The Skeptics Guide to Emergency Medicine

Dr. Brooks Walsh, an emergency physician and former paramedic, delves into the complex topic of excited delirium, revealing its historical roots dating back nearly 200 years. He critiques the term's racial biases and calls for a re-evaluation of its application in emergency medicine. Walsh emphasizes the need for diversity in decision-making to improve patient outcomes and discusses the challenges in translating research into practice. He advocates for better communication strategies in high-stress situations, aiming to foster equity in medical care.

Date: April 26, 2023 Reference: Han et al. The effect of telemental versus in-person mental health consults in the emergency department on 30-day utilization and processes of care. AEM April 2023 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 moonlighting at the Veterans Administration emergency department (ED) and are caring for an Iraq veteran complaining of post-traumatic stress disorder (PTSD) and severe anxiety. You desire a psychiatric consult and learn that you don’t have in-person consult availability at this facility, but instead use telehealth services. You wonder about how this compares to an in-person consult. Background: Mental health and behavioral complaints are common in the ED, but a shortage of mental health providers results in high numbers of patients requiring transfer, some of whom may have been appropriate for discharge. Telemental health (TMH) has been shown in settings outside the Veterans Administration (VA) to increase access to mental health providers, increase the proportion of patients discharged home, and decrease the number of patients transferred. However, what’s not well studied is the effect of TMH on post-evaluation utilization and processes of care such as medication changes, disposition, length of stay, involuntary holds, and use of chemical or physical restraints. Clinical Question: What is the effect of TMH, versus in-person consult, on 30-day outcomes and processes of care during the visit? Reference: Han et al. The effect of telemental versus in-person mental health consults in the emergency department on 30-day utilization and processes of care. AEM April 2023 Population: Veterans presenting to VA medical center (VAMC) EDs and urgent care centers (UCC) Intervention: Telemental health consult administered via iPad and Apple FaceTime software Comparison: In-person mental health consultation Outcome: Primary Outcome: Composite of 30- day return ED visits, 30-day return hospitalization after the index ED visit, and death from any cause. Secondary Outcomes: Number of medications changed, disposition, length of stay, involuntary hold, use of parenteral benzodiazepines or haloperidol, and use of physical restraints or seclusion Type of Study: Exploratory retrospective cohort study Dr. Jin Han This is an SGEMHOP episode which means we have the lead author on the show.  Dr. Jin Han is an emergency physician with Vanderbilt University Medical Center in Nashville TN, and a researcher with the Geriatric Research, Education, and Clinical Center at the Tennessee Valley VA Healthcare System. Authors’ Conclusions: “TMH was not significantly associated with the 30-day composite outcome of return ED/UCC visits, rehospitalizations, and death compared with traditional in-person mental health evaluations. TMH was significantly associated with increased ED/UCC length of stay and decreased odds of placing an involuntary psychiatric hold. Future studies are required to confirm these findings and, if confirmed, explore the potential mechanisms for these associations.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results/is the estimate of risk? Fairly narrow CIs Do you believe the results? Yes Can the results be applied to the local population? No Do the results of this study fit with other available evidence? Yes Funding/COI: Grant from the Office of Rural Health of the Veterans Health Administration and National Center for Advancing Translational Sciences. There were no declared COIs. Results: They identified 496 veterans that met inclusion criteria. The mean age was 55, almost 90% were male and 27% were rural. High-risk chief complaint (suicidal ideation, homicidal ideation, agitation, or psychosis) was 29%. Of the cohort, 70% received TMH and 30% received in-person mental health evaluations.  Key Results: No statistical difference in the primary outcome between TMH and in-person mental health evaluation. Primary Outcome: Composite 30-day return visits, rehospitalizations, deaths 4% TMH vs 17.3% In-Person: aOR 1.47 (95% CI; 0.87 to 2.49) Listen to the SGEM podcast to hear Jin answer our five nerdy questions. 1. External Validity: As with most VA studies, the cohort consisted mostly of middle-aged men. How much do you think this limits the external validity to other populations outside of the VA? 2. Baseline Demographics: There were several demographic differences between patients who received TMH and those who received an in-person consult. Do you have any thoughts as to why that occurred? 