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Date: February 28th, 2015

Guest Skeptic: Dr. Salim R. Rezaie. Salim is faculty member at University of Texas Health Science Center at San Antonio, TX. He is currently the creator/founder of REBEL EM blog and REBEL Cast available on iTunes.

Case: 28 year-old male is involved in an altercation and shot multiple times in the chest and presents to the emergency department. His initial vital signs include a BP 72/46, HR 140, RR 30, O2 sat 89% on NRB and a temp of 98.7F. You intubate the patient successfully, begin intravenous fluids, and place bilateral chest tubes with significant blood return from the right chest tube. Due to the patients blood loss you initiate damage control resuscitation including: permissive hypotension, source control of bleeding, and a massive transfusion protocol.

Background: In the United States, trauma is the leading cause of death among patients between the ages of 1 and 44 years of age and the third leading cause of death overall. Approximately 20 to 40% of trauma deaths occur after hospital admission and are a result of massive hemorrhage.

There have been no large, multi-center, randomized clinical trials with survival as a primary end point that support optimal trauma resuscitation practices with approved blood products and therefore there are many conflicting recommendations.

The Prospective Observational Multicenter Major Trauma Transfusion (PROMMT) Trial demonstrated that many clinicians were transfusing patients with blood products in a ratio of 1:1:1 or 1:1:2 (plasma, platelets, RBC) and that early transfusion of plasma and platelets was associated with improved 6-hour survival after admission. 

Clinical Question: What is the effectiveness and safety of transfusing adult patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio vs. with a 1:1:2 ratio?

Reference: Holcomb JB et al. Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs. a 1:1:2 Ratio and Mortality in Patients with Severe Trauma: The PROPPR Randomized Clinical Trial. JAMA February 2015

* Population: 680 patients age ≥ 15 years of age and/or ≥ 50kg meeting highest level of trauma activation

* Inclusion: Requiring at least 1 U of any blood component within the first hour of arrival or during pre-hospital transport and/or predicted by the ABC Score≥2 or clinical gestalt to need massive transfusion (≥10 U RBC within 24hrs)

* Exclusion: See list

* Intervention: Platelet, plasma and red blood cell transfusion in a 1:1:1 ratio

* Comparison: Plasma, platelet, and red blood cell transfusion in a 1:1:2 ratio

* Outcome:

* Primary Outcome: All cause mortality at 24 hour and 30 day

* Secondary Outcomes: Ancillary outcomes were time to hemostasis, blood product volumes transfused, and complications.

Authors’ Conclusions: Among patients with severe trauma and major bleeding, early administration of plasma, platelets and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups.

Quality Checklist for Randomized Clinical Trials:

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Date: February 20th, 2015

Guest Skeptics: Dr. Tony Seupaul and Dr. Chris Fowler. Tony is the Chair of the Department Emergency Medicine, University of Arkansas. Chris is a second year EM resident in Arkansas. He did his medical school in Arizona and Undergrad at Brigham Young University in Utah. 

Case: 58-year-old woman with diabetes and hypertension presents with two days of feeling “dizzy”. Her symptoms worsen when she turns her head. She has also noticed that is much worse when bending over and looking up while turning her head. She has extreme nausea and has had several episodes of vomiting. She has had some improvement in her symptoms with lying flat and closing her eyes. She is very worried about something serious and asks what can be done to help with her symptoms.

Background: Benign Paroxysmal Positional Vertigo (BPPV) is a short-lived condition characterized by the sensation of rotation or instability most often exaggerated by rapid movements of the head.

The etiology is believed to be from excessive movement of fluid (endolymph) and debris within one of the three semi-circular canals of the vestibular system of the inner ear. The debris causes the fluid to continue moving after head motion has stopped giving the sensation of continued motion causing the symptoms associated with vertigo. This mechanism is called canalithiasis.

Peak incidence is between 50-70 years and affects between 11 and 67 per 100,000 each year. Symptoms often resolve spontaneously after a period of weeks but symptoms can be severe causing many to seek medical attention.

