Stop and Think

DECEMBER 26, 2023

My Choice for Top Cardiology Story of 2023 Obesity Treatments: Here is what I wrote : Hyperbole is almost impossible when describing the potential benefits of the glucagon-like peptide-1 (GLP-1) receptor agonists. Semaglutide reduced cardiovascular outcomes in patients with established cardiovascular disease and obesity but without diabetes.

Outcomes 75

Outcomes 75

The Trauma Pro

DECEMBER 22, 2023

The reality is that no one will ever be able to design a study that definitively evaluates the very soft outcomes that result from using this technique. 1485, Dec 2023. It can help direct the surgical exploration if imaging was unnecessary or contraindicated. So yes, this is dogma.

Operations 264

Operations Outcomes 264

Don't Forget the Bubbles

NOVEMBER 11, 2024

One-liner… Traumatic brain injury (TBI) is a leading cause of mortality and morbidity in paediatric populations, and fever is associated with worse outcomes. The aim of TTM is to control the body and brain’s temperature, thus reducing secondary brain injury and improving the neurological outcome. Kochanek et al.

Hyperthermia / Hypothermia 117

Hyperthermia / Hypothermia Pediatrics Outcomes Resuscitation 117

The Trauma Pro

JANUARY 28, 2025

Preventing death: This drug doesn’t appear to reduce mortality, which is the outcome we are most interested in when treating these patients. The average cost of a course of treatment in 2023 was $26,787 (ref 6). Thrombotic complications. These do seem to be more common when AA is given.

Administration 189

Administration Outcomes Hospitals 189

Pediatric EM Morsels

AUGUST 9, 2024

Hussain, 2023 ] Leads to >300,000 perinatal deaths / year globally. Congenital syphilis differs from syphilis contracted by an “adult” in that: [ Hussain, 2023 ] T. Hussain, 2023 ] Excellent prognosis if treated early. If not treated early, then increased risk of poor outcomes and death. Epub 2023 Aug 18.

Hyperthermia / Hypothermia 152

Hyperthermia / Hypothermia Emergency Department Seizures Pediatrics 152

RebelEM

JUNE 1, 2023

Post-ROSC management is nuanced and challenging but helps to ensure good outcomes. In theory, rapid identification of the underlying cause should improve outcomes by allowing clinicians to tailor management. Diagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study.

Outcomes 142

Outcomes Resuscitation Hospitals CPR 142

The Skeptics' Guide to EM

SEPTEMBER 9, 2023

New England Journal of Medicine June 2023 Date: July 19, 2023 Guest Skeptic: Dr. Casey Parker is a Rural Generalist that includes in his practice emergency medicine, anesthesia, and critical care. New England Journal of Medicine June 2023 Reference: Snelling et al. He is also a fully-fledged ultrasonographer.

Fractures 126

Fractures Ultrasounds Pediatrics Outcomes 126

The Skeptics' Guide to EM

JULY 2, 2023

Date: July 1, 2023 Reference: PATCH-Trauma Investigators and ANZICS Clinical Trial Group. Date: July 1, 2023 Reference: PATCH-Trauma Investigators and ANZICS Clinical Trial Group. Most of the times the RCTs we critically appraised did not demonstrate superiority for their primary outcome.

EMS 123

EMS Outcomes Hospitals Research 123

RebelEM

NOVEMBER 6, 2024

Elbow Dislocation Definition: Disarticulation of the proximal radius & ulna bones from the humerus Epidemiology: Incidence Second most common joint dislocation (after shoulder) in adults Most commonly dislocated joint in children Accounts for 10-25% of all injuries to the elbow ( Cohen 1998 ) Posterolateral is the most common type of dislocation (..)

Dislocations 103

Dislocations Fractures Soft Tissue Injuries Outcomes 103

RebelEM

JUNE 22, 2023

Lancet Infect Dis 2023 PMID: 37302406 Clinical Question: Does outpatient treatment with ivermectin, fluvoxamine or metformin soon after SARS-CoV-2 infection reduce the risk of developing long-COVID in overweight patients? Outcomes: Primary: The development of long-COVID up to 300 days after enrollment. Lancet Infect Dis 2023.