3. Primary Outcome: Your primary outcome is a composite outcome, but you separated out the individual components for the exploratory outcomes. Can you explain why you used the composite for your primary? 4. Lost to Follow-Up: We could not find mention of patients being lost to follow up, which could introduce bias if 30-day outcomes aren’t accurate. Were there any patients lost to follow up? 5. Length of Stay: The results show longer length of stays and decreased use of involuntary holds in the telemental health group. Why do you think that occurred? Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusions but are concerned about the external validity of the findings. SGEM Bottom Line: Telemental health consults did not significantly change the primary outcome but did have some interesting process differences when compared with in-person consults in the American Veteran’s Administration system. Case Resolution: You connect to a TMH provider who assesses your patient, makes some medication changes, and discharges the patient home to follow up within a week. Dr. Corey Heitz Clinical Application: Telemental health may serve as a good option for mental health consultation when in-person evaluation isn’t available. What Do I Tell the Patient? “I’m going to set you up for a mental health evaluation. You’ll talk to a provider, but they won’t be here in the building. Instead, we’re going to use a videoconferencing app.” Keener Kontest: Last weeks’ winner was Dr. Kay Dingwell from PEI. She knew T’Pau was the name of the respected Vulcan leader in Star Trek the Original Series episode called Amok Time. Listen to the podcast to hear this weeks' question. If you think you know the answer, send an email to TheSGEM@gmail.com with “Keener” in the subject line. The first correct answer will receive a cool skeptical prize. SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on telemental health? What questions do you have for Jin and this team? Tweet your comments using #SGEMHOP or post your feedback on the SGEM blog. The best social media feedback will be published in AEM.   Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Dr. Michael Falk, a Pediatric Emergency Medicine expert from Mount Sinai, dives into the nuances of oxygen therapy for kids with respiratory failure. He discusses a clinical trial comparing high-flow nasal cannula to standard oxygen, revealing that high-flow didn’t significantly reduce hospital stays. Insights on potential biases in treatment decisions and challenges with pulse oximetry readings are also highlighted. Falk emphasizes the need for evidence-based practices and tailored approaches to improve outcomes in pediatric care.

Dr. Susanne DeMeester, an Emergency Physician and cardiovascular section editor, delves into the critical issues surrounding women's heart health in sports. She discusses the alarming incidence of sudden cardiac arrest among female athletes and highlights gaps in research and representation. The conversation emphasizes unique risk factors like estrogen influence and the prevalence of conditions like Takotsubo syndrome. Dr. DeMeester calls for targeted cardiovascular screening and enhanced awareness to better protect women in high-intensity sports.

Date: April 4th, 2023 Reference: Vaughan and Browne. Reconfiguring emergency and acute services: time to pause and reflect. BMJ Qual Saf. 2023 Apr Guest Skeptics: Dr. Louella Vaugh is an internist practising as a hospitalist physician at an academic centre in London, UK with a special interest in smaller, rural and remote healthcare. Her main job is working for a think tank. John Brown PhD is a Professor of Health Services Research in Ireland who has been studying rural healthcare issues since 2012. This is an SGEM Xtra episode. There have been many “temporary” rural emergency department closures during the past last year. In Ontario alone there have been approximately 160 emergency departments (ED) temporarily closed since the beginning of 2022. This is something that has only happened once since 2006 (Ottawa Citizen March 28, 2023) The study referred to in the editorial looks at the experience in Denmark with a reconfiguration of their emergency healthcare services (Flojstrup et al 2023). The objective of that study was the following: To investigate how the’ natural experiment’ of reconfiguring the emergency healthcare system in Denmark affected in-hospital and 30-day mortality on a national level. The reconfiguration included the centralisation of hospitals and the establishment of emergency departments with specialists present around the clock. It was a stepped-wedge reconfiguration of the entire Danish emergency healthcare system. The main outcome was the adjusted odds ratio for in-hospital mortality and hazard ratio for 30-day mortality with some pre-specified subgroups. They found no statistical difference for in-hospital mortality but slightly increased 30-day mortality. The pre-specified subgroup analyses showed a decrease in in-hospital or 30-day mortality for myocardial infarction, stroke, aortic aneurysm, and major trauma but not for pneumonia, bowel perforation or hip fractures. This was not the only study to come out of the Danish reconfiguration initiative. The dataset also reported increasing