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Date: November 22nd, 2016

Reference: Beach et al. Major Adverse Events and Relationship of Nil per Os Status in Pediatric Sedation/Anesthesia Outside the Operating Room. Anesthesiology January 2016

Guest Skeptic: Dr. Bob Edmonds has just completed his residence in Emergency Medicine from the University of Missouri in Kansas City. He is now an emergency department staff physician in the US Air Force at Langley Air Force Base.

Dr. Edmonds’ Disclaimer: The views and opinions of this podcast and blog are not the official position of the United States Air Force, the US government, or Langley Air Force Base.

Thanksgiving: This episode is being published on American Thanksgiving 2016 weekend. Happy Thanksgiving to all the SGEMers from the USA. We hope everyone has a wonderful holiday spent with family and friends.

Case: A 5-year-old girl was bit in the face by a neighbor’s dog. She has a complex lower lip laceration that extends beyond the vermillion border with a flap deformity. You believe it will require repair by an oral and maxillofacial surgeon in your emergency department and that the patient will require procedural sedation. The patient had been eating a turkey sandwich one hour ago and you consider how long to leave her NPO prior to the sedation.

Background: Procedural sedation is a somewhat common practice in the emergency department for a number of pediatric cases such as laceration repair, incision and drainage, closed reduction of fractures, and radiographic studies such as CT scans.

The American Society of Anesthesiologists 2011 Practice Guidelines recommends waiting two hours  for clear liquids, six hours for light meals and eight hours may be needed in other cases before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia. They recognize that these guidelines may not apply to emergency care.

The ACEP Clinical Policy on procedural sedation and analgesia in the emergency department from 2013 gives a Level B recommendation of not delaying procedural sedation in adults or pediatric emergency department patients based on fasting time.

* Pre-procedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia. 

Clinical Question: Do we need to delay procedural sedation of pediatric emergency department patients based on their NPO status?

Reference: Beach et al. Major Adverse Events and Relationship of Nil per Os Status in Pediatric Sedation/Anesthesia Outside the Operating Room. Anesthesiology January 2016

* Population: All pediatric patients undergoing procedural sedation at one of the 42 Pediatric Sedation Research Consortium (PSRC) sites from September 2, 2007 to November 9, 2011. Procedural sedation/anesthesia was defined as “any pharmacologic intervention made to facilitate an invasive procedure or test in a pediatric-age patient outside of the operating room environment.”

* Intervention: NPO to solids for at least eight hours, non clear fluids for at least six hours, and clear fluids for at least two hours

* Comparison: Patients who failed to meet the above NPO criteria

* Outcome: Two primary outcomes

* Rate of aspiration (Aspiration episode was defined as an event where emesis was noted or food material was found in the oral/pharyngeal cavity and associated with any or the following: new cough, wheeze,

SGEM#151: Groove is in the HEART Pathway Podcast: SGEMG […]

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 26th, 2016

Guest Skeptic: We have a number of guest skeptics for this episode. Dr. Munsif Bhimani is the program director of the CCFP-EM program at Western University. Drs. Kevinjeet Mahngar, Kelsey Cassidy, Jatin Kacker and Ben Fregeau are residents in the CCFP-EM program at Western University. Dr. Sean Ryan is a front line physician working in community emergency departments.

This is an SGEM Xtra. From time-to-time we like to pause from our usual structured critical appraisals and do a big picture issue. Being close to Hallowe’en we thought we would re-visit the issue of social media and ask…is #FOAMed scary?

We have addressed the issue of #FOAMed a few times before and the last time we had the Godfather of #FOAMed, Dr. Joe Lex on when he gave his famous quote in his best Marlon Brando impression.