Outcomes 135

Outcomes Research Documentation/Coding Wellness 135

RebelEM

MAY 29, 2023

Crit Care 2023. Limited, small studies on its use in septic shock do not make a clear argument for use. Paper: Ibarra-Estrada, M et al. Early Adjunctive Methylene Blue in Patients with Septic Shock: A Randomized Controlled Trial. NaCl over 6hrs once daily x3 doses Placebo: 500mL of 0.9% 95% CI 15.4 95% CI 15.4 95% CI 15.4 95% CI 15.4

Shock 145

Shock Fluid Resuscitation Sepsis Resuscitation 145

The Skeptics' Guide to EM

DECEMBER 16, 2023

AEM Dec 2023 Date: December 14, 2023 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. AEM Dec 2023 Date: December 14, 2023 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary.

Emergency Department 119

Emergency Department Research Outcomes 119

RebelEM

FEBRUARY 15, 2024

not a patient oriented outcome) Single country study which may limit generalizability Excluded pregnancy where risk of emesis is increased due to gravid uterus Alcohol was the implicated in the overwhelming majority of patients. Paper: Freund Y et al. References: Freund Y et al.

Poisoning 137

Poisoning Airway Management Seizures Shock 137

PulmCCM

SEPTEMBER 21, 2023

A 2015 meta-analysis of 13 randomized trials enrolling >12,000 patients suggested that active blood pressure management after ischemic strokes had little effect on eventual outcomes, and that delaying blood pressure control for three days did not lead to worse outcomes (death or disability).

Stroke 105

Stroke Outcomes 105

The Skeptics' Guide to EM

JUNE 3, 2023

Date: June3, 2023 Reference: Kotani et al. Journal of Critical Care April 2023 Guest Skeptic: Dr. Amber Gombash is an emergency physician in Concord, NC. Date: June3, 2023 Reference: Kotani et al. Journal of Critical Care April 2023 Guest Skeptic: Dr. Amber Gombash is an emergency physician in Concord, NC.

Outcomes 101

Outcomes Wellness 101

RebelEM

MAY 27, 2024

The primary outcomes are patient-centered and objectively measured, potentially ensuring relevance and reliability. The unblinded nature of the study could influence outcomes due to observer bias. Employing P-values to compare demographics between groups could mislead interpretations of the data’s relevance to the primary outcomes.

Outcomes 132

Outcomes Research Operations Hospitals 132

RebelEM

JUNE 26, 2023

Interventions such as early application of hemorrhage control, tranexamic acid, reduction of crystalloid fluid administration and balanced ratio blood product transfusion have improved many patients’ outcomes. However, mortality still remains high due to trauma-induced coagulopathy. Severe acute traumatic coagulopathy = PT >1.5

Administration 135

Administration Outcomes Resuscitation Radiology 135

EM Ottawa

NOVEMBER 6, 2023

Lancet 2023 Jul 1;402(10395):27-40. Question and Methods: Do 6 month outcomes improve after implementation of a goal-directed care bundle that corrects prognostically poor physiological abnormalities (systolic hypertension, fever, hyperglycemia, abnormal anticoagulation) for acute intracranial hemorrhage?

Outcomes 107

Outcomes 107

PulmCCM

JUNE 3, 2024

The ASTER Trial Ware et al conducted a phase 2b randomized trial from 2021 to 2023 among 447 patients admitted with sepsis and organ failure at 40 US academic hospitals. Patients received either 1 g of acetaminophen IV every six hours or placebo for five days.

