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SGEM#346: Sepsis – You Were Always on My Mind
Date: September 20th, 2021
Reference: Litell et al. Most emergency department patients meeting sepsis criteria are not diagnosed with sepsis at discharge. AEM 2021.
Guest Skeptic: Dr. Jess Monas is a Consultant in the Department of Emergency Medicine at the Mayo Clinic Hospital, Phoenix, Arizona. She is also an Assistant Professor, Department of Emergency Medicine Mayo Clinic Alix School of Medicine in Scottsdale, Arizona. Jess also does the ultra summaries for EMRAP.
Case: A 60-year-old man presents to the emergency department with a non-productive cough and increasing shortness of breath. He has a history of chronic obstructive pulmonary disease (COPD), hypertension (HTN), congestive heart failure (CHF), and benign prostatic hypertrophy (BPH). He’s afebrile. He has a heart rate of 93 beats per minute, a blood pressure of 145/90 mm Hg, respiratory rate of 24 breaths per minute, and an oxygen saturation of 92% on room air.
Initial labs come back with a slightly decreased platelet count (149) and a minimally elevated creatinine (1.21 mg/dl or 107 umol/L). He triggers a sepsis alert, and you get a pop-up suggesting IV antibiotics and 30cc/kg of IV fluids. So, you ask yourself, is this guy really septic and should we bypass those fluids?
Background: We have covered sepsis many times on the SGEM since 2012. This has included the three large RCTs published in 2014-15 comparing early goal-directed therapy (EGDT) to usual care. All three showed no statistical difference between the two treatments for their primary outcome (SGEM#69, SGEM#92 and SGEM#113).
There was also SGEM#174 which said don’t believe the hype around a Vitamin C Cocktail that was being promoted as a cure for sepsis and SGEM#207 which showed prehospital administration of IV antibiotics did improve time to get them in patients with suspected sepsis, but did not improve all-cause mortality.
The SGEM was part of a group of clinicians who were concerned about the updated 2018 Surviving Sepsis Campaign (SSC) guidelines. Specifically, the fluid, antibiotics, and pressor requirements within the first hour of being triaged in the emergency department.
Despite the lack of high-quality evidence to support these sepsis bundles, many hospitals incorporated them into their electronic medical record (EMR). They created these sepsis alerts with the intention of identifying septic patients, so they can be treated accordingly. Most physicians agree that antibiotics should be given early in septic patients. However, the jury is still out for other interventions with potential for harm, particularly, the infusion of 30cc/kg of IV fluids.
Worldwide sepsis contributes to the death of 5.3 million hospitalized people annually. It is the leading cause of death in the intensive care unit (ICU) in the US and the most expensive diagnosis. Since 2015, the Centers for Medicare & Medicaid Services (CMS) have indexed the quality of hospital care for sepsis to the SEP-1 core measure. Interventions, particularly early antibiotics, have been associated with improved mortality.
Diagnosing sepsis can be challenging. To adequately capture patients,
SGEM#345: Checking In, Checking Out for Non-Operative Treatment of Appendicitis
Date: September 16th, 2021
Reference: Sippola et al. Effect of Oral Moxifloxacin vs Intravenous Ertapenem Plus Oral Levofloxacin for Treatment of Uncomplicated Acute Appendicitis. The APPAC II Randomized Clinical Trial. JAMA 2021
Guest Skeptic: Dr. Rob Leeper is an assistant professor of surgery at Western University and the London Health Sciences Center. His practice is in trauma, emergency general surgery, and critical care with an academic interest in ultrasound and medical simulation.
Rules of SGEM Journal Club
Case: A 23-year-old man with CT confirmed uncomplicated appendicitis, mild abdominal pain, stable clinical signs, and essentially normal laboratory investigations has just concluded his bedside consultation with the on-call general surgery team. The patient and surgeons have had an evidence-informed discussion and have arrived at a mutually agreed upon decision to proceed with non-operative treatment of his appendicitis. The patient is recommended to undergo admission to hospital for serial observation and intravenous antibiotics. The patient asks; “gosh doc, if this disease is so mild why can’t I just go home and take antibiotics by mouth?”.