Here are previous episodes on this topic of #FOAMed:

* SGEM#30: My Generation (Social Media and Medical Education)

* SGEM#35: We are Young (Social Media and Medical Education)

* SGEM#72: Tiny Bubbles (#FOAMed and #MedEd)

* SGEM#77: Take the Hashtag, Leave the Classroom (Pro #FOAMed Argument)

Listen to the podcast and hear what the program director, residents and a community EM physician think about #FOAMed.

Questions for Dr. Bhimani:

* Is #FOAMed scary?

* How is the residency program using #FOAMed?

* Is the residency program creating any original #FOAMed content?

* What is your biggest concern about #FOAMed?

* What do you think would make #FOAMed better?

* What do you think your staff views of #FOAMed are into integrating this into their bedside teaching?

Questions for the Residents:

* Is #FOAMed scary?

* How do you use #FOAMed?

* How do you know what to trust?

* What is the best part about #FOAMed?

* What is the worse part of #FOAMed?

* What has been your experience with staff?

 

Questions for Dr. Ryan: 

* Is #FOAMed scary?

* What do community doctors think of #FOAMed and how are they using it?

* Are you have concerns about #FOAMed quality/content?

* Do you still subscribe and read journals?

* Can you comment on the residency training and how new grads are using social media?

* Does it annoy you when a trainee says I heard this on a podcast or read this on a blog?

* Are you paying for any education resources and how do you think they compare to the #FOAMed resources?

Other #FOAMed Questions: 

*  What are your top #FOAMed resources and why?

* Dr. Bhimani: Would you encourage other programs to use #FOAMed and where do you see #FOAMed in the next 3-5 years in the medical education world?

* Residents: What advice would you give other residents in using #FOAMed for their education?

* Dr. Ryan: What advice would you give to practicing doctors on how to get started on using #FOAMed?

*  Any final thought about #FOAMed?

Happy Hallowe’en SGEMers! We will be back next time with a new critical review trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media.

Keener Contest: The last winner of the keener contest was Brad Kinder from Fort Leonard Wood Missouri. Brad knew clindamycin is commonly used to treat MRSA infections and has a Black Box Warning for C. diff colitis by the FDA.

SGEMGlobal 139: Français – La suite était écrite dans le ciel: voici Idarucizumab!!

SGEM#139: One Thing Leads to Another – Idarucizumab for Dabigatran Reversal?

** Chers auditeurs, nous avons sortis ce podcast des boules à mites avec l’arrivée de “praxbind”!***

Date: Nous sommes le 7 décembre 2015 et je suis votre hôte, Élyse Berger-Pelletier.

Dr. Elyse Berger Pelletier

Titre:  Le titre de ce podcast est « One Thing Leads to Another – Idarucizumab for Dabigatran Reversal?». Cet épisode est la traduction du podcast #139 initialement publié le 3 décembre 2015 par Ken Milne et Rian Radecki.

Cette traduction est faite avec Dr Marcel Émond, professeur agrégé à l’Université Laval, spécialiste en médecine d’urgence travaillant au Centre hospitalier de l’Enfant-Jésus à Québec.

Bienvenue aux traductions en français des podcasts de SGEM Marcel!

Merci Élyse! Aujourd’hui nous avons 1 papier qui porte sur la renversement de l’anticoagulothérapie avec le dabigatran!!!   Un antidote très attendu!!.

Cas: Un homme de 67 ans se présente avec des atcds de fibrillation auriculaire et d’hypertension. Il prend métoprolol 50 mg deux fois par jour et de 150 mg de dabigatran deux fois par jour. Il a eu des douleurs épigastriques légères pendant environ une semaine et a eu un épisode de vomissements avec grains de café avec cette nuit. Il arrive par ambulance avec une pression artérielle de 120/70, une fréquence cardiaque à 74 battements par minute et la saturation en O2 de 98%.

Contexte: Le dabigatran est un anticoagulant non-antagoniste de la vitamine K qui agit en inhibant la thrombine. Il est approuvé pour la prévention et le traitement de la thromboembolie veineuse. Il est également approuvé le traitement de la fibrillation auriculaire non-valvulaire pour prévenir les AVC.

