The Skeptics Guide to Emergency Medicine Dr. Ken Milne

Date: February 27, 2023

Reference: Walsh PS, Schnadower D, Zhang Y, Ramgopal S, Shah SS, Wilson PM. Association of early oseltamivir with improved outcomes in hospitalized children with influenza, 2007-2020. JAMA Pediatr. 2022.

Guest Skeptic: Dr. Marisu Rueda-Altez is a pediatric infectious disease fellow at Children’s National Hospital in Washington, DC. She is also the President of the Junior Section of the Society for Pediatric Research.

Case: A 5-year-old child presents to the emergency department in the midst of flu season with three days of fever, upper respiratory symptoms, and malaise. His parents also report that he has lost his appetite and refusing to drink liquids. Nasopharyngeal PCR testing is positive for Influenza A. On physical exam, he is tired appearing and showing signs of respiratory distress with tachypnea and accessory muscle use. His lips look dry and cracked. His oxygen saturation is hovering around 88-90%. His chest radiograph does not demonstrate any focal opacities. After a discussion with his parents, you all agree that it is best for him to be admitted to the for IV hydration and close monitoring. His parents ask you, “A few years ago when we had the flu, we took a medication that helped reduce the length of our symptoms. Would he benefit from that too?”

Background: Oseltamivir is recommended by the American Academy of Pediatrics, Infectious Diseases Society of America and Center for Disease Control and Prevention for the treatment of influenza in both adults and children. [1-3] Possible benefits include reduction in duration of symptoms and improvement of outcomes in hospitalized patients. Most of these recommendations are based on data from adult studies during the H1N1 pandemic with limited pediatric data.

The SGEM has covered the use of oseltamivir for influenza on SGEM #98 and SGEM #312. Despite the recommendations from these various organizations, there remains some controversy (and skepticism) about the use of oseltamivir due to unpublished trial data, lack of access to the research data by the authors, and ghost-written papers. The BMJ was involved in a long legal battle with the manufacturer that you can read about here. Suffice it to say, that there were more harms than originally reported (including nausea and vomiting, neuropsychiatric events, headaches), and it is possible that the potential benefits were exaggerated.[4]



Clinical Question: Will early administration of oseltamivir reduce length of hospitalization and complications of influenza infection?



Reference: Walsh PS, Schnadower D, Zhang Y, Ramgopal S, Shah SS, Wilson PM. Association of early oseltamivir with improved outcomes in hospitalized children with influenza, 2007-2020. JAMA Pediatr. 2022.



* Population: Children 7 days between encounters, picked one at random; if 7 days, picked the first one), death/ECMO on day 0 or 1 to avoid immortal time bias.





* Exposure: Early administration of oseltamivir (HD 0 or 1)

* Comparison: Late administration of oseltamivir (HD 2 or later) or none.

* Outcome:



* Primary Outcome: Hospital length of stay (LOS)

* Secondary Outcomes: 7-day hospital readmission, late ICU transfer (on or after hospital day 2 after being admitted to general ward), composite outcome of in-hospital death or ECMO use.

Date: March 8, 2023

Reference: Smida et al. A Retrospective Nationwide Comparison of the iGel and King Laryngeal Tube Supraglottic Airways for Out-of-Hospital Cardiac Arrest Resuscitation. Prehospital Emergency Care 2023

Guest Skeptic: Dr. Chris Root is a third-year resident physician in the Department of Emergency Medicine at the University of New Mexico Health Sciences Center in Albuquerque, NM. He is also a flight physician with UNM’s air medical service, Lifeguard. He is a former New York City paramedic and this summer will be starting fellowship training in EMS medicine at UNM.

Case: A paramedic crew responds to a 54-year-old male in cardiac arrest at a private residence. A fire company is on scene providing high-quality cardiopulmonary resuscitation (CPR) and has defibrillated twice with an automated external defibrillator (AED). The fire-based crew has basic life support (BLS) airway supplies including the King Laryngeal Tube, the paramedic crew carries iGel supraglottic airways (SGAs) in addition to their intubation equipment. They plan to use a supraglottic airway as their initial airway strategy during the arrest, but they wonder if either of these two devices is superior.

Background: Airway management strategies for out of hospital cardiac arrest (OHCA) have been hotly debated since the dawn of CPR. Two large trials, PART by Wang et al and AIRWAYS-2 by Benger et al recently evaluated the King-LT and the iGel respectively as alternatives to endotracheal intubation (ETI) in cardiac arrest.

