85 episodes

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

The Skeptics Guide to Emergency Medicine Dr. Ken Milne

    • Education
    • 4.7 • 55 Ratings

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

    SGEM#390: I Can’t Feel My Face when I Have Bell Palsy, but will Steroids Help?

    SGEM#390: I Can’t Feel My Face when I Have Bell Palsy, but will Steroids Help?

    Reference: Babl et al. Efficacy of prednisolone for bell palsy in children: a randomized, double-blind, placebo-controlled, multicenter trial (BellPIC). Neurology 2022

    Date: January 3, 2023

    Guest Skeptic: Dr. Jennifer Harmon is an MD, Ph.D at Children’s National Hospital in Washington, DC. She is a board-certified pediatric neurologist and completing another fellowship in medical genetics.

    Case: A 9-year-old girl shows up at your emergency department (ED) with unilateral facial paralysis. Her parents noticed that one side of her face looked abnormal when she woke up in the morning. She has no other medical conditions and has not had any recent fevers, ear pain, or trauma. On exam, she is alert and active, but you note that the entire left side of her face does not move when you ask her to smile or raise her eyebrows. The remainder of her exam is unremarkable. You make a clinical diagnosis of Bell palsy, and the parents ask you, “Is there anything you can give her to help her recover faster?”

    Background: Bell palsy is a common cause of unilateral facial 7th nerve palsy in children. The differential diagnoses for this presentation can include trauma, otitis media, viral infections (herpes, varicella, CMV, EBV, etc), brain lesions or stroke, and acute leukemia. If the 7th nerve palsy is known to be caused by the herpes virus it is called Ramsay Hunt syndrome (herpes zoster oticus) [1].

    It is important to perform a careful history and physical before ultimately arriving at the diagnosis of Bell palsy. While many children spontaneously recover, the clinical manifestations of Bell palsy may significantly impact a child functionally and emotionally. 

    There have been studies in adults regarding the treatment of Bell palsy that have demonstrated that treatment with corticosteroids provide significant benefit (NNT 10) [2].  The SGEM covered the use of steroids and antivirals for Bell Palsy in SGEM#14. Unfortunately, the data for the use of steroids in treatment of pediatric Bell Palsy is still lacking [3].



    Clinical Question: Does prednisolone improve the proportion of children with Bell palsy with complete recovery at one month? 



    Reference: Babl et al. Efficacy of prednisolone for bell palsy in children: a randomized, double-blind, placebo-controlled, multicenter trial (BellPIC). Neurology 2022



    Population: Children 6 months to 18 years presenting to multiple emergency departments in Australia with Bell Palsy diagnosed by a senior clinician with onset of symptoms less than 72 hours prior to evaluation.



    Excluded: There were a lot of exclusion criteria that we will list in the show notes.



    Contraindication to prednisolone (active/latent tuberculosis, systemic fungal infection, hypersensitivity, diminished cardiac function, diabetes mellitus, peptic ulcer disease, chronic renal failure, multiple sclerosis, recent active herpes zoster or chickenpox)

    Use of any systemic or inhaled steroid within 2 weeks prior to onset of symptoms

    Current or past oncological diagnosis

    Pregnant or breastfeeding

    Receiving concomitant medications in which prednisolone is contraindicated

    Immunization with a live vaccine within previous one month

    Requirement for live vaccine within 6 weeks of first dose of study drug

    Signs of upper motor VII nerve weakness

    Acute otitis media concurrently or within 1 week prior to onset of symptoms

    Vesicles at ear suggestive of Ramsay-Hunt syndrome

    Known facial trauma within 1 week prior to symptom onset

    Any other condition at risk of being influence by the study treatment or might ...

    • 18 min
    SGEM#389: Does Dex, Dex, Dex, Dexamethasone Help with Renal Colic?

    SGEM#389: Does Dex, Dex, Dex, Dexamethasone Help with Renal Colic?

    Date: January 13, 2023

    Reference: Razi et al. Dexamethasone and ketorolac compare with ketorolac alone in acute renal colic: A randomized clinical trial. AJEM 2022

    Guest Skeptic: Dr. Kevan Sternberg is a urologist/endourologist. His focus is on the medical and surgical management of kidney stone disease. Dr. Sternberg did his medical school and residency training at the University of Buffalo (SUNY) and endourology fellowship at the University of Pittsburgh Medical Center.

    Kevan was on the SGEM Xtra episode three years ago that brought together Emergency Medicine, Radiologists and Urologists to discuss ultrasound vs CT scans for suspected renal colic. You can listen to the SGEM podcast to hear what he thinks the impact of this initiative has been.