Symptoms can be provoked with the Dix-Hallpike maneuver which elicits symptoms and nystagmus. The nystagmus is torsional (superior pole of the eye directed towards the lower most ear) and up beating. There can be a latency period of up to 45 seconds with duration of less than 1 minute. Repeated positioning causes fatigue of this finding.

Once the diagnosis of BPPV is made on history and physical examination a canalith repositioning maneuver can be attempted.

It was Epley who described one of the technique used to relocate and redistribute the debris within the posterior semi-circular canal thereby eliminating symptoms. The Epley Maneuver as it is commonly called is a sequence of four head positions that use gravity to treat the BPPV or canalithiasis.

There are a number of FOAMed resources out there that demonstrate how to properly do the Dix-Hallpike and Epley maneuver.

Clinical Question: Is the Epley Manoeuvre effective in the treatment of posterior canal BPPV?

Reference: Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014 

* Population: 745 patients (11 RCTS) ranging from 18 to 90 years old presenting to either primary care settings or tertiary care in otolaryngology clinic with complaints of dizziness, ultimately diagnosed with BPPV by a positive Dix-Hallpike and classical features with nystagmus.

* Intervention: The use of the Epley manoeuvre in treatment of posterior canal BPPV and a subsequent conversion of a positive Dix-Hallpike test to a negative test.

* Comparison: RCTs evaluated looked at Epley maneuver verses placebo (sham maneuver), Epley versus control or Epley vs. other active treatment.

* Outcome:

* Primary Outcome: Complete resolution of vertigo symptoms.

* Secondary Outcomes: conversion of positive Dix-Hallpike to negative; adverse side effects of treatment.

Authors’ Conclusions: “There is evidence that the Epley manoeuvre is a safe, effective treatment for posterior canal BPPV, based on the results of 11,

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Date: February 13th, 2015

Guest Skeptic: Dr. Manrique Umaña. Manrique (@umanamd) is an Emergency Physician from San Jose, Costa Rica and the Residency Program Director. He is the co-author of a Spanish-based blog called www.ViaMedEM.com and an active person in #FOAMed world. 

Case: You receive in your emergency department a 55-year-old male who goes into cardiac arrest minutes after he arrives. He´s rushed into the shock room and CPR is started.

Chest compressions are ongoing and as soon as the monitor pads are attached, you notice the patient to be in ventricular fibrillation. A resident next to you says that he has read that the patient can be shocked without stopping chest compressions.

Everyone in the room immediately turns their eyes on you to make the call and the intern doing CPR asks if it´s really safe to do so.

Background: Defibrillation is the treatment of choice for rhythm disturbances like ventricular fibrillation and ventricular tachycardia without a pulse. Rapid and early defibrillation has been shown to increase survival after cardiac arrest.

There was some suggestion that a short period of CPR should be done prior to defibrillation in out of hospital cardiac arrest. However, a systematic review by Simpson et al in Resuscitation 2010 on this topic demonstrated no superiority of delayed vs. immediate shocking.

High quality chest compressions have also been shown to improve outcomes in cardiac arrest, to the extent that delays in starting them and even brief interruptions are associated with worse survival rates.

* AHA Guidelines stress no interruptions. Travers et al. American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010

* Cheskes el al. Perishock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation 2011

Having this in mind, the use of hands-on defibrillation to reduce interruption of chest compressions after cardiac arrest has been suggested as a means of improving resuscitation outcomes.

Lloyd et al 2008 looking at the electrical current flow through the rescuers who had their hands on patients being defibrillated.

* 43 hands-on shocks with most at 200j but a few at 360j

* None of the rescuers felt the shocks who wore polyethylene gloves

* About 10% of the shocks were above the allowable 0.5mA

* The authors concluded shocking while doing CPR was feasible

The potential dangers of this strategy in regard to exposing rescuers to electrical energy are still being debated. There is a study on how much protection different glove types might provide. Sullivan and Chapman in 2012 study called Will medical examination gloves protect rescuers from defibrillation voltages during hands-on defibrillation?