admissions, mixed results on length of stay, increasing readmission rates, increasing COPD deaths if transported by ambulance, and expected productivity benefits were not realized. The SGEM advocated for having the evidence to inform/guide our decisions. Here is what the evidence say about the centralization of emergency healthcare services from the Danish study: some possible benefits for small groups of patients (myocardial infarction, stroke, aortic aneurysm, major trauma), there was no overall improvement in the in-hospital mortality trend and a slight worsening of the 30-day mortality trend. Five Assumptions Made about Emergency Healthcare Centralization Listen to the SGEM podcast to hear Louella and John discuss the five assumptions. Listed are the assumptions and some of the points we touched upon. Assumption#1: There is a problem with the quality of EM care that needs to be fixed Boarded patients length of stay (LOS) in the ED increases mortality Canary in the coal mine (fix the mine not the canary) COVID19 and staffing It’s about a system problem not a small hospital problem Assumption#2: Smaller hospitals provide worse care than their larger counterparts Myocardial infarction, stroke, and major trauma account for 1% of ED attendance Other skilled time-sensitive interventions (abdominal, vascular, obstetrical, and intracranial surgeries) still only amount to a total of 5% of ED attendance Little or no evidence that care in small hospitals is worse for 95% of cases Assumption#3: Reconfiguration produces better outcomes While studies of centralisation of care for individual services show better outcomes for specific patient groups, the population-level evidence for whole-scale reconfiguration through changes to ED services tells a different story. Two European studies and several studies in the USA. Renee Hsia has been looking at the impact of rounds of closures in California for nearly 20 years. At least 2 other national studies were conducted in the USA. There is also good evidence relating to the impact of service closure especially on maternity services Other studies have demonstrated that hospital closures affect socioeconomic, geographical and ethnic groups differently, with the burden of closures falling most heavily on the more vulnerable Assumption#4: Remaining organizations are minimally affected by reconfiguration Evidence suggests that the remaining hospitals often suffer from substantial negative ‘spillover effects’, with overall mortality actually rising for their emergency patients ED overcrowding with consequent increases in waiting times on trollies, increases in the pressures on ambulances services (time on the road, incidents and various other forms of ‘operational strain’. The biggest problems currently facing acute and emergency services internationally are rising admissions and overcrowding; These studies strongly suggest that removing any capacity from an already overstretched system is likely to do harm. Assumption#5: Reconfiguration has other benefits and no unintended consequences Qualitative studies strongly suggest that facility closures and mergers produce permanent losses to the workforce—both to the region, as skilled workforce members move away, and permanently, as workers either retire early or seek other work The closure or downgrading of EDs in small hospitals tends to be accompanied by the removal of other ‘front door’ services, such as general medicine, general surgery and obstetrics, as well as therapy and support services. (geographical ‘deserts of care’ These predominantly impact the older and poorer patients who live in rural and peripheral communities, urban areas are not wholly immune, with burden again falling disproportionately on the most vulnerable. Health facilities are important to community identity, and their removal can lead to hidden psychological and social costs beyond the pragmatic concerns about poorer access to healthcare Rural Mailbox   Keener Contest: Last weeks’ winner was Dave Michaleson a PA. He knew the longest time a human has remained awake is 264 hours. This is not a contest and we do not want anyone to try to break this record. There is no keener contest question this week. The SGEM will be back next episode doing a structured critical appraisal of a recent publication with a keener question. We will continue to try and cut the knowledge translation window down from over ten years to less than one year using the power of social media. So, patients get the best care, based upon the best evidence. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

In this discussion, Dr. Justin Morgenstern, an emergency physician and creator of First10EM.com, joins Lauren Fowler, a neuroscience professor focusing on fatigue, and Dr. Emily Hirsh, an associate professor dedicated to faculty wellbeing. They dive into the critical issue of fatigue in emergency medicine, revealing its ties to shift work and how it impairs performance and patient care. Insights into managing burnout, recent research findings on fatigue assessment, and the importance of systemic changes highlight the necessity for a healthier work environment in this demanding field.