    Case: A 38-year-old female presents to the emergency department (ED) with a five-hour history of acute onset left flank pain.  The pain comes in waves, radiates into her left groin and is associated with nausea and vomiting.  She noticed darkening of her urine, but does not have dysuria, fever, or vaginal discharge.

    Background: We have looked at many different therapies to treat renal colic on the SGEM. That has included things like fluid bolus or diuretics (SGEM#32), tamsulosin (SGEM#4, #71, #154, #230), acupuncture (SGEM#220) and lidocaine (SGEM#202).

    The SGEM bottom line to these different treatment options:



    * You don’t need to push fluids (oral/IV) or use diuretics to pass kidney stones.

    * Medical expulsive therapy with tamsulosin is unnecessary for stones 5 mm.

    * Acupuncture is not superior to morphine for renal colic.

    * The evidence doesn’t support the use of lidocaine for renal colic.



    Glucocorticoids (steroids) act as anti-inflammatories, immunosuppressants, antiproliferative drugs, and have vasoconstrictive effects. It has been hypothesized that adding a long-acting glucocorticoid like dexamethasone may help with pain and vomiting associated with passing a kidney stone and decrease opioid use.



    Clinical Question: Should we be adding a dexamethasone to NSAIDs for the management of suspected acute renal colic?



    Reference: Razi et al. Dexamethasone and ketorolac compare with ketorolac alone in acute renal colic: A randomized clinical trial. AJEM 2022



    * Population: Patients presenting to the ED with flank pain and presumed renal colic



    * Exclusions: Pregnancy (confirmed or possible), analgesic therapy during six hours before admitted to the emergency unit, near history of hemorrhagic diathesis, addiction or recent methadone use, use of warfarin and other anticoagulants, acute abdomen, fever, BP ≥ 180/100 mmHg; any contra- indication for ketorolac including hypersensitivity to aspirin or other NSAIDs, active or history of peptic ulcer disease, a recent history of GI bleeding or perforation or suspected or confirmed cerebrovascular bleeding, advanced hepatic or renal disease, patients at risk for renal failure, hyperkalemia,

    • 25 min
    SGEM#388: It Makes No Difference Now- Calcium Channel Blocker or Beta Blocker for Atrial Fibrillation with Rapid Ventricular Response & Heart Failure with Reduced Ejection Fraction

    SGEM#388: It Makes No Difference Now- Calcium Channel Blocker or Beta Blocker for Atrial Fibrillation with Rapid Ventricular Response & Heart Failure with Reduced Ejection Fraction

    Date: January 4th, 2023

    Reference: Hasbrouck et al. Acute management of atrial fibrillation in congestive heart failure with reduced ejection fraction in the emergency department. AJEM 2022

    Guest Skeptics: Dr. Timlin Glaser currently a fourth-year resident in emergency medicine at Lehigh Valley Health Network and future medical toxicology fellow at the University of Arizona College of Medicine – Phoenix.

    Dr. Matt Murphy is currently a third-year resident in emergency medicine at Lehigh Valley Health Network.  He has interests in FOAMEd and is currently following the EBM track in his residency. Welcome to the SGEM Matt.

    This episode is recorded live as an SGEM journal club. There are five rules to journal club



    1) You Must Talk/Tweet about SGEM-JC: The SGEM is a knowledge translation project. We know that it can take over ten years for high-quality, clinically relevant information to reach the patient. As Sir Mark Walport famously said: “science is not finished until it’s communicated.”



    2) The EBM Answer Is “It All Depends”: This rule was learned this from my EBM mentor Dr. Andrew Worster. There are lots of nuances to the application of the literature. It requires critical appraisal skills, clinical judgment and asking the patient about their values and preferences.



    3) Don’t Panic – Even Your Faculty Is Not Sure of Some of the Answers: It is hard to stay up on all the relevant medical literature. There is a tsunami of new information being published every day. It can be overwhelming at times. Don’t panic. As Professor Feynman said…It’s ok to say: “I don’t know”.



    4) It’s All About the Methods: The method section is the most important section of the paper. We just said there is so much research being published every day. It can be like drinking from a fire hose making it difficult to find the signal in all the noise. As Professor Altman said in the BMJ back in 1994; “we need less research, better research and research done for the right reasons.” This means we need to be asking the right questions that have patient-oriented outcomes and use proper high-quality methods to answer those questions.



    5) Be Skeptical of Anything you Learn, Even If You Heard It On the SGEM Journal Club: Skepticism is such an important concept to understand the medical literature and navigate through life. Aristotle advocated for this thousands of years ago and encouraged people to “be a free thinker and don’t accept everything you hear as truth. Be critical and evaluate what you believe in.”



