive Status Epilepticus. NEJM Dec 2016

* Population: Critically ill adult (> 18 years of age) with convulsive status epilepticus who were receiving mechanical ventilation

* Convulsive Status Epilepticus: Defined as seizing for five minutes or more continuously or more than two seizures without a return to baseline.

* Excluded: Full recovery, need for emergency surgery,

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Date: November 28th, 2017

Reference: Motov S et al. A Prospective Randomized, Double-Dummy Trial Comparing Intravenous Push Dose of Low Dose Ketamine to Short Infusion of Low Dose Ketamine for Treatment of Moderate to Severe Pain in the Emergency Department. AJEM 2017.

Guest Skeptic: Dr. Salim Rezaie is a faculty physician at Greater San Antonio Emergency Physicians (GSEP) in San Antonio, Texas. He is the founder and creator of REBEL EM and REBEL Cast.

Case: A 54-year old female patient with acute back pain comes to your emergency department for her forth visit in seven days for recurring pain.  She was lifting something heavy and felt a“pop” in her back.  She denies bowel or bladder issues, saddle paresthesia, lower extremity weakness, but does feel radicular pain down both of her legs.  She has been given intravenous hydromorphone, diazepam, and ketorolac without relief of her symptoms.  You decide to give her low dose ketamine, as this has worked in the past.

Background: Low back pain is a common and challenging presentation to the emergency department. While the vast majority of presentations are benign, these cases can be time consuming and frustrating for both patients and physicians.

Physician frustrations with managing acute non-traumatic low back pain include considering rare dangerous back pain patient (epidural abscesses, osteomyelitis, pathological fractures, etc), patients demanding imaging, difficulty in relieving pain and concern about opiate abuse or diversion.

There are multiple “Red Flag” lists to help identify patients at risk for more serious causes of their back pain. One simple red flag list is called TUNA FISH.

Other things to consider would be immunocompromised patients besides just those on steroids (ex: patients with HIV, diabetes, alcoholics or taking biologic agents) who are at risk for spinal epidural abscess, discitis, or osteomyelitis.

When it comes to patient demands for imaging, Choose Wisely from ACEP and CAEP encourages emergency physicians to avoid ordering lumbar spine imaging in patients without serious underlying conditions (red flags).

As mentioned, it can be difficult to treat low back pain in the emergency department. Many different treatment modalities have been tried to treat low back pain with limited success. A systematic review was just published in the Emergency Medicine Journal looking at 43 management of acute low back pain in the ED. The conclusions…we need more evidence.

* SGEM#87: Let Your Back-Bone Slide (Paracetamol for Low-Back Pain)

* SGEM#173: Diazepam Won’t Get Back Pain Down

* Muscle Relaxant Friedman et al(JAMA 2015)

* NSAIDs Machado et al (Ann Rheum Dis 2017)

* Systematic Review Ashbrook et al (Emerg Med J 2017)

Then there is the issue of opioids use for low back pain. ACEP has guidelines with the American Pain Society from 2007 on the use of opioids. They state opioids should be reserved for severe, disabling pain that is not controlled or not likely to be controlled with NSAIDs or acetaminophen.

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Date: November 24th, 2017

Reference: Andersen et al. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA 2017

Guest Skeptic: Dr. Bob Edmonds is an Emergency Physician in the US Air Force.  He is currently deployed, practicing emergency medicine in an undisclosed location.

DISCLAIMER: The views and opinions of this podcast do not represent the United States Government or the US Air Force.

Case: You are working a regular shift in the emergency department when you hear a code blue called. You are the first physician to respond and you begin to resuscitate the patient. Your respiratory therapist is adequately ventilating the patient with a bag valve mask, and they ask you if they should prepare to intubate at the pulse and rhythm check.

Background: We have talked about out-of-hospital cardiac arrests (OHCA) many times on the SGEM.

* SGEM#64: Classic EM Papers (OPALS Study)

* 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

This time, as the case identifies, we are going to be talking about in-hospital cardiac arrests (IHCA) today.

The American Heart Association (AHA) reports that were 209,000 IHCA arrests in 2016. The survival rate for adults to hospital discharge is 24.8%.

The  survival rate for IHCA has almost doubled from the year 2000 when it was only 13.7%. From a patient oriented outcome perspective, more than 80% of adults with IHCA who do survive end up having a favorable neurologic outcome at discharge. This is defined as a Cerebral Performance Category (CPC) score of 1 or 2.