Background: The appendix is a structure about as long as your pinkie finger that hangs off the beginning of the colon, in the right lower quadrant of your abdomen. There are lots of theories about subtle functions of the appendix, but its most prominent role is to become inflamed or infected in approximately 7% of people.
Usually appendicitis occurs because the lumen, or inside, of the appendix is obstructed by something. Often that is a piece of stool called a fecalith, but other times it can be lymph tissue or another process we may never actually identify. This causes the pressure in the appendix to increase eventually obstructing venous outflow and then arterial inflow.
We used to assume that this was an ordered progression that always leads to appendiceal rupture in a stepwise fashion, but we now think that there is more of a spectrum of severity based on individual anatomic and other factors. While the presentation of appendicitis can vary from patient to patient, as our emergency medicine colleagues know well, most patients are not diffusely peritonitic or systemically unwell.
Before we had things like surgery or antibiotics, appendicitis carried up to a 50% case fatality rate. Luckily now, with these treatments the mortality rate is almost zero. For the last 135 years we have treated appendicitis with an appendectomy, which is now almost always performed in laparoscopic fashion.
A laparoscopic appendectomy involves a general anesthetic, making three small incisions between 1 and 2 cm in length; and the operation usually takes somewhere between 30 to 60 minutes. Most patients go home the same day or the next morning, either with a short course of antibiotics or with none after surgery.
Most patients who have this surgery are back to work and their usual routine at around the two-week mark. The chance of requiring additional procedures is quite low unless we find that the appendix has already perforated. It is a good, and generally very safe operation, with a high rate of patient satisfaction.
Omar et al published a study in 2008 showing just how safe laparoscopic appendectomies have become. They found in over 230,000 UK patients the death rate was less than half compared to the open procedure (0.64% vs 0.29%; p0.001).
Nonoperative treatment of appendicitis (NOTA) was first described in the 1940s and moved into the public consciousness when a href="https://www.chicagotribune.
SGEM#344: We Will…We Will Cath You – But should We After An OHCA Without ST Elevations?
Date: September 8th, 2021
Reference: Desch et al. The TOMAHAWK Investigators. Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation. NEJM 2021.
Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. He heads curriculum and conference for the academic year and is passionate about resident education on- and off-shift, from procedural to evidence-analytical.
Dr. Kaushal Khambhati is also a fourth-year resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. He is interested and experienced in healthcare informatics, previously worked with ED-directed EMR design, and is involved in the New York City Health and Hospitals Healthcare Administration Scholars Program (HASP).
Five Rules of the SGEM Journal Club
Case: A 70-year-old woman is found unresponsive and apneic at home by her partner. EMS arrives and finds the patient in monomorphic ventricular tachycardic (VT) cardiac arrest. She has a history of hypertension and non-insulin dependent diabetes mellitus. The paramedics achieve return of spontaneous circulation (ROSC) after CPR, advanced cardiac life support (ALCS), and Intubation. She arrives in the emergency department (ED) with decreased level of consciousness and shock. The EKG shows sinus tachycardia with nonspecific changes and no ST segment elevations, Q waves, or hyperacute T waves. Her point-of-care ultrasound (POCUS) shows appropriate-appearing global ejection fraction and no marked wall motion abnormalities. Cardiology has been consulted and asks for a neurology consultation given her mental status.
Background: The American Heart Association estimates there are approximately 350,000 EMS-assessed out-of-hospital cardiac arrests (OHCAs) in the United States per year. Half of these arrests are witnessed with the other half being un-witnessed. Many of these OHCAs are due to ventricular fibrillation or pulseless VT. Defibrillation is the treatment of choice in these cases but does not often result in sustained ROSC (Kudenchuk et al 2006).
Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients. There is evidence that taking those patients with ROSC and EKG showing STEMI directly for angiography +/- angioplasty is associated with positive patient-oriented outcomes.
The AHA has a statement with recommendations based on the available data. They suggest to perform catheterization and reperfusion for post-arrest patients with ST-segment elevation, even if the patient is comatose However, there is no consensus if this strategy should be employed in patients without ST-segment elevation (Yannopoulos et al, Circulation 2019).