    Case: A 62-year-old male with a past medical history of heart failure with reduced ejection fraction presents to your emergency department (ED) via ambulance for palpitations and shortness of breath that started earlier that day. He arrives with an irregular heart rate of 142 beats per minute (bpm). The remainder of his vital signs are unremarkable. On physical exam, you notice three plus pitting edema of both lower extremities and bibasilar rales when auscultating his lungs. He takes multiple medications at home, including a beta-blocker, an angiotensin converting enzyme inhibitor (ACEi), and a loop diuretic.  You order an ECG and confirm the patient has atrial fibrillation (AF) with rapid ventricular response (RVR).  The patient is very symptomatic, and you need to decide which pharmacologic agent you will use to treat his current condition.

    Background: Atrial fibrillation is a common dysrhythmia seen on a regular basis by emergency physicians. We have covered this topic several times on the SGEM including:



    * SGEM#88: Shock Through the Heart (Ottawa Aggressive Atrial Fibrillation Protocol)

    • 29 min
    SGEM #387 Lumbar Punctures in Febrile Infants with Positive Urinalysis-It’s Just Overkill

    SGEM #387 Lumbar Punctures in Febrile Infants with Positive Urinalysis-It’s Just Overkill

    Date: Dec 15, 2022

    Reference: Mahajan et al. Serious bacterial infections in young febrile infants with positive urinalysis results. Pediatrics. October 2022

    Guest Skeptic: Dr. Brian Lee is a pediatric emergency medicine attending at the Children’s Hospital of Philadelphia and Assistant Professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania.

    Guest Authors:

    Dr. Prashant Mahajan is a Professor of Emergency Medicine and Pediatrics at the University of Michigan Department of Emergency Medicine in Ann Arbor, Michigan. He is the Vice-Chair for the Department of Emergency medicine and Section chief for Pediatric Emergency Medicine in CS Mott Children’s Hospital. Currently, he is the founding chair of Emergency Medicine Education and Research by Global Experts (EMERGE), a global emergency research network across 17 countries and 23 emergency departments.

    Dr. Nathan Kuppermann is a Distinguished Professor of Emergency Medicine and Pediatrics, and the Bo Tomas Brofeldt Endowed Chair of the Department of Emergency Medicine at UC Davis and Associate Dean for Global Health at UC Davis Health. He chaired the first US research network in Pediatric Emergency Medicine (the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics) then became founding chair of the Pediatric Emergency Care Applied Research Network (PECARN). He also recently completed a term as Chair of the Executive Committee of the global Pediatric Emergency Research Network (PERN).

    Both of our guests have received federal funding for their research and played huge roles in establishing multicenter research networks dedicated to improving the care of children across the world.

    Case: A 6-week-old girl is brought into the emergency department (ED) for fever of 38.5°C that started four hours prior to presentation. Her parents noted that she has been fussier today and has had feeding a little less than normal, but she’s had no other symptoms. She is otherwise healthy, full-term female who had no pre- or postnatal complications. On exam she is well-appearing, and there are no focal signs of infection. You decide to start by obtaining blood and catheterized urine for testing.

    The urinalysis shows 15 WBCs, 2+ leukocyte esterase and positive nitrites. While waiting for the results of the blood tests, you tell the family the news that their child likely has a urinary tract infection. The family asks you, “does this mean we found the source of her fever? Our son also had a fever when he was very young, and he had to get a lumbar puncture? Do we need to do a lumbar puncture for her today?”

    Background: Febrile infants ≤ 60 days are at higher risk for serious bacterial infections (SBI) including urinary tract infections (UTI), bacteremia, and meningitis. While UTIs tend to be the most common, we really do not want to miss those infants with bacteremia and meningitis, termed invasive bacterial infections (IBI).

    Multiple groups have worked to risk stratify these infants and have listed positive urinalysis as a risk factor for IBI. The SGEM covered the Step-by-Step Approach on SGEM #171 and PECARN Clinical Prediction Rule for Low Risk Febrile Infants on SGEM #296. Recently, the American Academy of Pediatrics (AAP) published guidelines for the management of febrile infants 8-60 days old covered in SGEM #241.

    • 35 min
    SGEM Xtra: Holding Out for a Hero – Lessons from The Dark Knight

    SGEM Xtra: Holding Out for a Hero – Lessons from The Dark Knight

    Date: December 11th, 2022

    Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine physician at Children’s National in Washington, DC. You may also know him as the host of this season’s SGEM Peds.

    This is an SGEM Xtra for the holidays. We have done previous shows on what we have learned from Star Trek and Top Gun. It is hard to believe that we have not done an SGEM Xtra about what Batman has taught us about medicine and life.