There are five steps in the AHA IHCA Chain of Survival:

Sudden IHCA is a high stakes emergency with a high mortality rate. The decision to intubate is difficult to make and varies widely between clinicians. Due to the nature of intubation in cardiac arrest, it is difficult to study, and the studies that do exist are largely observational.

Until this paper, there were no studies of IHCA arrest intubation and survival.

Clinical Question: Does tracheal intubation during adult in-hospital cardiac arrest affect survival?

Reference: Andersen et al. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA 2017

* Population: Adult patients 18 years of age and older with an index cardiac arrest for which they received chest compressions.

* Cardiac Arrest: Pulselessness requiring chest compressions and/or defibrillation, with a hospital wide or unit based emergency response.

* Exclusions: Having a do-not resuscitate (DNR) order, already having an advanced airway in place (tracheal tube, tracheostomy, laryngeal mask airway, or other invasive airways but not including oropharyngeal o...

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Date: November 24th, 2017

Reference: Roldan et al. Trial Comparing Haloperidol Combined With Conventional Therapy to Conventional Therapy Alone in Patients With Symptomatic Gastroparesis. AEM November 2017

Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the Director of Simulation Education at Markham Stouffville Hospital in Ontario. He is the creator of the excellent #FOAMed project called First10EM.com

Case: You charge nurse approaches as you finish charting on the trauma patient who was just transferred out. “Mrs. G. is back again, vomiting and screaming in pain. This is the third time this month, and nothing ever seems to help. Is there anything we can do for her?”

Mrs. G is a 37-year-old female with gastroparesis secondary to diabetes. You know her well, and none of the usual anti-emetics seem to help her symptoms. While inwardly wishing you worked in a country where droperidol was available, you wonder whether there is any new research to guide your management.

Background: Gastroparesis is a challenging and frustrating condition for both patients and providers. Patients can present with abdominal pain, nausea, vomiting, early satiety and postprandial fullness. Gastroparesis has also been called delayed gastric emptying and it literally means paralysis of the stomach.

The most common cause of gastroparesis is idiopathic. However, when a cause is known it is often due to diabetes or surgery. Unfortunately, nothing really works well for this condition. The Food and Drug Administration has only approved metoclopramide for gastroparesis. It works by blocking dopamine receptors with antiemetic and prokinetic properties.

Multiple other drugs have been tried to treat gastroparesis. This includes serotonin 5-HT3 antagonists (ondansetron), histamine antagonists (meclizine and promethazine) prokinetic agents like serotonin 5-HT4 receptor agonists (cisipride) and motilin receptor agonists (erythromycin).

One drug that has been tried is haloperidol. It is an antipsychotic drug used for a number of psychiatric conditions including schizophrenia. Haloperidol blocks the dopamine receptors in the brain. It has been used for years to treat nausea and vomiting in post-operative patients and cancer patients.

A retrospective study was published earlier this year on haloperidol for the treatment of gastroparesis secondary to diabetes mellitus. It was called HUGS and showed lower hospital admissions and opioid use in patients receiving 5mg of haloperidol (Ramirez et al AJEM). You can find a good review on this paper on REBEL EM.

There has never been a randomized control trial looking at the efficacy of haloperidol on nausea and vomiting in any setting, until now.

Clinical Question: Does haloperidol, when added to conventional therapy, decrease abdominal pain and nausea at one hour in patients presenting to the emergency department with known gastroparesis?

Reference: Roldan et al. Trial Comparing Haloperidol Combined With Conventional Therapy to Conventional Therapy Alone in Patients With Symptomatic Gastroparesis. AEM November 2017.

* Population: Adults 18 years and older presenting to the emergency department with abdominal pain due to their known gastroparesis.

* Exclusions: Past history or current evidence of QT prolongation, hypotension (systolic blood pressure < 90 mm Hg), presence of other acute abdominal pathologic conditions, allergy to haloperidol, pregnancy, incarcerated status, or an inability to give informed consent.

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Date: November 11th, 2017

Reference: Sundén-Cullberg et al. Fever in the Emergency Department Predicts Survival of Patients With Severe Sepsis and Septic Shock Admitted to the ICU. Critical Care Medicine 2017.