* Four types of gloves (latex, chloroprene, nitrile, and vinyl)

* Tested single glove and double glove both tested in two parts

* Part 1 looked at 8 gloves and increased the voltage until breakdown occurred

* Part 2 looked at two current levels (0.1mA and 10mA)

* 45% of single gloves and 77% of double gloves allowed at least 0.1 mA of current flow with external defibrillation

* 5% of single gloves and 6.2% of gloves allowed at least 10 mA of current flow with external defibrillati...

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Date: February 3rd, 2015

Guest Skeptics: Dr. Anand Swaminathan (EM Swami). Swami is an assistant program director at NYU/Bellevue Hospital in the department of EM. He is also part of the REBEL EM Alliance and as of January 2015 part of the East Coast Team doing Emergency Medical Abstracts (EMA).

Dr. Emily Junck. She is a third year Emergency Medicine resident physician at University of Washington. Emily created a list of classic practice-changing Emergency Medicine articles called 52 Articles in 52 Weeks designed for EM interns to read throughout their intern year.

Case: 62-year-old woman who has an unwitnessed ground-level fall while walking on ice and hits her head. There was a possible brief loss of consciousness.. Her daughter brought her to the emergency department right away concerned that she might have hurt herself. The patient complains of a headache, but has not vomited and denies other complaints. The daughter feels her mother is acting appropriately. On your evaluation, the patient has a posterior scalp contusion, but no palpable step-off, and otherwise has Glasgow Coma Scale 15 and a non-focal neurological examination.

Question: Does this patient need a head CT to rule out a clinically significant brain injury?

Background: CT scans are frequently done after head injury to evaluate for intracranial hemorrhage, which can be costly and causes radiation-exposure. Much of the time, these are negative, or find injuries for which no intervention is ever done and do not clinically affect the patient. CT Head decision rules help clinicians decide when to order a CT.

Reference: Stiell et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001

* Population: Adult patients presenting to the emergency departments at 10 large Canadian hospitals with Glasgow Coma Scale 13 or greater within 24 hours after blunt head trauma resulting in witnessed loss of consciousness, amnesia, or witnessed disorientation.

* Exclusions:

* Age under 16

* Minimal head injury with no LOC, amnesia, or disorientation

* Unclear history of trauma as the primary event (ie primary seizure or syncope)

* Obvious penetrating skull injury or depressed fracture

* Acute focal neurological deficit

* Unstable vital signs associated with major trauma

* Seizure prior to ED assessment

* Anticoagulation or bleeding disorder

* Pregnancy

* Intervention: Standardized clinical assessments were performed on all consecutive eligible patients before performing a CT scan at the discretion of the attending physician.

* Comparison: They took all the pre-CT variables and compared them with the CT and outcomes at 14 days looking for associations. From there they selected the combination of variables that would give the highest sensitivity/specificity for detecting the outcome measures using logistic regression and recursive partitioning. Overall, 44 variables were assessed (24 primary and 20 created by cut-offs/combinations)

* Outcome:

* Primary Outcome: Need for neurological intervention, defined as need for neurologic intervention as death within 7 days due to the head injury or need with 7 days for craniotomy, elevation of skull fracture, intracranial pressure monitoring, or intubation for head injury.

* Secondary Outcome: Clinically important brain injury on CT, defined as any acute brain finding on CT that would normally require admission to a hospital and neurological follow-up.

Authors’ Conclusions: “We have developed the Canadian CT Head Ru...

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Date: January 29th, 2015

Guest Skeptics:  Dr. Matt Dawson. Director of Point of Care Ultrasound at the University of Kentucky. Co-creator of Ultrasound Podcast, Introduction to Bedside Ultrasound digital textbooks, One Minute Ultrasound smartphone app, Sonocloud.org, and other random ventures. Matt has also received numerous teaching awards.

