91 episodes

Meet 'em, greet 'em, treat 'em and street 'em

The Skeptics Guide to Emergency Medicine Dr. Ken Milne

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Meet 'em, greet 'em, treat 'em and street 'em

    SGEM#338: Are Children with CAP Safe and Sound if Treated for 5d Rather than 10d of Antibiotics?

    SGEM#338: Are Children with CAP Safe and Sound if Treated for 5d Rather than 10d of Antibiotics?

    Date: July 14th, 2021



    Reference: Pernica et al. Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial. JAMA Pediatr. 2021.

    Guest Skeptic: Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder of website lead of Don’t Forget the Bubbles (DFTB). When not drinking coffee and reading Batman comics he is playing with his children.

    Case: Six-year-old Morten comes into your emergency department (ED) with what looks like pneumonia.  He has been febrile with a temp of 39 degrees Celsius, he is mildly tachypneic but shows no real signs of respiratory distress and you can hear some crackles in the right mid-zone.  His chest X-ray (CXR) confirms your findings, but he is well enough to be treated as an outpatient.





    Background: It is hard to believe we have not covered the common condition of pediatric community acquired pneumonia (CAP) on the SGEM. Perhaps it is because there is limited evidence on this common condition. However, we have covered other pediatric infectious issues like:



    * Honey for Cough SGEM#26

    * Fever Fear SGEM#95

    * Lumbar Punctures SGEM#296

    * Bronchiolitis SGEM#228

    * Invasive Bacterial Infection SGEM#334



    We do have high-quality evidence that a CXR is not necessary to confirm the diagnosis of CAP in patients who are well enough to be managed as outpatients. There is also high-quality evidence that pre-school children do not routinely need antibiotics. This is because most  pneumonias in this age-group are caused by viral pathogens (Bradley et al 2011).

    Antibiotics are recommended for school age children diagnosed with CAP. However, how long should they be treated is an open question. The IDSA guidelines provide a strong recommendations based on moderate quality of evidence to guide our care. (Bradley et al 2011).



    * Treatment courses of 10 days have been best studied, although shorter courses may be just as effective, particularly for more mild disease managed on an outpatient basis. (strong recommendation; moderate-quality evidence)



    There is an RCT reporting five days of amoxicillin (80mg/kg divided TID) was non-inferior to ten days for CAP in children six months to 59 months of age (Greenberg et al 2014). This was a relatively small study (n=115) from Israel.

    A short course (five days) has also been recommended by the American Thoracic Society and the IDSA for adults with CAP under certain conditions (Metlay et al 2019).



    * We recommend that the duration of antibiotic therapy should be guided by a validated measure of clinical stability (resolution of vital sign abnormalities [heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature], ability to eat, and normal mentation), and antibiotic therapy should be continued until the patient achieves stability and for no less than a total of 5 days (strong recommendation,

    • 29 min
    SGEM#337: Amazing GRACE-1 How Sweet the Guidelines – Recurrent, Low Risk Chest Pain in the Emergency Department

    SGEM#337: Amazing GRACE-1 How Sweet the Guidelines – Recurrent, Low Risk Chest Pain in the Emergency Department

    Date: July 1st, 2021

    Guest Skeptic #1: Dr. Chris Carpenter is Professor of Emergency Medicine at Washington University in St. Louis and a member of their Emergency Medicine Research Core. He is a member of the SAEM Board of Directors and the former Chair of the SAEM EBM Interest Group and ACEP Geriatric Section. He is Deputy Editor-in-Chief of Academic Emergency Medicine. He is also Associate Editor of Annals of Internal Medicine’s ACP Journal Club and the Journal of the American Geriatrics Society, and he serves on the American College of Emergency Physician’s (ACEP) Clinical Policy Committee. Dr. Carpenter also wrote the book on diagnostic testing and clinical decision rules.