Guest Skeptic: Jesse Spurr works as a Nurse Educator in the Emergency Department at Redcliffe Hospital in Australia. Outside his family and work, Jesse pours energy into his professional hobbies: healthcare simulation podcast Simulcast, nursing practice development blog and podcast Injectable Orange and faculty and team member of The Teaching Coop. Jesse classes himself a lifelong student of teaching, learning, health and human performance.

Case: You are working night shift in the emergency department. Two patients present to the front desk in close succession, brought in by concerned family members. Both are similarly hypotensive and tachypnoeic,drowsy but orientated, with hot, reddened and increasingly painful cellulitis. Following the triage sepsis pathway, recently amended to use qSOFA. The nurse triages both to beds in the acute/resuscitation area of the department. Each patient is seen quickly and has initial vital signs and blood samples obtained. One patient has a temperature of 38.3C and the other 35.5C. Being a night shift, staff resources are tight. How do you allocate resources wisely?

Background:  If you work in emergency medicine, you are probably aware of the continuous debate about fever. Is it harmful? Is it helpful? Should it be treated?

There are two opposing schools of thought about the value of fever in infection. One side argues that fever causes an increased metabolic stress than might be detrimental to already sick patients. The other side points out that fever is a natural immune response designed to fight infection. So, eliminating this natural line of defense could make sick patients even sicker.

We have covered fever before on the SGEM in pediatric patients. There was the great episode on pediatric fever fear with PedEM Super Hero Anthony Crocco (SGEM#95).  We also did a RANThony on pediatric fever fear that you can watch on YouTube.

The American Academy of Pediatrics Guides say: “fever, in and of itself, is not known to endanger a generally healthy child.  In contrast, fever may actually be of benefit; thus, the real goal of antipyretic therapy is not simply to normalize body temperature but to improve the overall comfort and well-being of the child.”

There were three questions covered in that pediatric fever fear episode:

* Should parent’s combine/alternate acetaminophen and ibuprofen?

* Parents and caregivers should focus on patient comfort instead of normalizing a temperature in febrile children. Alternating therapy may be beneficial for comfort, but more research is required to address this specific question.

* Will treating the fever make the child sicker, longer?

* Probably not. Antipyretics should be used to improve comfort during an illness.

* Will treating with antipyretics prevent a febrile seizure?

* Antipyretics appear to offer no significant improvement in the recurrence rates of febrile seizures in children.

When looking at fever in adult patients in the intensive care unit (ICU), we did an episode with Justin Morgenstern from First10EM. The question in SGEM#146 w...

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Date: November 9th, 2017

Reference: Cronin JJ et al. A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. Ann Emerg Med 2016

Guest Skeptic: Dr. Michael Falk is a Pediatric Emergency Medicine provider who works at Harlem Hospital Center in New York and Children’s National Medical Center in Washington, DC.  He was Director of Emergency Department Simulation and the Co-Fellowship Director at ST Luke’s-Roosevelt Hospital in New York and is a Best Evidence in Emergency Medicine (BEEM) presenter and author. This episode is based upon a BEEM critical review.

Case: A four-year old male who is a known asthmatic presents to the emergency department with an asthma exacerbation. He has been sick with an upper respiratory infection for the last two days. He is getting worse despite his mother giving albuterol every four hours. You order three treatments with albuterol and atrovent and you ask the medical student who is with you, which would be the best steroid to give to this patient by mouth and why?

Background: Untill recently prednisolone have been the standard of care for oral steroids used in the treatment of an asthma exacerbation.  But this medication has a bitter taste which can make it very hard to administer to a younger child.  Also, it is associated with a significant amount of vomiting and this is one of the leading reasons for treatment failure for outpatient asthma [1].

Dexamethasone has been wildly used for a number of pediatric conditions including croup [2], has a longer half-life [3] and is much better tolerated than prednisolone.

There have been a number of recent studies that have compared prednisolone to dexamethasone for outpatient treatment of asthma. A systematic review and meta-analysis demonstrated a single or two-dose regimen of dexamethasone is as effective as a 5-day course of prednisone/prednisolone with less vomiting in the dexamethasone group [4].

The Canadian Guidelines now include the option of giving oral prednisolone or dexamethasone for moderate asthma [5].