The 2015 AHA Guidelines make the following recommendations:
* Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG (Class I, LOE B-NR).
* Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG (Class IIa, LOE B-NR).
Lemke et al 2019 published a multicentre RCT done in the Netherlands looking at patients without ST segment elev...
SGEM#343: Doctors are Doctors So Why Should It Be, You and I Should Get Along So Awfully – Weight Bias in Medicine
Date: August 31st, 2021
Reference: McLean et al. Interphysician weight bias: A cross-sectional observational survey study to guide implicit bias training in the medical workplace. AEM Sept 2021
Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine.
Case: You are working in the emergency department (ED) with the new resident, one of whom is overweight. You overhear his colleagues wonder where he went, chuckling, and one of them comments that “he probably went for second breakfast.” Realizing that these residents are making fun of their colleague’s weight, you decide to address the issue.
Background: We have talked about biases many times on the SGEM. Usually when we use the term bias it is in the context of something that systematically moves us away from the “truth”. Science does not make truth claims and the term is used as a shorthand for the best point estimate of an observed effect size.
An example in the medical literature would be selection bias. This is when subjects for a research study are not randomly selected. This can skew the results and impact the conclusions. Another example would be publication bias. Studies with “positive” results are more likely to be published while those with “negative” results are more likely to end up in the bottom of the file drawer.
There are many other types of bias in the practice of medicine. Some of my favourite ones are anchoring bias, base-rate neglect, and hindsight bias. For a description of these and many more check out Dr. Pat Croskerry list of 50 cognitive biases in medicine. You can also click on the codex for an extensive list of different biases.
This SGEM episode focuses on a kind of bias as defined by the common English language as “a particular tendency, trend, inclination, feeling, or opinion, especially one that is preconceived or unreasoned”. It is a sense of prejudice or stereotyping and the formation of a foregone conclusion independent of current evidence.
There are many biases in the house of medicine. We have discussed some of them on the SGEM. They include things like age, gender, socioeconomic status, race, and other factors. The gender pay gap is one of the topics that has been spoken about most on the SGEM. A paper by Wiler et al AEM 2019 showed females in academic emergency medicine were paid ~$12,000/year less than their male colleagues (SGEM#248).
The September 2021 issue of AEM is a special issue focusing on biases in emergency medicine. It includes articles on racial, ethnic and gender disparities. One specific topic jumped out as something that has not received much attention, weight bias. There is literature on physicians’ weight biases towards patients and patients’ weight bias towards physicians. However, there is limited information on physician-to-physician weight bias.
Clinical Question: What is the prevalence of interphysician implicit, explicit, and professional weight bias?
Reference: McLean et al. Interphysician weight bias: A cross-sectional observational survey study to guide implicit bias training in the medical workplace. AEM Sept 2021
* Population: Practicing physicians and physicians-in-training in North America
* Excluded: Those who did not consent; did not identify as physicians or physicians-in-training; or were not currently residi...
SGEM#342: Should We Get Physical, Therapy for Minor Musculoskeletal Disorders in the ED?
Date: August 27th, 2021
Reference: Gagnon et al. Direct-access physiotherapy to help manage patients with musculoskeletal disorders in an emergency department: Results of a randomized controlled trial. AEM 2021
Guest Skeptic: Dagny Kane-Haas is a physiotherapist who also has a master’s degree in Clinical Science in Manipulative Therapy.
Case: A forty-year-old woman presents to the emergency department (ED) with a sore lower back after moving some boxes at home over the weekend. She tried acetaminophen with limited relief. Her pain is eight out of ten on the zero-to-ten-point numeric pain rating scale (NPRS). She has no red flags (TUNA FISH) and is diagnosed as having mechanical back pain without imaging as per ACEP Choosing Wisely. You know mechanical low back pain is difficult to treat effectively and are trying to set expectations. While preparing her for discharge you wonder if seeing a physiotherapist before going home from the ED would improve her outcome.
Background: Acute and chronic back pain has been covered many times on the SGEM. There is no high-quality evidence that acetaminophen, NSAIDS, steroids, diazepam, muscle relaxants or combinations of pharmacologic modalities provide much relief.