Dr. Casey Parker, a Rural Generalist specializing in emergency medicine and ultrasound, shares insights from his work between remote and urban hospitals in Australia. He discusses the effectiveness of point-of-care ultrasound (POCUS) in diagnosing biliary diseases, revealing its advantages over traditional methods. The real clinical case of a woman with abdominal pain highlights the importance of ultrasound training in emergency settings. Casey emphasizes the impact on surgical decision-making and the need for better research methods to enhance diagnostic accuracy.

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. Dr. Marisu Rueda-Altez 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 <18 year from Pediatric Health Information System (PHIS) database hospitalized with Influenza from 2007-2020. Excluded: Transfers to other hospitals, repeated encounters (if >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. Authors’ Conclusions: "Early use of oseltamivir is associated with shorter hospital stay and lower odds of 7-day readmission, ICU transfer, ECMO use and death." Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Unsure. Was the cohort recruited in an acceptable way? Unsure Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Unsure How precise are the results? Unsure Do you believe the results? Yes Can the results be applied to the local population? Yes Do the results of this study fit with other available evidence? Yes Funding of the Study: None Results: There were 55,799 patients were included, who were diagnosed with influenza by ICD 9/10 coding. Of those, 56% were male, and mean age was 3.6 years. 33,207 (59.5%) received early oseltamivir. 4,098 (7%) received oseltamivir on day 2 or later, and 18,494 (33%) were untreated. Key Result: Children treated with early oseltamivir was associated with a shorter length of stays and lower odds of 7-day readmission, late ICU transfer, ECMO use, and death. Primary Outcome Length of Stay Secondary Outcomes The Diagnosis of Influenza: The diagnosis of influenza for this study was determined by review of ICD-9 and 10 codes. The authors do cite previous research that administrative databases have high specificity (99%) and positive predictive value (60-88%) for laboratory-confirmed influenza, these two studies only looked at records from one or three institutions respectively. [5-6] The data set used in this study is significantly larger and encompasses 36 hospitals where there may be much more variation in diagnosis and coding. The gold standard for diagnosis of influenza infection is a positive nasopharyngeal PCR test. Patients could have been missed if positive and not coded as such. Also, patients who were not tested but had symptoms suggestive of influenza could have been coded as having influenza. Using ICD codes is an imperfect gold standard or copper standard. There is also possible confusion from lingering positivity of respiratory viral PCR testing as well. There was a study showed that influenza can remained positive for at least a week after symptom onset. [7] If a patient who had influenza a week ago presents now with new respiratory distress, still influenza positive, but now had a bacterial superinfection with S. pneumoniae or S. aureus. Those patients would not benefit from oseltamivir, but may still have erroneously have been coded as influenza positive, and included in the study. Duration of Illness and Timing of Oseltamivir: We had mentioned a big limitation of the PHIS database before on SGEM #384 was that it lacks clinical information. With influenza, the recommendations state that the greatest benefit in the administration of antivirals is within the first 48 hours of symptoms. However, there may still be some benefit in hospitalized patients after that period. There’s a possibility that a portion of the providers that did not treat those 33% of patients with oseltamivir may have been influenced by the duration of illness prior to presentation. Not only do we not know when the illness started, but we also don’t know when the child got started on oseltamivir prior to their presentation at the hospital. This may be the reason for why they did not receive it again during the admission. This also raises the possibility that there was a portion of patients were classified into the “early oseltamivir” group inappropriately. Exclusion due to Immortal Time Bias: The authors chose to exclude encounters with discharge, in-hospital death, or ECMO use on hospital day 0 or 1 due to immortal time bias (there is a period of time before researchers are able to classify participants as being treated). This excluded 13,641(19.2%) of eligible patients. Given the limitations mentioned prior, another interpretation of this is that there