Un saignement mortel peut se produire lors de la prise de dabigatran. Contrairement à la warfarine qui peut être renversée par plusieurs façons, il n’y a pas eu de traitement possible ou efficace pour renverser le dabigatran lors de saignements potentiellement mortels chez les patients utilisant le dabigatran. La seule méthode actuelle de l’enlèvement, par l’hémodialyse, est c’est irréaliste dans la grande majorité des situations cliniques.

Il n’y a aucun agent de renversement spécifique jusqu’à présent. Boehringer Ingleheim le fabricant de dabigatran a développé un anticorps monoclonal appelé idarucizumab.

La FDA a approuvé idarucizumab en Octobre dernier (!) comme le premier agent de renversement de dabigatran. Pour autant que nous savons, il n’a pas encore été approuvé pour une utilisation au Canada. (NDLR: Il l’est maintenant – Praxbind!)

Question clinique:

Est-ce que l’idarucizumab est sûr et efficace pour renverser les patients anticoagulés prenant dabigatran avec hémorragie grave ou qui ont besoin d’une procédure d’urgence?

 

L’article est : Pollack CV et al. Idarucizumab for Dabigatran Reversal. NEJM  en août 2015. 

Quelle est la question PICO?

Population: Les patients âgés de 18 ans ou plus, prenant du Dabigatran.

   Groupe A: Les patients présentant un saignement évident, incontrôlable, voire mortel (selon le clinicien).

                Groupe B: Les patients nécessitant une intervention chirurgicale ou une autre procédure invasive qui ne pouvait être retardée d’au moins 8 heures.

Intervention: Tous les patients ont reçu 5 g de idarucizumab intraveineuse sous la forme de deux bolus de 2,5 g à 15 minutes d’intervalle.

Comparaison: Aucun, ce fut une étude observationnelle prospective.

Issue principale: Renversement maximal en pourcentage de l’effet anticoagulant du dabigatran dans les quatre heures ce qui était évalué par la mesure du temps de thrombine diluée ou d’ecarin.

         Issues secondaires: la réduction de la concentration de dabigatran libre, la restauration de l’hémostase et événements thrombotiques ou de décès de 90 jours.

Les co[...]

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Date: October 13th, 2016

Reference: Talan et al. Trimethoprim–Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. NEJM March 2016

Guest Skeptic: Chip Lange is an Emergency Medicine Physician Assistant working primarily in rural Missouri in community hospitals. He has international experience in critical care and emergency medicine. He has a new blog called TOTAL EM, which stands for Tools Of the Trade and Academic Learning in Emergency Medicine. He has recently started podcasting and is always looking to expand this new project. He cares about providing TOTAL care everywhere and wants us all to be excellent when we see and treat out patients.

Case: A 40 year-old male with a history of MRSA presents complaining of an area of redness and swelling consistent with an abscess developing on his arm. He says that he has heard that antibiotics may not be necessary after his friend had an incision and drainage (I&D) and they did not give her any antibiotics. He denies any allergies to antibiotics and has taken Sulfa drugs in the past without complication. 

Background: Cutaneous abscesses are a very common complaint in the emergency department and we have discussed the management of these before on the SGEM.

One issue was whether or not to pack after I&D? Our bottom line in 2012 was that routine packing of simple cutaneous abscesses might not be necessary (SGEM#13: Better Out than In).

We recently looked at whether irrigation of a cutaneous abscess after I&D reduces the need for further intervention. The SGEM bottom line from that review was that irrigation is probably not necessary (SGEM #156: Working at the Abscess Wash).

Another issue that has been debated over the years is if antibiotics should be routinely prescribed after I&D. We covered a review by Hankin and Everett from 2007 on SGEM#13. It identified that there was very little high quality evidence available on the subject.

They stated: “A conclusive, multicenter, double-blind, randomized, placebo-controlled clinical trial is lacking and sorely needed.”