Dr. Mike Mallin. Director of Emergency Ultrasound and the Emergency Ultrasound Fellowship at the University of Utah. He is particularly interested in echocardiography and has sat for and passed the Echo Boards. He is published in multiple journals that can be found in a trashcan near you.

Case: 23-year-old woman presents to the emergency department with sudden onset of vaginal bleeding and lower abdominal pain. There has been no change in her bowel or bladder habits. She has a history of irregular periods, does not know when her last “normal” period was and has never been pregnant. She is sexual active and sometimes uses condoms.

Her vitals are blood pressure 110/70, heart rate 90, afebrile and oxygen saturation 99% on room air. Abdominal exam reveals a tender suprapubic area, volunteer guarding with positive bowel sounds. The pelvic exam is normal. Urine pregnancy test is positive. You are concerned about an ectopic pregnancy.

Background:

* Ectopic pregnancies represent approximately 2-3% of all pregnancies

* Leading cause of 1st trimester maternal death

* Higher incidence in in vitro fertilization population

* Less than half of emergency department patients present with the classic abdominal pain and vaginal bleeding

* 50% of patients with ectopic pregnancies have no identifiable risk factors

Ectopic pregnancies represent a significant medical-legal risk. The Canadian Medical Protection Association (CMPA) reviewed all the ectopic cases from 2003 to 2007. They found 23 total open and closed cases. Of the 17 closed cases, delayed diagnosis was the number one reason for the medical/legal problem. There were 10 tubal ruptures and no maternal deaths in this series.

Experts thought the following factors contributed to the diagnostic delay:

* Delay in attending the patient

* Failure to perform a pelvic examination

* Failure to perform appropriate diagnostic investigations in women of reproductive age who presented with abdominal pain and vaginal bleeding

* Inadequate systems for the follow up of diagnostic investigations and/or patients

Based on the College decisions in the cases presented and the opinions of experts in the other cases, the following risk management considerations are suggested:

* Have you considered the diagnosis of ectopic pregnancy when a woman of reproductive age presents with abdominal pain and vaginal bleeding?

* Are you familiar with the current clinical practice guidelines for the investigation and management of suspected ectopic pregnancy?

* Have you performed the appropriate physical examination and arranged for any appropriate diagnostic investigations?

* Is there a system in place to facilitate timely follow up of investigations and/or patients?

* Does the documentation reflect your clinical impressions at the time of assessment, discussions with consultants, and patient instructions?

Clinical Question: Does this woman have an ectopic pregnancy?

Reference: Crochet, J.R., Bastian, L.A., Chireau, M.V. Does this Woman Have an Ectopic Pregnancy? JAMA. 2013;309(16):1722-1729.

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Date: January 23rd, 2015

Guest Skeptic: Nadia Awad is an assistant professor of emergency medicine at the Ernest Mario School of Pharmacy at Rutgers University, and the emergency medicine pharmacist at Robert Wood Johnson University Hospital Somerset.

She serves as associate editor and staff blogger of the blog, Emergency Medicine PharmD where she regularly contributes her thoughts, ideas, and clinical pearls related to her experiences in emergency medicine pharmacy and academia.

Nadia also is the co-host of the EMPOWER Podcast. She is actively involved in research in areas that include emergency medicine, toxicology, disaster preparedness, acute neurocritical care, and social media in pharmacy education. She is a strong supporter of all that Free Open Access Medical Education (FOAMed) has to offer, and she hopes to continue to have a fulfilling experience in both learning from and contributing to this outstanding and inspiring effort.

Case Senario: 28-year-old male who presents to your emergency department with a three-day history of urethral discharge and moderate to severe dysuria. He lives with his wife and denies, denies, denies any other sexual contacts. He reports experiencing a similar problem occurring shortly after his bachelor party last summer. On physical exam, you note the presence of a yellowish urethral discharge and bilateral inguinal adenopathy, which is moderately tender to palpation. A swab of the urethral discharge is collected, but the results of the gram stain will not be made available for a few days. You note that his chart states that he has an allergy to ceftriaxone, and when you question him further regarding the type of reaction that occurred, he states to you that the last time he was treated for this, he developed an anaphylactic reaction to the drug. You would like to empirically treat him for gonorrhea and chlamydia.