    Reference: Musey et al. Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department. AEM July 2021



    This is an extra special SGEM. It is a combo of an SGEM Xtra and an SGEMHOP. The Society of Academic Emergency Medicine (SAEM) has decided to publish its own clinical practice guidelines (CPGs). They are called Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE). This episode will review the GRACE-1 guideline looking at low-risk recurrent chest pain.

    Because this is a new initiative by SAEM, I interviewed Dr. Chris Carpenter about these new GRACE guidelines.

    Listen to the SGEM podcast to hear him answer five background questions about these new CPGs.







    Who came up with the idea of doing CPGs?

    Why do we need more guidelines?

    Walk us through the GRACE process?

    Why pick recurrent, low-risk chest pain to be the first CPG?

    What do you hope to achieve with these CPGs







    Guest Skeptic #2: Dr. Suneel Upadhye is an Associate Professor of Emergency Medicine & Clinical Epidemiology at McMaster University. He is a founding member of the Best Evidence in Emergency Medicine (BEEM) program. Suneel is also the inaugural Research Lead for the EM Researchers of Niagara, which is a novel community-based EM research group within Niagara region, Canada. He is also a Guidelines Methodologist within CAEP and the SAEM GRACE groups.

    Case: You are seeing a patient who has returned to the emergency department (ED) with recurrent chest pain. It is their fourth visit in the last twelve months.  He has had his chest pain for approximately three to four hours now and is not classic for ischemic symptomatology.  His initial high-sensitivity (hs) troponin is negative, and his ECG is unremarkable.  In reviewing his records, you note that he has undergone significant cardiac testing in the recent past, which was unremarkable. This included a normal exercise stress test and CCTA 18 months ago.  You also note that he has an underlying anxiety disorder, which is being treated and followed by his family physician.



     

    Background: This new SAEM GRACE initiative is committed to using the Grading of Recommendations, Assessment, Development,

    • 1 hr 3 min
    SGEM#336: You Can’t Always Get What You Want – TTM2 Trial

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

    Date: July 1st, 2021

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

    Reference: Dankiewicz et al: TTM2 Trial Investigators. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest. NEJM 2021

    Case: A 58-year-old man collapsed in front of his family. When paramedics arrived, they found him to be in cardiac arrest, with ventricular fibrillation on the monitor. Paramedics managed to get return of spontaneous circulation after a single defibrillation, but the patient is still comatose on arrival. The charge nurse turns to you and asks: should I grab the ice packs?

    Background: Hypothermia has been a mainstay of post-arrest care after the publication of two trials in 2002 that both suggested a benefit. This trial by Bernard and colleagues randomized 77 patients with an initial cardiac rhythm of ventricular fibrillation who had achieved return of spontaneous circulation (ROSC) but were persistently comatose. The trial was not truly randomized, as the groups were based on the day of the month, and they also weren’t blinded.

    The results of this Australian trial seemed too good to be true. Hypothermia resulted in a large improvement in neurologic outcomes, defined as well enough to be sent home or to a rehab facility. It was 49% of the hypothermia group versus only 26% of the normothermia group. This gives a NNT of 4. The reported p value was borderline at 0.046, and when I re-calculate, it comes out as 0.06 (not statistically significant).

    The other trial was the Hypothermia After Cardiac Arrest (HACA), also published in NEJM 2002. They randomized 273 comatose adult patients out of 3,551 screened patients. These were witnessed OHCA who had a shockable rhythm, achieved ROSC, and had a short downtime. This trial used an air mattress to cool patients and was also not blinded.

    This second trial done in Europe also showed impressive results for favorable neurologic outcome. It was 55% in the hypothermia group vs 39% in the normothermia group (NNT 6). They also reported a 14% absolute decrease in mortality with therapeutic hypothermia post-OHCA.

    As a result of these two-small trials, hypothermia was widely adopted. However, there were many voices in the evidence-based medicine world that reminded us of the significant uncertainty that remained, and the weaknesses of these two trials.