were potentially 13,641 patients for which oseltamivir had no impact on their hospital length of stay, death or ECMO. Adverse Effects: Another thing missing from this study is that it did not report any adverse effects from oseltamivir administration. The Cochrane review from 2014 that included clinical study reports from drug manufacturers demonstrated that the use of oseltamivir increases risk of nausea, vomiting (NNH of 19 in children), and psychiatric effects. Adverse effects are important when weighing the potential risks and benefits of any treatment or intervention. Future Research: The authors write “it would likely be unethical to perform a RCT of oseltamivir given the current recommendations, so observational studies such as this one are the most practical way to evaluate its use.” Observational trials allow us to establish associations and can only control for known confounding factors. I think it is fair to say that the evidence for oseltamivir is mixed at best and still very limited in the pediatric population. We should not shy away from questioning clinical guidelines or standards of care. This is important for driving progress and striving to provide the best care for our patients based on the best evidence. I do not find the idea of a randomized controlled trial unethical and would love to see a multi-center, placebo-controlled, blinded randomized controlled trial to assess the effectiveness of oseltamivir in the pediatric population. Comment on Authors’ Conclusion Compared to SGEM Conclusion: Early oseltamivir use in hospitalized children with influenza may be associated with shorter hospital LOS, and lower odds of 7-day readmission, ICU transfers, ECMO use and death but these findings should be interpreted within the limitations of study. SGEM Bottom Line: We do not have high-quality evidence to support the routine use of oseltamivir in the treatment of children admitted to hospital with suspected influenza. Case Resolution: You tell the parents that there is an option to start their child on a medication called oseltamivir.

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 Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Unsure Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? No How precise are the results? Adequately Precise Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Funding of the Study: No external funding sources Results: The assessed 286,192 OHCA cases for eligibility and were able to include 93,866 patients treated by 1,613 EMS agencies. iGels were inserted in 54,189 (58%) cases, and King- LTs were inserted in 39,677 (42%) cases. The average age of patients in this dataset was 63 years and 37% were female. Just over half (52%) of the 93,866 patients were transported to an emergency department. Of those transported to hospital (49,302), only 19% (9,456) had available disposition data. This means we have data on 10% of the original 93,866 patients. Among the 10% of patients that disposition data was available: 7% were discharged to home or self-care 84% died after arrival at a hospital 4% were discharged to hospice 3% were discharged to skilled nursing 7% were discharged to long-term acute care Key Result: No statistical difference in discharge home between the two devices when a supraglottic airway was employed as the initial airway management strategy. Primary Outcome: Survival to hospital discharge home Overall: adjusted Odds Ratio (aOR) 1.36 [95% CI; 1.06 to 1.76] Primary Strategy: aOR 1.26 [95% CI;0.95 to 1.68] Rescue Strategy: aOR 2.16 [95% CI; 1.15 to 4.04]) Secondary Outcomes: Use of the iGel was associated with higher first pass success with device placement, higher rates of prehospital ROSC, higher intra-arrest ETCO2 values, and lower rates of re-arrest. 1. Retrospective Data Set: This was a retrospective analysis. When retrospective data is used to answer clinical questions there is less ability to control for confounding factors than in a prospective study.  The authors attempted to control for compounding factors through their propensity scoring however any retrospective study must be interpreted cautiously. These statistical tools cannot achieve the same rigor as a properly conducted randomized control trial. 2. Discharge Home: The authors utilized discharge home as their primary outcome. This is a pragmatic choice based on the available dataset. However, it is probably not the most patient-oriented outcome (POO). Having a good neurologic outcome is likely to be more important to patients than merely surviving with a severe disability. This dataset does not provide this important information. 