The SGEM conclusion at that time was that the evidence did not support using antibiotics routinely in simple cutaneous abscesses even in the era of MRSA.

Now we have a multicenter, double-blind, randomized, placebo-controlled clinical trial to address this issue.

Clinical Question: Does TMP/SMX offer a higher clinical cure rate than placebo in patients with a drained uncomplicated cutaneous abscess?

Reference: Talan et al. Trimethoprim–Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. NEJM March 2016

* Population: All emergency department patients greater than 12 years of age with cutaneous abscess that presented less than one week after onset and that measured at least 2 cm in diameter (whether by borders of induration if the lesion was fluctuant or by ultrasound of the cavity if not fluctuant).

* Exclusion Criteria: Indwelling device; suspected osteomyelitis or septic arthritis; diabetic foot, decubitis, or ischemic ulcer; mammalian bite; wound with organic foreign body; infection or another organ system/site; perirectal, perineal or paronychial location; intravenous drug use within previous month and fever; underlying skin condition; long-term care residence; incarceration; immunodeficiency (e.g., absolute neutrophil count <500/mm3, immunosuppressive drugs, active chemotherapy,

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Date: October 6th, 2016

Reference: Piazza et al. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism. JACC 2015

Guest Skeptic: Dr. Essie Reed is one of the Chief Residents in the Department of Emergency Medicine at the University of Buffalo.

Case: A 75-year-old female with a past medical history of hypertension and non-insulin dependent diabetes presents with chest pain. She describes the pain as sharp, stabbing, and exacerbated with deep inspiration. She reports associated shortness of breath. She denies syncope, nausea, and diaphoresis. The pain has been present for one week, and is nearly constant. She reports that she traveled to Florida to visit her grandchildren three weeks ago. She has no fever, chills, cough, or sputum production. She is complaining of ongoing chest pain, 5/10, increased to 7/10 when asked to breathe deeply for the exam.

On examination, she is hemodynamically stable, lungs are clear and the heart is regular without murmurs. Her skin is warm and dry and she is generally well appearing. The EKG shows sinus rhythm with a rate of 80bpm.

The patient has negative serial troponins. Pain is unchanged after nitroglycerin, but improved with morphine. She eventually developed tachycardia, with a heart rate 125bpm, but remained normotensive. A    CTA is performed demonstrating a submissive pulmonary embolism in the right pulmonary artery is made with RV/LV diameter ratio >0.9. The Pulmonary Embolism Response Team is paged and bedside ECHO performed confirming RV dysfunction.

Background: A pulmonary embolism (PE) can be a life-threating condition. The 2015 Chest Guidelines recommend systemically administered thrombolytic therapy in patients with acute PE associated with hypotension (systolic BP<90mmHg) who do not have a high risk of bleeding (Kearon et al 2016).

* In patients with acute PE associated with hypotension (eg, systolic BP <90 mm Hg) who do not have a high bleeding risk, we suggest systemically administered thrombolytic therapy over no such therapy (Grade 2B).

Treating patients with full-dose systemic thrombolytics can reduce the risk of death but also increases the risk of major bleeding including hemorrhagic stroke (Chatterjee et al JAMA 2014). To mitigate the risk of bleeding while still maintaining efficacy, low-dose thrombolysis has been tried. Reviews of the literature suggest that this may be a reasonable strategy (Zhang et al 2014) especially in patients with a high risk of bleeding (Brandt et al 2015).

A new method being studied to treat submassive and massive PEs is ultrasound-facilitated catheter-directed thrombolysis (CDT). A small randomized control trial of 59 patients demonstrated that compared to anticoagulation alone, ultrasound-facilitated CDT improved right ventricular function compared with anticoagulation alone with no major bleeding observed (Kucher et al 2014).