    The SGEM covered a few  trials looking at therapeutic hypothermia for OCHA in the pre-hospital setting. The bottom line is there is not good evidence that therapeutic hypothermia is superior to usual care and cannot be recommended.



    * SGEM#21: Ice, Ice, Baby (Hypothermia post Cardiac Arrest)

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

    * SGEM#183: Don’t RINSE, Don’t Repeat



    Because of that uncertainty, a much larger, multi-center trial was run. This is the original Target Temperature Management (TTM) trial by Nielson et al NEJM 2013. As almost everyone knows, they compared two difference hypothermia targets, 33C and 36C. The result was no benefit for their primary outcome of mortality at the end of the trial and no benefit Cerebral Performance Category (CPC), modified Rankin Score (mRS) or mortality at 180 days.

    We did a structured critical appraisal of the TTM trial on SGEM#82. The bottom line was that the trial did not demonstrat...

    • 27 min
    SGEM#335: Sisters are Doin’ It for Themselves…Self-Obtained Vaginal Swabs for STIs

    SGEM#335: Sisters are Doin’ It for Themselves…Self-Obtained Vaginal Swabs for STIs

    Date: June 25th, 2021

    Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM.

    Reference: Chinnock et al. Self-obtained vaginal swabs are not inferior to provider-performed endocervical sampling for emergency department diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis. AEM June 2021

    Case: A 31-year-old female presents to the emergency department with pelvic pain and vaginal discharge for the past 24 hours. She is afebrile, vital signs are normal and she is having a significant amount of pain. She says the pain is so severe that she cannot even imagine having a pelvic exam done right now for STI testing.

    Background: Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) are the two most common sexually transmitted infections (STI) reported in the United States. Emergency departments (EDs) now diagnose an increasing percentage of NG/CT cases compared to STI clinics. (1,2)

    The standard of care for NG/CT diagnosis is nucleic acid amplification testing (NAAT), with the collection method being provider-performed endocervical sampling (PPES). PPES is uncomfortable for patients and has numerous other limitations, including the need for exam rooms, an available provider and often a female chaperone. These limitations can delay sample collection and can also add significant delay in a busy ED. The need for universal pelvic examination in the ED to perform STI testing has also come under increasing scrutiny. (3)

    Vaginal sample collection with self-obtained vaginal swabs (SOVS) was first developed and researched in non-ED settings based on these reasons and others. These studies demonstrated comparable sensitivity for NG/CT diagnosis when comparing SOVS to PPES, and high patient acceptability. (4-8)

    However, those studies were performed in a wide range of non-ED settings and were mostly asymptomatic screening rather than STI testing in an acute care environment. This study compares PPES with SOVS in an ED setting and explores patient’s acceptability or preference of SOVS versus PPES.



    Clinical Question: Do self-obtained swabs have noninferior sensitivity for the diagnosis of NG/CT compared to provider performed swabs in an ED setting using a rapid NAAT.



    Reference: Chinnock et al. Self-obtained vaginal swabs are not inferior to provider-performed endocervical sampling for emergency department diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis. AEM June 2021



    * Population: Female patients 18 years of age or older who were judged by the treating practitioner to need NG/CT testing



    * Exclusions: Incarcerated any acute psychiatric condition precluded understanding instructions or giving informed consent, not English or Spanish proficient, or treated for NG/CT within the previous four weeks.





    * Intervention: Self-obtained vaginal swab (SOVS) for NG/CT

    * Comparison: Provider performed endocervical sampling swab for NG/CT

    * Outcome:



    * Primary Outcome: Noninferiority of SOVS sensitivity for NG/CT, with noninferiority being demonstrated if sensitivity was 90% or above.

    * Secondary Outcomes: Kappa measurement of the SOVS and PPES, SOVS organism-specific sensitivity for NG and CT, acceptance rate of SOVS, rate of patients worried about doing SOVS correctly, and SOVS refusal rate.