Given the difficulty associated with intra-arrest endotracheal intubation, use of supraglottic airways in the prehospital setting is becoming more common. This was discussed with paramedic and physician assistant (PA), Missy Carter when critically appraising the AIRWAYS-2 trial regarding the use of the iGel in OHCA on SGEM #247



Clinical Question: Which supraglottic airway is associated with better patient outcomes, the iGel or the King-LT in patients with an out-of-hospital cardiac arrest.



Reference: Smida et al. A Retrospective Nationwide Comparison of the iGel and King Laryngeal Tube Supraglottic Airways for Out-of-Hospital Cardiac Arrest Resuscitation. Prehospital Emergency Care 2023



* Population: Adult OHCA patients treated by EMS contained within the ESO database from 2018-2021 who received prehospital iGel or King-LT supraglottic airway insertion.



* Excluded: Patients who were less than 18 years of age, pregnant, had do not resuscitate or other physician orders for life sustaining treatment, achieved ROSC after bystander CPR only, or experienced OHCA due to trauma or hemorrhage were excluded from downstream analyses





* Exposure: iGel

* Comparison: King-LT

* Outcome:



* Primary Outcome: Survival to hospital discharge home

* Secondary Outcomes: First-pass success, return of spontaneous circulation (ROSC), prehospital rearrest, Intrarrest ETCO2 values





* Type of Study: Retrospective observational





Authors’ Conclusions: “In this dataset, use of the iGel during adult OHCA resuscitation was associated overall with better outcomes compared to use of the King-LT. Subgroup analyses suggested that use of the iGel was associated with greater odds of achieving the primary outcome than the King-LT when used as a rescue device but not when used as the primary airway management device.”



Quality Checklist for Observational Study:



Did the study address a clearly focused issue? Yes

Date: March 3, 2023

Reference: Hosseinialhashemi et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial. Ann Emerg Med. 2022

Guest Skeptic: Dr. Dominique Trudel is a CCFP-EM resident in Ottawa, Ontario. Her interest is serving French minority communities delivering care at the Montfort Hospital in Ottawa.

Case: Jim is a 50-year-old male who presents to the emergency department with anterior epistaxis. He reported it started last night in his bedroom where he used a space heater. He denies nose picking. He tried applying pressure, but it didn’t work. Vitals are stable and he is not on any anticoagulants.

Background: We have covered the topic of epistaxis several times on the SGEM. The first episode was SGEM#53: Sunday Bloody Sunday. This trial looked at 216 adult patients with anterior epistaxis and randomized them to topical TXA (500mg in 5ml) compared to anterior nasal packing. The results were impressive for stopping bleeding in 10min, discharge 2hrs, rebleeding 24hrs, and patient satisfaction. 





TXA is a synthetic derivative of lysine that inhibits fibrinolysis and thus stabilizes clots that are formed. It has been tried in several medical conditions and been reviewed on the SGEM. There is also a short YouTube video discussing the evidence for TXA.



* Trauma (CRASH-2): 1.5% absolute mortality benefit (SGEM#80)

* Isolated TBI (CRASH-3): No statistical difference in mortality (SGEM#270)

* Post-Partum Hemorrhage (WOMAN): No statistical difference in primary outcome (SGEM#214)

* Gastrointestinal Bleeding (HALT-It): No statistical difference in primary outcome (SGEM#301)

* Intracranial Hemorrhage (TICH-2 & ULTRA): No superiority for good neuro outcome (SGEM#236 and SGEM#322)





That first SGEM episode on using TXA for epistaxis showing favorable results also discussed eleven questions concerning epistaxis. It’s a good overview on the management of epistaxis. The episode included the Dundee protocol for adult epistaxis management from 2012.

A second RCT from the same group looked at TXA for adults with anterior epistaxis who were also taking antiplatelet medications. This too showed impressive results claiming superiority of TXA(SGEM#210).



When the NoPAC trial was published, it curbed some of the enthusiasm for TXA in epistaxis (SGEM#321). It was the largest double-blinded RCT (N=496), and found no reduction in the need for anterior packing with the use of intranasal TXA. However, this trial included patients who had already failed 10 min of pressure and 10 min of packing with a topical vasoconstrictor. They also used a lower dose of TXA in the noPAC study. Another issue was that 65% of the patients were taking anticoagulants. Lastly, the primary outcome was different than the previous two RCTs claiming efficacy.