Question: What viable options do we have in the empiric treatment of gonorrhea in the patient who has a cephalosporin allergy or if there are concerns related to cephalosporin-resistant infections?

Background: For any clinician who really wants to get a good handle and better appreciation of how antimicrobial resistance has really affected the way we treat infections, look no further than the history and evolution of how we have managed gonococcal infections over the past century.

The evolution of treatment strategies for the management of gonorrhea over the past century is rather fascinating and disheartening. We have exhausted the use of penicllins, sulfonamides, tetracyclines, and fluoroquinolones for the treatment of this condition.

In 2011, due to treatment failures, decreased in vitro susceptibility, and greater demonstrated efficacy for pharyngeal infection, the Centers for Disease Control and Prevention (CDC) recommended higher doses of ceftriaxone to be used for gonococcal infection (250 mg from 125 mg administered parenterally as a one-time dose).

Concerns related to an increase in the number of isolates of gonorrhea that exhibited elevated minimum inhibitory concentrations (MICs) to cefixime prompted the CDC to no longer recommend the use of oral cephalosporins for the treatment of gonorrhoea. And just in 2013, the CDC named gonorrhoea as one of the top three diseases considered to be an urgent threat to the United States.

Actions recommended to address the increase in cephalosporin-resistant gonococcal infection included increased public awareness and preparedness by public health agencies and studies to be conducted related to alterna...

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Date: January 17th, 2015

I hope everyone has been having a great start to 2015. It’t been really, really busy for me as I get more involved with Emergency Medical Abstracts (EMA). Just did my first EMA recording with Dr. Rob Rogers and Dr. Anand Swaminathan.

EMA is available for free for residents as part of their EMRA Membership in the US or CAEP Residents Membership in Canada. You get an amazing medical education product as part of your residency membership.

I think there are five great reasons why EMA is such an outstanding packing:

* 30 papers a month critically appraised

* A deep dive lecture on a specific topic

* An interview by Dr. Richard Bukata the man, the myth the legend that started EMA

* A 30 minute lecture from the emergency medicine critical care course

* Editorial segment with one of the giants of emergency medicine, Dr. Jerome Hoffman.

As I move forward on the SGEM in 2015 let me know what you think. I am always trying to find better ways to cut that knowledge translation window down from over 10 years to less than one year. Let me know how I can do a better job.

Previous suggestions which have really made the SGEM better are:

* SGEM HOP – Getting advanced copies of manuscript prior to publication and doing a critical review, interviewing the author, posting the podcast the week of publication and then having the best social media interactions published in a future peer reviewed journal article. Basically the SGEM-HOP is the best of both worlds. Traditional and non-traditional dissemination of medical education. Check out the latest one with Chris Carpenter and Sanjay Arora on texting emergency department patients to improve follow-up. give us your feedback and you too may be published.

* SGEM Extras – Taking 10,000 foot looks at bigger issues in emergency medicine. Check out the one with Jeremy Faust from FOAMCast called Everything you know is wrong. It looks at the limitations and weaknesses of the standard peer review process.

* SGEM Classics – These are done with Swami and have been a huge hit. There was OPALS, CRASH-2 and of course NINDS. We are currently working on another SGEM Classic so stay tuned.

A recent suggestion was flipping the SGEM. A listener suggesting posting the paper to be critically reviewed in advance. That way people could read the article before the blog and podcast are posted. This would make the written SGEM review and podcast even more educational. So I will be trying to Flip the SGEM by tweeting and posting on Facebook a link to the next article to be put under the skeptical eye of the SGEM.

Case Scenario: 25-year-old smoker is seen in emergency department for acute respiratory distress. He has a diagnosis of asthma and is an occasional user of salbutamol. He has about two asthma exacerbations/year, one previous hospital admission and no intensive care unit admissions. You are preparing to discharge him home and wonder if inhaled steroids would benefit the systemic steroids you are prescribing.