    This is an SGEMHOP episode which means we have the lead author on the show. Dr Brian Chinnock is Professor in Department of Emergency Medicine at the UCSF-Fresno Medical Education Program, and Research Director.

    • 44 min
    SGEM#334: In My Life there’s been Earache and Pain I don’t know if it’s IBI again – in an Afebrile Infant with Acute Otitis Media

    SGEM#334: In My Life there’s been Earache and Pain I don’t know if it’s IBI again – in an Afebrile Infant with Acute Otitis Media

    Date: June 11th, 2021

    Guest Skeptic: Dr. Dennis Ren is a paediatric emergency medicine fellow at Children’s National Hospital in Washington, DC.

    Reference: McLaren SH, et al. Invasive bacterial infections in afebrile infants diagnosed with acute otitis media. Pediatrics 2021

    Case: You are working with a medical student at the emergency department when a 2-month-old boy is brought in by his parents for fussiness. They note that he has had upper respiratory symptoms for the past few days and fussier than usual. He has still continued to feed well and make wet diapers. He has not had any fever. Yesterday, they noticed that he seemed to be pulling at his right ear. On exam, he is afebrile, active, and alert. He cries and moves vigorously when you look into his ear. You see a bulging, red tympanic membrane. His left tympanic membrane is clear. The rest of his exam is unremarkable.

    You turn to the medical student and ask her what she would like to do for this patient. She replies that she thinks the patient has an acute otitis media (AOM) but given his age, she is also thinking about the possibility of an invasive bacterial infection (IBI) and would like to obtain some blood for labs and even consider a lumbar puncture for cerebral spinal fluid.

    How do you reply?

    Background: Acute Otitis media is the second most diagnosed illness in children and the most common indication for antibiotic prescription [1-2]. We have covered the of AOM twice on the SGEM:



    * SGEM#132: One Balloon for Otitis Media with Effusion with Dr. Richard Lubell

    * SGEM#278: Seen Your Video for Acute Otitis Media Discharge Instructions SGEMHOP with lead author Dr. Naveen Poonai?



    In 2013, the American Academy of Pediatrics (AAP) updated recommendations for the diagnosis and management of acute otitis media (AOM) for children older than 6 months. Unfortunately, there is limited guidance for patients younger than 6 months. The diagnosis of AOM becomes more complicated by the concern for concurrent invasive bacterial infections (IBI) in infants less than 3 months of age.

    Previous studies have demonstrated low prevalence of concurrent IBI in infants with AOM, but sample size has been small and included a mix of afebrile and febrile infants [3-4]. Additionally, the microbiology of pathogens causing AOM has shifted after the implementation of the pneumococcal conjugate vaccine with a higher proportion of patients having culture negative AOM [5].

    This uncertainty has led to wide practice variation and controversy surrounding diagnostic testing (blood and cerebrospinal fluid testing), antibiotic administration (IV vs oral), and disposition (discharge vs admission) in infants with AOM.



    Clinical Question: What is the prevalence of invasive bacterial infections and adverse events in afebrile infants ≤ 90 days of age with acute otitis media?



    Reference: McLaren SH, et al. Invasive bacterial infections in afebrile infants diagnosed with acute otitis media. Pediatrics 2021



    * Population: Afebrile infants ≤ 90 days of age with clinically diagnosed acute otitis media across 33 pediatric emergency departments (29 USA, 2 Canadian and 2 Spanish EDs) from 2007 to 2017



    * Excluded: Temperature ≥38°C and 36°C in the ED or within 48 hours, antibiotic use (other than topical) within 48 hours of presentation, concurrent mastoiditis, evidence of focal bacterial infection, transferred to ED with previous diagnostic testing/antibiotics





    * Intervention: Evaluation of invasive bacterial infections in blood or cerebrospinal f...