Reference: Cashen K, Reeder RW, Ahmed T, et al. Sodium bicarbonate use during pediatric cardiopulmonary resuscitation: a secondary analysis of the icu-resuscitation project trial. Pediatric Crit Care Med. 2022

Date: February 15, 2023

Guest Skeptic: Dr. Carlie Myers is Pediatric Critical Care Attending at Cincinnati Children’s Hospital Medical Center.

Case: A 6-month-old boy presents to the emergency department (ED) with three days of worsening cough, cold symptoms, and fever. Parents note that he has been progressively more tired and difficult to arouse. He is found to be in hypoxic respiratory failure and septic shock. Intravenous (IV) access is obtained. He is quickly intubated. Despite multiple fluid boluses, he remains hypotensive and is started on vasoactive support. His blood gas reveals a mixed respiratory and metabolic acidosis with a lactate of 5.0. Despite your best efforts, he has an episode of agitation leading to hypoxia and subsequent cardiac arrest. Your team begins high quality cardiopulmonary resuscitation (CPR). An arterial blood gas is obtained demonstrates a pH of 7.0, PaCO2 of 70, PaO2 of 28, HCO3– of 7, Base Deficit of -10, and Lactate 10.0.

A team member asks if you want to administer some sodium bicarbonate (1mEq/kg).

Background: We often manage patients in cardiac arrest in the ED or the intensive care unit (ICU). Apart from high-quality CPR and early defibrillation, many other interventions we try lack a strong evidence base. But that does not stop us from trying to save the patient’s life and may represent some intervention bias.[1] The SGEM has covered the use of epinephrine, vasopressin, methylprednisolone, and calcium for cardiac arrest in SGEM#238, SGEM#350, and SGEM#353. Today we are focusing on sodium bicarbonate.

Sodium bicarbonate has historically been used during CPR with the goal of alkalizing blood pH and treating metabolic acidosis. There are a few key assumptions about the use of sodium bicarbonate. 



* Low pH decreases cardiac function and responsiveness to catecholamines.

* Sodium bicarbonate administration will increase the pH.

* The increase in pH will lead to improved responsiveness to catecholamines and cardiac function.



But it’s not that straightforward. Many of the studies supporting these claims were conducted on animal models or in vitro. [2] It is unclear if we see the same effects of acidosis and sodium bicarbonate in vivo.

HCO3– + H+ ↔ H2O + CO2

Rapid bicarbonate infusion can cause an imbalance in CO2 across the cell membrane. HCO3– + H+ converts to H2CO3 and then to CO2 +H20. Extracellular CO2 rises rapidly, it diffuses across cell membranes and the reverse reaction occurs H2O + CO2→ HCO3– + H+; therefore, creating intracellular acidosis.

There was a lack of evidence about the benefits and potential harm from using sodium bicarbonate in cardiac arrest [3], so it was removed from the American Heart Association’s (AHA) guidelines.

The latest guidelines from the AHA in 2020 state, “clinical trials and observational studies since the 2010 guidelines have yielded no new evidence that routine administration of sodium bicarbonate improves outcomes from undifferentiated cardiac arrest and evidence suggests that it may worsen survival and neurological recovery.” [4]

This association seems to hold true in the pediatric literature as well. [5-6]



Clinical Question: What is the association between sodium bicarbonate use and pediatric in-hospital cardiac arrest mortality and morbidity?

Date: February 17, 2023

Reference: Gettel et al. Rising high-acuity emergency care services independently billed by advanced practice providers, 2013 to 2019. AEM Feb 2023

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.

Case: You are an administrator responsible for staffing emergency departments (EDs) in a health care system comprising both urban and rural locales. The hiring pool includes emergency medicine trained physicians, non-emergency trained physicians, and advanced practice providers (physician assistants and nurse practitioners). Prior to your hiring search, you wonder how many patient encounters are being seen by each type of physician or advanced practice provider. You also wonder the breakdown of visit acuity being seen by the different provider types.

Background: Advanced practice providers (APPs), primarily physician assistants (PAs) and nurse practitioners (NPs), make up more of the emergency medicine (EM) workforce each year (1-4). While APPs have traditionally focused on low-acuity patient encounters, as ED visit volumes and physician shortages increase, APPs are seeing more complex, high-acuity patients (5-6).