Question: Is there a benefit for inhaled cortic...

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Date: January 6th, 2015

Guest Skeptics: Dr. Chris Carpenter. Chris is an Associate Professor, Emergency Medicine. Director, Evidence Based Medicine, Washington University. Chris also wrote the book on EMB Co-Author of Evidence Based Emergency Care- Diagnostic, Testing and Clinical Decision Rules.

This is the third episode of the Skeptics’ Guide to Emergency Medicine Hot Off the Press (SGEM-HOP). The SGEM has entered into an arrangement with Society of Academic Emergency Medicine (SAEM) and the Canadian Association of Emergency Physicians (CAEP) to achieve that goal. SAEM publishes the Academic Emergency Medicine (AEM) Journal and CAEP publishes the Canadian Journal of Emergency Medicine (CJEM).

SGEM Hot Off the Press (HOP) Process:

* We pick a manuscript in conjunction with the Editorial Boards of each journal that has been submitted, peer-reviewd, and ultimately accepted for AEM/CJEM put not published yet.

* The SGEM then put a skeptical eye upon the manuscript using the BEEM critical appraisal tool.

* One of the authors of the paper will be invited to discuss the strengths/weakness/limitations/clinical application their paper.

* A special SGEM Hot Off the Press podcast that will be posted the week the journal gets published.

* The SGEM audience will get a chance to respond via the blog, twitter or on Facebook.

* A summary of the SGEM critical appraisal will be published in a subsequent issue of each journal including the top social media feedback.

The 1st SGEM-HOP looking at predict falls in the elderly was a huge success (SGEM#89). There were thousands of interactions on Facebook, the SGEM blog and twitter. The bottom line was “These people fall, get injured and even die. We do not have good ED evidence to help us predict accurately or reliably who is at risk of falling. High quality research is need for healthcare providers, funders, and guideline developers to use in deriving screening protocols.”

The summary of SGEM#89 has just been published in Academic Emergency Medicine Journal. The top tweet was from Dr. Jeremy Faust the co-creator of FOAM Cast with Dr. Lauren Westfer. He tweeted about the inability to cut one’s own toenails had the best negative likelihood ratio for 6-month fall risk. If you want to get published in the next future edition than tweet your comments about this episode using the hashtag #SGEMHOP.

Case: 37 year old right-handed attorney presents with right wrist pain after diving for a racquetball during a competitive game with one of his senior partners. Pain is localized diffusely over the posterior wrist, including concerning pain with thumb longitudinal compression test and resisted supination. No other injuries are identified and x-rays of the wrist reveal no scaphoid fracture or other injury. Your concern is an occult scaphoid fracture, which occurs in about 25% of ED wrist pain patients with suspected scaphoid injury & unremarkable x-rays. In addition to pain control, your management options include:

* No thumb spica splint & follow-up with primary care physician (PCP) or Orthopaedic ...

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Date: January 7th, 2015

This is a SGEM Xtra. Rather than being my usual skeptical self I am going to be Happy. Why am I so happy? Is it to wish all the SGEM listeners Happy New Years? Well sure, Happy New Years, but what I really want to do is make a Happy announcement

I have joined the New Emergency Medicine Abstracts (EMA) Team. For those of you not familiar with EMA they have been producing EM education for over 30 years. EMA has been trying to cut the knowledge translation window down by disseminating critically appraised literature before there was an internet!

Dr. Richard Bukata started EMA back in the 1970’s. He was subsequently joined by Dr. Jerome Hoffman and the two of them became the voices of EM medical education.

Their audio product quickly became known as the Rick and Jerry show.

I am one of the EM physicians these two giants have helped train. I am a better doctor who provides better care to patients because of listening to Rick and Jerry over the years.

They each bring a unique perspective and style to the literature. Rick was the front line, hard working community emergency physician. He could easily put the complex research into an easily understandable and digestible form. Rick had the gift of being able to translate how the literature could be applied in the “real” world.