    The release of Season#9 of the SGEM as a PDF book seemed like an excellent opportunity to discuss Batman. This is because the book has a DC comic theme.  Some people might find that a bit dark. However, this edition arrives at a time of uncertainty. We have been navigating our way through a pandemic, understaffing, emergency department closures, boarding crises, astronomical wait times sometimes barely keep our heads above water and struggling to do everything we can to care for the patients who depend on us.

    Despite the challenges we face, I hope the SGEM has been a beacon in the darkness, a bat signal, to remind us that the application of the principles of evidence-based medicine is more important than ever. We discussed this early in the pandemic with Dr. Simon Carley from St. Emlyn’s.



    Before we start talking nerdy about Batman, I think it is important we give a shout out to Dr. Tayler Young. She is a first year Family Medicine resident at Queen’s University. Her interests are quality improvement and Free Open Access to Medical Education (FOAMed). Tayler did Season#8 book with an Avengers theme.

    SGEM Season#9 contains the an introduction by Dr. Chris Carpenter. He takes us back to 1934 and the start of DC comics. Batman first appears in 1939. The first page for each chapter has the clinical question, the SGEM bottom line and introduces the guest skeptic. Next comes the case presentation and some background material. This is followed by the PICO with each letter looking like the superman symbol. Each episode has the authors’ conclusions and the appropriate quality checklist to probe the study for its validity. The key results are listed. The Talk Nerdy To Me section has a Green Lantern theme. This is followed by the clinical application, what do I tell the patients and a case resolution section. Each chapter ends with any other FOAMed resources, twitter poll results and the Paper in a Picture infographic by  Kirsty Challen

    You can listen to the SGEM podcast and hear Tayler discuss the layout of SGEM Season#9.  You can also download all the previous SGEM books clicking on this LINK.



    Batman and How it Relates to Medicine and Life



    We discuss eleven ways that Batman relates to emergency medicine and life. You can listen to the entire discussion on the SGEM podcast available on iTunes.

    1. Emergency Medicine is Batman

    • 29 min
    SGEM386: Blood on Blood – Massive Transfusion Protocols in Older Trauma Patients

    SGEM386: Blood on Blood – Massive Transfusion Protocols in Older Trauma Patients

    Date: December 16th, 2022

    Reference: Hohle et al. Massive Blood Transfusion Following Older Adult Trauma: the Effect of Blood Ratios on Mortality. AEM December 2022

    Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals. She is also the wonderful educator that creates the Paper in a Pic infographics summarizing each SGEM episode.

    Case: A 71-year-old man is brought to your emergency department (ED) by emergency medical serviced (EMS) having fallen two steps at home. EMS have already splinted an obvious mid-shaft femoral fracture, but he continues to be tachycardic and hypotensive. After a bedside ultrasound shows fluid in the right hemithorax, you insert an intercostal drain which immediately fills with one litre of blood. Noting with some relief that at least he isn’t anticoagulated, you activate the hospital massive transfusion protocol. The transfusion tech calls to remind you that your protocol is currently under review, and asks if would you like the 1:1 or the 1:3 version of fresh-frozen plasma (FFP) to packed red blood cells (pRBC)?

    Background: Major trauma in older patients is increasing in frequency (1), with the median age of major trauma patients in the UK from 2012-2017 being 63.6 years (2). Falling is the most common cause of traumatic injury resulting in older adults presenting to the ED [4]. Approximately 20% of falls result in injuries, and falls are the leading cause of traumatic mortality in this age group [5,6,7].

    Over the last few years there has been increasing concern that the practice of transfusing only PRBC might worsen traumatic coagulopathy. Although a number of trials have attempted to find optimal ratios for transfusion components and the Eastern Association for the Surgery of Trauma practice guidelines suggest a “high” ratio, little of the literature has addressed how this might be applied in an older population.

    We looked at the PROPPR trial on SGEM#109 when it came out in 2015 and concluded then that a 1:1:1 transfusion strategy was a reasonable approach to massive transfusion and that it seemed to achieve more hemostasis and less death from exsanguination at 24 hours.

    We’ve also looked at trauma in older patients in SGEM#324 (we don’t yet want to use spirometry to aid discharge decisions in patients with rib fractures), SGEM#212 (increasing age, more rib fractures, more underlying disease and poor oxygenation are risk factors for poor outcome in older patients with chest trauma) and in SGEM#89 in 2014 when we first concluded that identifying older patients at risk of falls is really tricky.

    • 33 min

Customer Reviews

4.7 out of 5
55 Ratings

55 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.

Gorsh ,

Political

I am here to learn about emergency medicine....not to be preached to about race relaions...ughhh.

JGC Photos ,

Very informative

Very informative and Dr. Milne is very knowledgable.

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