Sepsis 52

Sepsis Outcomes Academics Hospitals 52

RebelEM

SEPTEMBER 14, 2023

to 1.03) Poor Neurologic Outcome (CPC 3 or 4): 24.8% to 1.03) Poor Neurologic Outcome (CPC 3 or 4): 24.8% to 1.03) Poor Neurologic Outcome (CPC 3 or 4): 24.8% The benefits of this strategy may be outweighed by the risk of the device-related complications (i.e. bleeding, stroke, limb ischemia, and hemolysis). Zeymer HT et al.

Shock 130

Shock Outcomes Resuscitation Stroke 130

The Trauma Pro

OCTOBER 6, 2023

Although many of these injuries were managed within hours, a growing number were delayed by a few days to improve outcomes. 2023 Jun 28;15(6):e41078. Ann Surg 278:e848-e854, 2023. We learned that temporizing with strict blood pressure control worked wonders at protecting the patient. doi: 10.7759/cureus.41078.

Head Injuries 147

Head Injuries Research Hospitals Resuscitation 147

RebelEM

OCTOBER 30, 2023

This could dilute any beneficial effects seen Lack of blinding may bias results (Although mortality is a solid objective primary outcome, bias may still creep in terms of management) Discussion: Authors were looking for an absolute mortality difference of 7% from baseline mortality of 26% with a 90% power. Paper: Davenport R et al.

Administration 123

Administration Blood Transfusions Outcomes Hospitals 123

ACEP Now

MARCH 6, 2024

The Sisyphean task remains to try to keep up—and, in that vein—here is a light round of the emergency medicine literature from 2023. 4 Repeated trials have not shown alteplase to have any signal of better outcomes, nor tenecteplase to have an association with increased adverse events. How Best to Stop the Bleeding in Trauma?

Research 52

Research Airway Management Stroke Outcomes 52

Dr. Smith's ECG Blog

JUNE 5, 2024

As per my review of this subject ( Check out My Comment at the bottom of the page in the November 16, 2023 post in Dr. Smith's ECG Blog ) — the 3 most common Causes of ACS ( A cute C oronary S yndrome ) with a "negative" cath are: i ) Myocarditis; ii ) Takotsubo cardiomyopathy; and , iii ) MINOCA.

EKG/ECG 126

EKG/ECG Outcomes 126

Don't Forget the Bubbles

JANUARY 1, 2024

Data from the Nurse-Family Partnership program involving 60,171 families were analysed across four cohorts, including pre-pandemic and three pandemic cohorts (from July 2022 to October 2023). 2023 Dec 22. 2023 Dec 21. 2023 Dec 19. 2023 Dec 12 Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics.

Pediatrics 98

Pediatrics Ultrasounds Blood Transfusions Sepsis 98

ACEP Now

AUGUST 13, 2024

Studies consistently show that having a diverse physician workforce leads to improved patient outcomes, lower mortality, reduced morbidity rates, and, ultimately, a more robust health care system. Published June 6, 2023. Published April 20, 2023. Diversity improves performance and outcomes. Published June 29, 2023.

Leadership 111

Leadership Outcomes Academics Emergency Department 111

Sensible Medicine

MAY 28, 2024

In June 2023 , the same was recommended to adults. A 2008 Cochrane review found adult depression screening does not improve outcomes. The last two trials convincingly demonstrate that when patients with postpartum depression have better access to mental health services, outcomes improve.

Military 139

Military Outcomes Psychiatric Wellness 139

Pediatric EM Morsels

JULY 28, 2023

Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema. Is your patient hyperglycemic, acidotic, with ketonuria? Then we’ve likely got DKA. Triple bag, triple bag, triple bag! The Pediatric Emergency Medicine Collaborative Research Commitee. 2002 Dec;141(6):793-7. PMID: 12461495.

Fluid Resuscitation 246

Fluid Resuscitation Pediatrics Resuscitation Research 246

The Skeptics' Guide to EM

OCTOBER 21, 2023

Date: October 20, 2023 Reference: Cai et al. AEM October 2023. Date: October 20, 2023 Reference: Cai et al. AEM October 2023. AEM October 2023. Implementation of a Clinical Management Tool for Spinal Epidural Abscess Early Diagnosis. Reference: Cai et al.