However, the Chest Guideline still suggest systemic thrombolytic therapy using a peripheral vein over CDT in patients with acute PE who are treated with thrombolytic agents. They do note that patients with a higher risk of bleeding and have access to CDT are likely to choose CDT over systemic thrombolytic therapy.

* In patients with acute PE who are treated with a thrombolytic agent, we suggest systemic thrombolytic therapy using a peripheral vein over catheter directed thrombolysis (CDT) (Grade 2C).

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Date: September 29th, 2016

Reference: Kudenchuk et al. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. NEJM April 2016

Guest Skeptic: Dr. Rory Spiegel is a clinical instructor at University of Maryland and a recent graduate of Stony Brook’s Resuscitation Fellowship. He writes an excellent blog called EM Nerd, which he describes as nihilistic ramblings.

Case: Your local EMS agency has asked your opinion on which anti-arrhythmic medication, if any, their ambulances should stock for the management of ventricular fibrillation or pulseless ventricular tachycardia refractory to defibrillation. Additionally, they want to know how best to incorporate these agents into their current resuscitation protocol?

Background: The American Heart Association estimates there are about 350,000 EMS-assessed out-of-hospital cardiac arrests in the United States each year. Half of these arrests are witnessed with the other half being un-witnessed.

Many out-of-hospital cardiac arrests are due to ventricular fibrillation or pulseless ventricular tachycardia. Defibrillation is the treatment of choice in these cases but do not often result in sustained return of spontaneous circulation (Kudenchuk et al 2006).

Both lidocaine and amiodarone may be considered for the treatment of ventricular fibrillation or pulseless ventricular tachycardia, which is unresponsive to defibrillation (Link et al 2015).

Two randomized control trials demonstrated that the use of amiodarone led to more patients with return of spontaneous circulation at the time of hospital arrival when compared to lidocaine or placebo (Kudenchuk et al 1999 and Dorian et al 2002). But these early benefits did not translate into a benefit in survival to hospital discharge or neurologically intact survival.

Clinical Question: Does amiodarone or lidocaine improve survival to hospital discharge with good neurologic outcome in non-traumatic out of hospital cardiac arrest secondary to refractory ventricular fibrillation or pulseless ventricular tachycardia?

Reference: Kudenchuk et al. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. NEJM April 2016

* Population: Adult patients with non-traumatic out-of-hospital cardiac arrest and shock refractory ventricular fibrillation or pulseless ventricular tachycardia after one or more shocks anytime during resuscitation.

* Exclusions: Patients who had already received open-label intravenous lidocaine or amiodarone during resuscitation or had known hypersensitivity to these drugs (see supplementary appendix in NEJM for complete list of inclusion and exclusion criteria).

* Intervention: Amiodarone or lidocaine

* Comparison: Placebo

* Outcome:

* Primary: Survival to hospital discharge

* Secondary: Favorable neurologic function at discharge defined as a modified Rankin Scale (mRS) of 3 or less.

Author’s Conclusions: Overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.

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Date: September 21st, 2016

Reference: Racine et al. Delayed complications and functional outcome of isolated sternal fracture after emergency department discharge: a prospective, multicentre cohort study. CJEM Sept 2016

Guest Skeptic: Dr. Chris Bond. Chris is an emergency physician and clinical lecturer at the University of Calgary. He is currently the host of CAEP Casts, which highlights educational innovations from emergency medicine residency programs across Canada. Chris also has his own #FOAMed blog called Standing on the Corner Minding My Own Business (SOCMOB).

Case: A 49-year-old male presents to the emergency department after being in a motor vehicle collision. You diagnose him with an isolated sternal fracture on X-ray. Specifically there are no rib fractures or lung abnormalities identified. He also has a normal ECG and troponin. As you are preparing to discharge him, he asks if there are any potential complications to expect from the injury, and how long he should expect to have pain?

Background: Sternal fractures are often the result of a significant blunt thoracic trauma and have an incidence between 0.33% of all trauma patients (Recinos et al and 3.7% of patients admitted after a motor vehicle accident (Yeh et al).