3. ESO Data Collaborative: The dataset comes from a software vendor of over 2,000 EMS agencies in the US. That may sound like a lot but there are over 18,000 EMS agencies in the US (EMS World 2020). Only 1,600 of the agencies voluntarily submit their data for research purposes. This could create some selection bias. In addition, only 10% of the OHCA cases in the data set had data for the primary outcome of survival to hospital discharge home. This severely limits the strength of any conclusions from the available evidence. They did provide some information on geographical region. However, there was no granularity on other factors such as urban vs rural setting or transport time to hospital. The nature of the available dataset forced the authors to exclude any patients transferred to another hospital for continuing care form their analysis which may introduce a form of survival bias. The patients analyzed may have been more likely to recover completely without requiring transfer for subspecialty care. 4. Supraglottic Airways as Primary vs Rescue Device: The authors wanted to study the difference between the King-LT and the iGel as an initial airway management device and found that both devices were associated with similar rates of discharge home. Interestingly, the iGel was associated with higher rates of discharge home when it was employed as a rescue device after failed endotracheal intubation, however in this data set the King-LT was used as a rescue device almost twice as often (12.6% iGel vs 22.4% King-LT, p < 0.001). 5. ETCO2 Waves vs Numbers: The authors utilized recorded ETCO2 data in their sensitivity analysis to evaluate the ventilatory effectiveness of each device. The data available was in the form of discrete numbers charted by the clinicians or uploaded from the EMS monitor, not continuous waveform, and these values may have been influenced by factors like minute ventilation and device leak that are not clearly captured in numeric data alone. UPDATE: March 11th, 2023 Tanner Smida We are not perfect at the SGEM and do make mistakes sometimes. The lead author, Tanner Smida, reached out to us to clarify a few things and provide some additional background information after we posted the SGEM episode. Tanner is an MD/PhD student studying at West Virginia University. He is currently in his second year of medical school and about to start his PhD in clinical and translational science. Tanner noticed some issues with our reporting of what we thought was the primary outcome. Guest skeptic Chris Root thought perhaps he made a transcription error filling out the result section of the SGEM critical appraisal form for observational studies. It may have been me confusing the primary airway device used (iGel or King-LT) with the primary outcome. When we were made aware of the issue we apologized to Tanner and invited him record a short update to the SGEM episode. He clarified the primary outcome was survival to hospital discharge home regardless of whether the supraglottic device was as the primary airway management strategy or as a rescue strategy following a failed intubation attempt. This means the primary outcome DID find superiority of the iGel over the King-LT with an adjusted Odds Ratio (aOR) 1.36 [95% CI; 1.06 to 1.76]. Tanner provided some background information about the peer review process. It was the peer reviewers who insisted on the subgroup analyses and that the results be included in their conclusions.

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. These conflicting results have led to uncertainty regarding the use of TXA in patients with epistaxis. Hosseinialhashemi et al sought to provide some clarity with their trial looking at TXA in uncomplicated anterior epistaxis. Clinical Question: Should we use TXA for uncomplicated anterior epistaxis? Reference: Hosseinialhashemi et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial. Ann Emerg Med. 2022 Population: 18-year-old and older, stable patients with atraumatic anterior epistaxis, without bleeding disorders or anticoagulation. Excluded: Posterior bleeds, hemodynamically unstable, allergic to TXA; known nasopharyngeal, nasal cavity, or paranasal malignancy; pregnancy; the experience of out-of-hospital nasal packing; and epistaxis caused by trauma, known bleeding disorders, recent use of anticoagulation drugs or clopidogrel and patients who were prisoners. Intervention: Cotton pledgets soaked in TXA 500mg, phenylephrine 0.05g and lidocaine 10% x five sprays. Packing was removed after 15 minutes Comparison: Cotton pledgets without TXA but still soaked in phenylephrine 0.05g and lidocaine 10% x five sprays Outcome: Primary Outcome: Need for anterior nasal packing Secondary Outcomes: ED length more than 2h, needing electrical cauterization, rebleeding within 24h, rebleeding within 1-7 days. Type of Study: Single-center, double-blind RCT in a specialized ENT ED in Iran. Authors’ Conclusions: “Intranasal topical application of tranexamic acid is associated with a lower rate of need for anterior nasal packing and a shortened stay in the ED; it may be considered a part of the treatment for atraumatic anterior epistaxis.