Emergency Department 108

Emergency Department Radiology Radiology Hospitals 108

ACEP Now

JUNE 21, 2023

The lack of differences in the observed outcomes do not suggest one EM training length is superior. The additional year may improve career trajectory or longevity, entrance into fellowship or academic practice, or other longer-term outcomes including successful development of a niche in the specialty. 11 What should we take away?

EMS 114

EMS Academics Telemedicine Operations 114

RebelEM

JANUARY 29, 2024

Clin Exp Emerg Med 2023. REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE? Click here for Direct Download of the Podcast Paper: Aykan AC et al. Reduced-Dose Systemic Fibrinolysis in Massive Pulmonary Embolism: A Pilot Study. in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 in the paper but 2.7%

Stroke 130

Stroke Outcomes Hospitals Administration 130

EMDocs

NOVEMBER 29, 2023

2023 May 25;388(21):1931-1941. Included 584 patients > 18 years admitted to ICU with severe PNA based on IDSA/ATS criteria Primary Outcome: 60-day all-cause mortality Hydrocortisone 16% vs. placebo 18%, adjusted OR 0.90 (95% CI 0.57-1.40) 2023 Jul 8;27(1):274. 2023 May 31;27(1):212. #4: 2023 Jul;188:109785.

Resuscitation 85

Resuscitation Outcomes EKG/ECG 85

EMDocs

SEPTEMBER 30, 2024

2023 May;64(5):555-563. Primary outcome: Prescription of ICS on ED discharge from the index visit Secondary outcomes: ICS prescription rates in high-risk subgroups Rates of outpatient follow-up within 30 days of an ED visit for asthma Variation in ICS prescription rates among attending ED physicians. J Emerg Med.

Outcomes 95

Outcomes Documentation/Coding Academics Administration 95

RebelEM

MAY 25, 2023

vs 3U) but no difference in mortality (Study not powered for this outcome) Clinical Take Home Point: The use of vasopressors is controversial and requires a nuanced approach SUMMARY OF MINIMIZING IATROGENIC INJURY RESTORE PERFUSION VOLUME REPLACEMENT Blood Products >>> Crystalloids Holcomb JB et al. NEJM 1994. [2]

Resuscitation 145

Resuscitation Fluid Resuscitation Head Injuries Shock 145

The Skeptics' Guide to EM

JANUARY 6, 2024

July 2023 Date: Dec 11, 2023 Guest Skeptic: Dr. Rachel Hatcliffe is a pediatric emergency medicine attending at Children’s National Hospital in Washington, DC. July 2023 Date: Dec 11, 2023 Guest Skeptic: Dr. Rachel Hatcliffe is a pediatric emergency medicine attending at Children’s National Hospital in Washington, DC.

Emergency Department 106

Emergency Department Pediatrics Anaphylaxis Leadership 106

RebelEM

JULY 27, 2023

In this group of patients, the use of alteplase poses a fine line of potential benefit (functional outcomes) vs potential harm (symptomatic intracranial hemorrhage). Many patients, however, will have minor strokes (defined as an NIHSS score ≤5). Paper: Chen HS et al. Alteplase: 91.4% Risk Diff: 2.3%; 95% CI -1.5 Alteplase: 0.9% Alteplase 5.4%

Stroke 97

Stroke Outcomes EMS Hospitals 97

Broome Docs

MARCH 28, 2024

doi: 10.1136/emermed-2023-213285. PMID: 38050078 Bottom line: High dose nitroglycerin seems to result in better outcomes in SCAPE, at least according to this small, single center, unblinded trial. 2023 Sep 21:ciad571. 2023 Sep 19:S0196-0644(23)00671-6. 2023 Dec;193:109991. 2023 Aug 21:S0012-3692(23)05350-3.

PPE 96

PPE Ultrasounds Resuscitation Administration 96