In the United States, policies have been implemented to permit more independent APP practice, with or without direct physician support. This increase in independent service provision by APPs and change in practice pattern to more high-acuity patients has not been formally assessed (7-8).

There is concern regarding the expanding practice pattern of APPs, and a March 2022 Guideline by the American College of Emergency Physicians (ACEP) stated that PAs and NPs should not perform independent, unsupervised care in the ED setting (9). Given current workforce limitations, it is not feasible to continue current 24/7 staffing models in certain EDs and communities without APPs (1,3).

Similarly, many rural Canadian emergency departments have reduced their open hours or closed over recent years due to inadequate staffing (MacLean’s Magazine – Dr. Alan Drummond) There are both NPs and PAs working in Canadian EDs currently and we could see their role increase in the future should staffing shortages increase.

The SGEM has done two previous podcasts on APPs in the ED. These focused on productivity, safety and diagnostic testing differences between emergency physicians and APPs (SGEM#308 and SGEM#316).



Clinical Question: How has the role of APPs in the provision of emergency care changed in recent years?



Reference: Gettel et al. Rising high-acuity emergency care services independently billed by advanced practice providers, 2013 to 2019. AEM Feb 2023



* Population: Emergency care providers including emergency physicians, non-EM physicians and APPs (Physician assistants, nurse practitioners, certified nurse midwives, certified registered nurse anesthetists) who provided fee-for-service Medicare in the United States emergency departments from 2013 to 2019.



* Exclusion Criteria: Providers who received less than 50 total reimbursements within a study year for evaluation services refle...

Date: February 7, 2023

Reference: Cheskes et al. Defibrillation Strategies for Refractory Ventricular Fibrillation. NEJM 2022

Guest Skeptic: Dr. Sean Moore is an emergency physician working in Kenora Ontario, where he is Chief of Staff at Lake of the Woods District Hospital, Northern Medical Director for the Ornge air medical transport program and associate medical director with CritiCall Ontario.  Research interests include simulation-based assessment, transport medicine, and critical care analgesia.   He is an assistant professor at the Northern Ontario School of Medicine University and is passionate about health equity for rural and indigenous populations.  He has been an ACLS instructor for close to 30 years and notably his first publication focused on out-of-hospital defibrillation.



Case: A 60-year-old health professional suffers a cardiac arrest while working at a clinic outside the hospital.  An anesthetist is working with him for the procedures.  He confirms pulselessness, initiates CPR, gets a colleague to call 911, and intubates the patient on the floor. He is found to be in ventricular fibrillation and receives two defibrillation attempts with an automatic external defibrillator (AED) at the clinic, and subsequently three more with a primary care ambulance crew enroute to the hospital.  He arrives at the hospital 18 minutes into his arrest and his monitor shows persistent ventricular fibrillation.

Background: Out-of-hospital cardiac arrest (OHCA) is something we have covered extensively on the SGEM over the years. This has included things like therapeutic hypothermia (SGEM#54, SGEM#82, SGEM#183 and SGEM#275), supraglottic devices (SGEM#247), crowd sourcing CPR (SGEM#143 and SGEM#306), epinephrine (SGEM#238) and IO vs IV (SGEM#231 and SGEM#340).

One issue that has not been covered on the SGEM is pad placement and double sequential external defibrillation.



Clinical Question: Does refractory ventricular fibrillation respond better to standard defibrillation, vector-change defibrillation, or double sequential external defibrillation?



Reference: Cheskes et al. Defibrillation Strategies for Refractory Ventricular Fibrillation. NEJM 2022



* Population: Ontario patients who were at least 18 years of age and had an OHCA and refractory ventricular fibrillation.

* Intervention:



* Vector Change Defibrillation: Pads are placed in an anterior-posterior pad placement after standard anterior-anterior configuration following the third shock with standard defibrillation.

* Double Sequential External Defibrillation: Pads are placed in both the anterior-anterior and the anterior-posterior pad placements following the third shock with standard defibrillation.





* Comparison: Standard defibrillation with pads placed in anterior-anterior configuration

* Outcome:



* Primary Outcome: Survival to hospital discharge

* Secondary Outcomes: Termination of ventricular fibrillation,