Poor outcomes in patients with sternal fracture are associated with the severity of other injuries, complications and pre-existing comorbidities (Yeh et al). Many studies have demonstrated that a patient with an isolated fracture of the sternum can be safely discharged from the emergency department after an appropriate investigation (Hossain M, Khoriati et al and Kouritas et al), which should include cardiac biomarkers and ECG (Clancy et al).

Therefore, the clinical significance of isolated sternal fracture has change over the past years and admission is no longer required for those patients. When looking at other minor thoracic injuries discharged from emergency department, delayed hemothorax has been reported as a significant delayed complication (Misthos et al and Plourde et al) and a risk factor for poor functional outcome (Emond et al).

Clinical Question: What are the complications and outcomes of patients with isolated sternal fracture discharged from the emergency department compared to those with other minor thoracic injury?

Reference: Racine et al. Delayed complications and functional outcome of isolated sternal fracture after emergency department discharge: a prospective, multicentre cohort study. CJEM Sept 2016

* Population: Patients 16 years and older presenting to the emergency department with minor thoracic trauma defined by the prese...

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Date: September 8th, 2016

Reference: Body et al. The use of very low concentrations of high sensitivity troponin T to rule out acute myocardial infarction using a single blood test. AEM Sept 2016.

Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the director of simulation education at Markham Stouffville Hospital in Ontario. He is the author of the excellent #FOAMed blog called First10EM.com and is an associate editor of Emergency Medicine Cases.

This is a SGEM Hot Off the Press episode.  Here is a summary of the process but you can click on the SGEMHOP link for more details and previous episodes:

* A peer reviewed paper is selected pre-publication from AEM or CJEM that we think will be of interest to the SGEMers.

* We do a structured critical review of the paper using the quality check list developed by the Best Evidence in Emergency Medicine (BEEM) group.

* The paper is then discussed with one of the paper’s authors to give us a better understanding of the strengths and weaknesses of the paper.

* A blog and podcast are posted encouraging the FOAMed world to engage with us and the author over a one week period.

* A summary of the critical review and the best social media engagement is then published in AEM or CJEM to help cut that knowledge translation window down.

SGEMHOP from AEM Now has CME Credits

We have some exciting news to start Season# 5 of the SGEM. Hot off the Press papers from AEM will now have continuing medical education (CME) credits attached to the episodes. Dr. Corey Heitz will be writing up the five questions and alternating with Justin as the guest skeptic.

Corey is an associate professor of emergency medicine at the Virginia Tech Carilion School of Medicine in Roanoke Virginia. He has been a member of the executive board of the Clerkship Directors in Emergency Medicine, is co-chair of the National EM M4 Examination committee and sits on the examination development board for the NBME EM-Advanced Clinical Exam. In addition, Corey is the CME editor for Academic Emergency Medicine and the associate editor for emergency medicine simulation at the AAEM MedEdPORTAL.

SGEMers can claim their CME credits by following this process:

* Go to the Wiley Health Learning website

* Register and create a log in

* Search for “Academic Emergency Medicine – September”

* Complete the five questions and submit your answers

As this is a new feature there may be some glitches. Please email Corey ([email protected]) with any questions or difficulties.

Case: A 53-year-old woman presents to your emergency department a little less than two hours after her anterior, squeezing chest pain hits its peak. She has a history of hypertension, but is otherwise healthy. Thanks to a medical directive, when you sit down with the patient, she already has a normal ECG and a high sensitivity troponin T (hs-cTnT) test that has come back below the limit of detection. She is feeling a lot better and would like to go home. 

Background: Patients presenting to the emergency department with chest pain are a daily conundrum. There are a number of life threatening conditions that must be efficiently ruled out.

Unfortunately, for the most common acute coronary syndrome, there is no universally agreed on algorithm. In addition to serial ECGs,