* SGEM#87:Let Your Back Bone Slide (Paracetamol for Low-Back Pain)
* SGEM#173: Diazepam Won’t Get Back Pain Down
* SGEM#240: I Can’t Get No Satisfaction for My Chronic Non-Cancer Pain
* SGEM#304: Treating Acute Low Back Pain – It’s Tricky, Tricky, Tricky
We do know that opioids are very effective at reducing many types of pain including muscular skeletal pain. However, opioids have many side effects and concerns about substance misused.
The ACEP 2020 clinical policy on the use of opioids states:
“Preferentially prescribe nonopioid analgesic therapies (nonpharmacologic and pharmacologic) rather than opioids as the initial treatment of acute pain in patients discharged from the emergency department. For cases in which opioid medications are deemed necessary, prescribe the lowest effective dose of a short-acting opioid for the shortest time indicated.” (Level C Recommendation)
There are several non-pharmaceutical treatments that have also been tried to treat low back pain. They include: Cognitive Behavioural Therapy and mindfulness (Cherkin et al JAMA 2016), chiropractic (Paige et al JAMA 2017), physical therapy (Paolucci et al J Pain Research 2018) and acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013). None of these other treatments has high-quality evidence supporting their use.
We have covered a randomized control trial looking at acupuncture to treat painful conditions presenting to the ED, including acute back pain,
SGEM#341: Are the AAP Guidelines for the Evaluation and Management of the Well-Appearing Febrile Infant the Answer to a Never Ending Story?
Date: August 19th, 2021
Reference: Pantell et al. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics 2021
Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine fellow at Children’s National Hospital in Washington, DC.
Case: A 25-day-old, full-term boy presents to the emergency department with fever. His parents report that he felt warm that evening, and they found that he had a rectal temperature of 38.2°C (100.8°F). He has an older sister at home with a cough and rhinorrhea. Overall, he has no symptoms and appears well. He has continued to feed normally and produce wet diapers. The parents ask you, “Do you really think he needs any additional testing? He probably caught something from his sister, right?”
Background: Parents often bring their infants to the ED with concerns about fever. They can develop a real “fever fear” or “feverphobia” and often need reassurance that fever alone is not dangerous. We have talked about pediatric fever and fever fear with Dr. Anthony Crocco from Sketchy EBM back on SGEM#95 and made a “Ranthony” video on the topic. The American Academy of Pediatrics says that
“…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.”
However, fever without source in infants less than three months of age represents a significant diagnostic dilemma for clinicians. Several clinical decision instruments had been developed previously, including the Rochester (Jaskiewicz et al 1994), Boston (Baskin et al 1992) and Philadelphia (Baker et al 1993) criteria to help clinicians stratify the risk of significant bacterial infections. A new clinical decision instrument called the Step-by-Step approach was reviewed on SGEM#171.
SGEM#171 Bottom Line: If you have availability of serum procalcitonin measurement in a clinically relevant time frame, the Step-by-Step approach to fever without source in infants 90 days old or younger is better than using the Rochester criteria or Lab-score methods. With the caveat that you should be careful with infants between 22-28 days old or those who present within two hours of fever onset.
We have been trying to optimize our approach to evaluating and managing febrile infants for more than four decades. Our goal is to identify the febrile infants with urinary tract infection, bacteremia, and bacterial meningitis (or what was referred to as serious bacterial infections) while simultaneously trying to spare them from invasive and potentially unnecessary procedures like lumbar punctures or the possible iatrogenic consequences of empiric antibiotics or hospitalization.
Several risk stratification tools have been published over the years. These clinical decision instruments included subjective clinical criteria along with pre-determined thresholds for lab criteria like white blood cell count (WBC) and immature to total neutrophil ratio. Unfortunately, these criteria may not be appropriate in the current era. In fact, the Modified Boston and Philadelphia Criteria for invasive bacterial infections may misclassify almost a href="https://pediatrics.aappublications.org/content/145/4/e20193538?ijkey=3bc803ec1955973028aed80e2d7bc03bf9cf9d59&keytype2...
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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.
I am here to learn about emergency medicine....not to be preached to about race relaions...ughhh.
Very informative and Dr. Milne is very knowledgable.