    • 25 min
    SGEM#333: Do you gotta be starting something – like tPA before EVT?

    SGEM#333: Do you gotta be starting something – like tPA before EVT?

    Date: May 25th, 2021

    Guest Skeptic: Dr. Garreth Debiegun is an emergency physician at Maine Medical Center in Portland, ME and clinical assistant professor with Tufts University School of Medicine. He also works at an urgent care and a rural critical access hospital. Garreth is interested in wilderness medicine and is the co-director of the wilderness medicine clerkship at Maine Med, and the medical director for Saddleback Ski Patrol and for Maine Region NSP. At work Garreth imagines himself as a student of evidence-based medicine trying to provide the best care based on the best evidence.

    References:





    * Suzuki et al. Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial. JAMA 2021

    * Zi et al. Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke: The DEVT Randomized Clinical Trial. JAMA 2021



    Case: A 74-year-old woman presents to your emergency department with 1.5 hours of right-sided weakness, aphasia, and neglect. On rapid bedside assessment you calculate the National Institute of Health Stroke Score/Scale (NIHSS) of 11 and a Field Assessment for Stroke Triage for Emergency Destination (FAST-ED) score of 7; you suspect a large vessel occlusion (LVO) based on the high NIHSS and FAST-ED score >3. A non-contrast CT shows no evidence of intracranial hemorrhage. A CT angiogram plus CT perfusion demonstrate a clot in the left proximal middle cerebral artery (MCA) with a small infarcted area and a large penumbra. Based on your institution’s current guidelines, the patient is a candidate for endovascular therapy, but they are also within the current window for the administration of thrombolytics. You wonder if you gotta be starting something?  Specifically, you wonder if you should give the thrombolytics while waiting for your neurointerventional/endovascular team?

    Background: Management of acute ischemic stroke has been discussed on the SGEM ever since this knowledge translation project was launched in 2012. My position remains that there is uncertainty as to whether tPA provides a patient-oriented outcome and this was summarized in the downgrading of the NNT recommendation to “yellow” with Dr. Justin Morgenstern from First10EM.

    The world of stroke management has changed in the last few years the more robust evidence to support endovascular therapy (EVT) for large vessel occlusion (LVO) strokes. The tipping point came with the publication of MR. CLEAN in 2015. It was a multicenter, randomized, unblinded trial of patients with an LVO stroke in the anterior circulation treated in less than six hours after onset of symptoms. The primary outcome was good neurologic function defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days. The trial included 500 patients and reported an absolute risk reduction of 14% (33% EVT vs 19% control) with a NNT of 7.



    Four other RCTs were stopped early due to the publication of MR. CLEAN.  All of these were published in the NEJM in the following six months.



    * SWIFT PRIME (n=196) NNT of 4

    * EXTEND-IA (n=70) NNT of 2-5 depending on which outcome you picked

    * REVASCAT (n=206) extended the window to eight hours NNT 6.5

    • 39 min

Customer Reviews

4.8 out of 5
49 Ratings

49 Ratings

DJ General Delivery ,

Amazing Free Open Access Medicine Content.

The SGEM (skeptics guide to emergency medicine) has been providing evidence based reviews and high quality fun education to emergency physicians for 9 years now. Dr Milne is entertaining, organized, and a world renowned educator in EBM and emergency medicine. What sets him apart is the quality of the topics and papers reviewed, coupled with his skill and fairness at looking at the impact of new information on patient care and work in day to day emergency medicine. As a rural academic emergency physician, this is my go-to source for keeping up with topics. I highly recommend for all students, residents, and practicing emergency professionals including MD’s, Nurses, PAs, and Paramedics. For rural physicians, this is a great way to stay current with useful emergency medicine topics.

JGC Photos ,

Very informative

Very informative and Dr. Milne is very knowledgable.

KDKinzzz ,

Nicely nerdy EBM

Friendly and informative, one article at a time

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