While all these studies have shown that dexamethasone was as good as prednisolone for the treatment of asthma, of the seven randomized control trials that have been done, they all have issues with methodology and utilizing different dose of steroids.

This study was designed to address these issues and look at a single dose of dexamethasone compared to three days of prednisolone and all the patients were assessed using the Pediatric Respiratory Assessment Measure (PRAM) to control for some of these variations.

The PRAM has five components and has a maximum total score of 12 points: suprasternal retractions (0 to 2), scalene muscle contraction (0 to 2), air entry (0 to 3), wheezing (0 to 3), and SaO2 (0 to 2).

Clinical Question: Is a single oral dose of dexamethasone non-inferior to three days of prednisolone in treating children who present to the emergency department with an acute exacerbation of asthma?

Reference:  Cronin JJ et al. A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. Ann Emerg Med 2016

* Population: All patients between the ages of 2 to 16 with history of asthma presenting to the emergency department with an acute asthma exacerbation.

* Excluded: Anyone with critical or life-threatening exacerbation; varicella of HSV infection; TB exposure; fevers > 39.5C; steroid use with in the last 4 weeks; those with metabolic disease; or any comorbid condition.

* Intervention Dexamethasone (DEX) 0.3 mg/kg (max.

Aktuelle FOAMed Infos rund um die klinische Notfallmedizin, Notfallmedizin und Intensivmedizin, auf den Spuren vom Skeptics Guide to emergency medicine

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Date: October 24th, 2017

Reference: Harrison et al. Sweet Solutions to Reduce Procedural Pain in Neonates: A Meta-analysis. Pediatrics 2017

Guest Skeptic: Dr. Anthony Crocco is a Pediatric Emergency Physician and is the Medical Director & Division Head of the Division of Pediatric Emergency at McMaster’s Children’s Hospital. Anthony is also the creator of SketchyEBM.

Case: A 12-day old girl presents with fever and is otherwise well. You are planning to begin a full septic workup including some painful procedures including bloodwork.  You wonder whether there is a way to mitigate the painful experience for the child.

Background: Painful procedures are common in the neonatal period, including bloodwork, lumbar punctures and bladder catheterization. There is evolving evidence to the long-term neuro-developmental harms associated with pain in the preterm infants (Field T. Infant Behavior and Development 2017)

We have covered pain a number of times on the SGEM including the following episodes:

SGEM#78: Sunny Days (Pediatric Pain Control)

SGEM#149: Share Decision Making for Pain Control in Older ED Patients

SGEM#173: Diazepam Won’t Get Back Pain Down

SGEM#175: Dancing on the Ceiling with Ketorolac for Pain

SGEM#187: Pin Cushion – Acupuncture in the Emergency Department

One aspect is the lack of pain control referred to as oligoanalgesia. There are certain patient populations who are at risk for in adequate pain management.

The pediatric age group represents one of the populations at risk for oligoanalgesia. There are many ways to address pain in pediatric patients with both pharmacologic and non-pharmacologic treatments.  One medication that should not be use in children under 12 years of age is codeine.

There is a RANThony on pediatric pain control and one of the interesting treatments was sucrose. That rant relied upon a Cochrane SRMA by Stevens B et al 2013 and a randomized clinical trail published in Pediatrics by Gray L et al 2015. Stevens and colleagues updated their review in 2016 and concluded “sucrose is effective for reducing procedural pain” and “no serious side effects or harms have been documented with this intervention”.

Clinical Question: 1) What is the current evidence for the use of sucrose in neonatal infants undergoing painful procedures?  2) Using a Cumulative meta-analysis (CMA), when did the evidence for the use of sucrose become statistically significant?

Reference: Harrison et al. Sweet Solutions to Reduce Procedural Pain in Neonates: A Meta-analysis. Pediatrics 2017

* Population: Randomized or quasi-randomized controlled trials of neonates

* Exclusions: Non-neonatal patients, inability to extract data from study or from author, untranslatable data.

* Intervention: “sucrose, glucose, or other sweet solutions orally”

* Comparison: “no treatment, water, pacifier, swaddling/positioning, skin-to-skin care, formula feeding, expressed breast milk, breastfeeding,

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Date: October 20th, 2017

Dr. Jen Gunter is a gynaecologist from Canada who practices in San Francisco. She writes a blog discussing women’s health issues and debunking pseudoscience. She is known to wield the lasso of truth, just like Wonder Woman.