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Yes The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. Yes All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. Yes Financial conflicts of interest. No Results: They screened 315 patients and enrolled 240 patients. The patients were divided in two groups in a 1:1 ratio. The mean age of participants was 52 years, 52.5% were male and 30% were on aspirin. Key Results: TXA was superior to usual care for adult patients presenting with anterior epistasis. Primary Outcome: Need for anterior packing TXA Group 50.0% vs No TXA group 64.2% (NNT 7) Odds Ratio [OR], 0.56; 95% confidence interval [CI], 0.33 to 0.94. Secondary Outcomes:  No statistical differences between the two groups in terms of the need for electrical cauterization and the rate of rebleeding within 1 to 7 days. TXA was associated with a lower rate of stay in the ED for more than 2 hours (9.2% vs 20.8%) OR 0.38 (95% CI, 0.18 to 0.82) and rebleeding in 24 hours (15.0% vs 30%) OR 0.41 (95% CI, 0.22 to 0.78) compared with the rates in the control group. 1. Selection Bias: These were patients that from an ENT emergency department of a referral academic-teaching otolaryngology center. It is unclear if these represent the same patients who present to a community emergency department. You could argue that patients with more severe nose bleeds would present to this subspecialized ED. If TXA works in these cases than it should work in milder cases. Or if disease severity is lower than the impact of TXA might be less and not be statistically different from usual care. 2. External Validity: The second point is related to the first nerdy point. This was not only a specialist ENT ED, but it was also a single centre study in Iran. The patient population may not have external validity to patients we see in our own EDs? 3. Standard Care: Standard care in Iran may differ from our standard care. Some places like to apply ice packs, or use different external devices to stop bleeding and a variety of intranasal medications. 4. Electric Cautery: After the treatment in both groups, bipolar cauterization was used when there was a visible bleeding site in the anterior part of the nasal cavity. Many patients required electric cautery in this trial. This included about two-thirds of the patients in both groups. This result is much higher than in my practice experience. It further suggests that these are selected patients with more severe disease and/or Iran has a different standard practice. In addition, electric cautery is not available where I've worked in multiple sites in Ontario, Canada. Perhaps those in the UK, USA, Europe, Australia/NZ and elsewhere could respond about their use of electric cautery. Electric cautery could have some potential harms. These direct harms or any other harms/adverse events were not mentioned in the manuscript. It is an unfortunate trend for studies either to under-report or not report harms at all.  How can clinicians and patients make an informed decision with only knowing the potential benefits and not knowing the potential harms? 5. Other Situations: This trial is silent on other clinical situations of epistaxis which are routinely encountered in the ED. This includes traumatic bleeding, patients on anticoagulants drugs or patients who represent to the ED with refractory bleeding. Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors' conclusions but would have made a friendly amendment to qualify that it was in a select population at a subspecialized ENT ED in Iran. SGEM Bottom Line: It is reasonable to add TXA to your cotton pledgets for adults with uncomplicated anterior epistaxis. Case Resolution: Jim blew out his nose and you applied cotton pledgets soaked with vasoconstricting solution and TXA. His epistaxis resolved without the need for anterior packing. You provide him instructions to avoid nose picking, you improved patient satisfaction and ED flow. Clinical Application: If TXA is rapidly available, consider adding it to patients with atraumatic anterior epistaxis in your cotton pledgets. An NNT 7 for decreasing the need for anterior packing is clinically important, TXA is cheap, and a single topical application is very unlikely to cause harm. Dr. Dominique Trudel What Do I Tell the Patient?  Blow your nose to remove some of the blood. Then we will put a cotton pack up your nose. It will have two medications on the cotton. One medication stops bleeding by pinching off the blood vessels.