Jerry on the other hand taught me how to be skeptical of anything I read. He had a laser focus on the method sections, limitations of studies and conflicts of interests. Jerry was teaching and talking about over testing, over diagnosing and over treating before anyone mentioned the term choosing wisely.

Now, I grew up when the Muppet Show was popular on TV. Years later, when I started listening to EMA it brought back some fond memories. Rick and Jerry reminded me of the two men sitting in the balcony commenting on the program. Stalter and Waldorf would combine sharp wit with their editorial comments. They seemed just like Rick and Jerry picking out the essential take home points about each article while always finding the balance between education and entertainment.

There is a very cool quote from Marshall McLuhan who said; “Anyone who tries to make a distinction between education and entertainment doesn’t know the first thing about either.” Rick and Jerry found that balance every month. Their chemistry was phenomenal and you could hear it come across month after month.

Emergency Medicine Abstracts is one of the main reasons I got involved in medical education. I am happy, humbled and honored to join the New EMA Team. What an opportunity to work with the Lennon and McCartney of emergency medicine education. It is a cliché only because it is true…I am going to be standing on the shoulders of giants.

But don’t panic! If you are a long time subscriber to EMA you will still get your monthly dose of Rick and Jerry. There will be no going into withdrawal or what could be called DA (Delirium Abstractem).

Dr. Bukata will be doing a monthly interview with a leader in emergency medicine. They may be a researcher, administrator or opinion leader. It will be a chance to hear from the voices of people who have changed or are changing emergency medicine through their work.

Dr. Hoffman will also have a monthly section where he brings his unique style, approach and opinion we have all come to expect and appreciate. I am affectionately calling this the

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Date: January 4th, 2015

Guest Skeptic: Eve Purdy is a fourth year medical student from Queen’s University. Eve is interested in all things medicine but especially emergency medicine, rural medicine, medical education and social media. She is the creative force behind the excellent medical student blog Manu et Corde (Hand and Heart). She is also an editor for BoringEM. When not learning to be a doctor, Eve is usually running, playing guitar or planning an outdoor adventure.

Case: You are working in the emergency department when you pick up the chart for an otherwise healthy 35-year-old male with the chief complaint of abdominal pain and nausea. On history you learn that he has had crampy generalized abdominal pain for the past 24 hours associated with one episode of emesis. The pain started after he went out for wings night with some of his buddies and he hasn’t had much by mouth since then. He has been keeping down a bit of water. His last bowel movement was 12 hours ago and it was “loose” but was a normal colour with no blood. He hasn’t had any surgeries, he hasn’t been traveling, but is a grade 3 teacher and many of the kids in his class have had “gastro”. In the department he vomits while you are taking a history. His vital signs are normal and his abdomen is soft with some mild tenderness but no peritoneal signs. How will you treat his symptoms?

Background: Nausea and/or vomiting are common emergency department presentations. While investigating underlying cause and establishing a diagnosis are important, so too is the goal of relieving the patient’s symptoms. The success of pharmacologic anti-emetic strategies in oncology and post-operative patients (1, 2) has been extrapolated to support their use in patients with un-differentiated nausea and vomiting in the ED. Four studies (3, 4, 5, 6) have shown success of metoclopramide and/or ondansetron in reducing the severity of nausea in the ED but the only two placebo controlled studies showed no benefit of these medications over placebo (3, 4). Severity of nausea and vomiting is frequently measured using a visual analogue scale (VAS) and a minimally significant change has previously been defined as 15mm (7).

Clinical Question: What anti-emetic is most effective for Emergency Department patients with undifferentiated nausea?

Reference: Egerton-Warburton et al. Antiemetic Use for Nausea and Vomiting in Adult Emergency Department Patients: Randomized Controlled Trial Comparing Ondansetron, Metoclopramide, and Placebo. Annals of Emergency Medicine 2014.

* Population: Adult patients with nausea and vomiting during emergency department care for which the physician prescribed intravenous anti-emetics