Jen became an internet sensation recently after challenging Gwyneth Paltrow and her lifestyle company GOOP over some of their products. This included vaginal steaming and jade eggs. Jen’s blog posts got a lot of national and international media coverage. Here is some more information:

* Gwyneth Paltrow Admits She Doesn’t Know

* Uncensored Word from our Doctors

* GOOP Misogynistic Mansplaining Hit Job

Jen was invited to give a talk at Western University for homecoming 2017. She contacted me about doing a SGEM podcast we had been talking about for the last few years. Rather than doing a structured critical review of a recent publication, I suggested doing the first SGEM Facebook Live event.

In preparation for the Super Hero of Science Event a YouTube Save the Date video and a Movie Trailer were created. The movie trailer featured Jen, #BatDoc and Tim Caulfield. Tim is a law professor from Edmonton who wrote the book: Is Gwyneth Paltrow Wrong about Everything? When Celebrity Culture and Science Clash. 

A number of smart, skeptical people were invited to the bat cave for a tweet-up followed by a live interview of Jen. You can watch the 30 minute Facebook Live interview by clicking on this link or listen to it on iTunes.

It was a great night of science, skepticism and friendship with special guests from The Reality Check and Bad Science Watch. We even made a #BatDoc Video with Jen.

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

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Date: October 19th, 2017

Reference: Hofmann et al. Oxygen Therapy in Suspected Acute Myocardial Infarction. NEJM Sept 2017.

Guest Skeptic: Marcus Prescott is a nurse in Norway. He is also now a first-year medical student.

Case: A 68-year-old man with a history of hypertension and dyslipidemia develops chest pain while grocery shopping. Emergency medical services are called, arrive quickly and find a man with 7/10 chest pain. His vitals are: heart rate of 72 beats per minute, blood pressure of 150/90, respiratory rate of 14 breaths per minute and oxygen saturation of 93%. The ECG shows an inferior ST-Elevated Myocardial Infarction (STEMI). They give him 180mg of ASA to chew and package him for transportation to the hospital. While preparing to depart, they wonder if they should provide him with supplemental oxygen?

Background: Oxygen is a drug and like all drugs can have potential benefits and potential harms depending on how and when it is used. Studies have shown that oxygen can cause vasoconstriction, increase blood pressure and decrease coronary artery blood flow (Kones et al AM J Med 2011).

A systematic review by Wijesinge et al from 2009 found only two randomized control trials looking at supplemental oxygen. One study of 200 patients demonstrated increased mortality (4% in controls vs. 11% in oxygen treatment group).

A second smaller study of 50 patients did not look at mortality but showed less ventricular tachycardia (VT) with supplemental oxygen (23% vs. 25%). However, this difference between the two groups was not statistically significant (relative risk 0.9; 0.3 to 2.7, p = 0.86). What would you rather have, more death or less VT?

Oxygen supplementation in non-hypoxemic patients with acute myocardial infarction has been a hot topic since the publication of the AVOID-trial (Stub et al Circulation 2014). The AVOID trial showed no benefit, and possible harm, to patients with an oxygen saturation over 94% when given supplemental high-flow oxygen. Their conclusion was: “Supplemental oxygen therapy in patients with ST-elevation–myocardial infarction but without hypoxia may increase early myocardial injury and was associated with larger myocardial infarct size assessed at 6 months.”

A 2016 Cochrane review by Cabello et al found five RCTs in patients with suspected or confirmed acute myocardial infarction. They found “There is no evidence from randomised controlled trials to support the routine use of inhaled oxygen in people with AMI, and we cannot rule out a harmful effect.”

The Cochrane authors said that a well-designed RCT is needed due to the uncertainty of routinely using supplemental oxygen in patients with acute myocardial infarctions. They felt this would help inform guideline writers on making recommendations in this area.

The American Heart Association (AHA) Guidelines were updated in 2015 and did not provide a strong recommendation on the issue. The say supplemental oxygen may be withheld in normoxic patients with suspected or confirmed acute coronary syndrome

* The usefulness of supplementary oxygen therapy has not been established in normoxic patients. In the prehospital, ED, and hospital settings, the withholding of supplementary oxygen therapy in normoxic patients with suspected or confirmed acute coronary syndrome may be considered. (Class IIb, LOE C-LD)