2023 Emergency Medicine Journal Review with Drs. Lucas Dingman and Cady Welch

Ridgeview Podcast: CME Series

This podcast, Dr. Lucas Dingman and Dr. Cady Welch, emergency medicine physicians with EMPAC and Ridgeview, discuss six articles on various topics related to emergency medicine, as part of this first ED journal review.

Enjoy the podcast.

Objectives:Upon completion of this podcast, participants should be able to:

• Identify emergency medicine journal articles that may be potentially practice-changing
• Describe how to rule out a pulmonary embolism (PE) in the emergency department using the YEARS criteria and age adjusted d-dimer.
• Differentiate when antibiotics for treating diverticulitis is warranted.
• Describe the benefits of using a small percutaneous catheter chest tube for treating a traumatic hemothorax.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at [e-mail].

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES: *See the attachment for additional information.

Study #1: Efficacy and Safety of Nonantibiotic Outpatient Treatment in Mild Acute Diverticulitis (DINAMO-study) A Multicentre, Randomised, Open-label, Noninferiority Trial

- DINAMO study & diverticulitis - Multicenter, randomized, open label, non-inferiority trial (Nov.2016 - Jan.2020) - 480 randomized participants and put into two groups - Results: admission to hospitals, ED revisits, no complications, no major significant findings - Nonantibiotic outpatient treatment of mild acute diverticulitis is safe and effective and is not inferior to current standard treatment.

Study #2: Anterior–Lateral Versus Anterior–Posterior Electrode Position for Cardioverting Atrial Fibrillation

- EPIC Atrial Fibrilation ( EPIC AF) - Two positions for pad placement for cardioverting patients - Multicenter, randomized, open label trial - 467 randomized patients, scheduled for elective cardioversion - Results: 50% successful conversion to normal sinus rhythm after one biphasic shock, many patients needed multiple shocks to cardioconvert (4-5 shocks). - AHA Guidelines: pad placement for AF and VF, treatment recommendations - Anterior-lateral electrode positioning was more effective than anterior-posterior electrode positioning for biphasic cardioversion of atrial fibrillation. There were no significant differences in any safety outcome.

Study #3: The small (14 Fr) percutaneous catheter (P-CAT) versus large (28–32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial

- Poiseuille's law and chest tubes - and involves components of rate of flow, radius of the tube, change in pressure and viscosity. - 120 participants - 8 years and older, traumatic hemothorax or pneumothorax, hemodynamically stable patient only - Treatment arm: 14 Fr cook catheter used (seldinger techique, anterior axillary or midaxillary line) - Control arm: 28-32 Fr. chest tube placed (standard way - 4th-5th intercostal, midaxillary line) - Results: Failure rate of the tube, repeat hemothorax requiring intervention, drainage outputs at different designated times, total chest tube days, insertion complications, ventilator days, ICU length of days, hospital length of stay - Patients had better experience with percutaneous catheter - Hemlich valve - Study discussed looks specifically at hemothoraces which require drainage of blood and chest tubes connected to traditional pleuro vac chamber - Small caliber 14 Fr PCs are equally as effective as 28- to 32-Fr chest tubes in their ability to drain traumatic HTX with no difference in complications. Patients reported better IPE scores with PCs over chest tubes, suggesting that PCs are better tolerated.

Study #4: Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial - ScienceDirect

- Single center, placebo controlled, blinded, randomized trial - Sample: 120 healthy adults, median age 40 years old presenting to ED with chief complaint of nausea/vomiting - Change in nausea score at 30 min. (drop in mm on VAS) - Mean nausea baseline = 50 - Limitations: fairly young healthy participants, difficult to blind (can smell difference) - Among ED patients with acute nausea and not requiring immediate IV access, aromatherapy with or without ondansetron provides greater nausea relief than oral ondansetron alone.

Study #5: Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial

- YEARS criteria with age adjusted vs only age adjusted - Cluster, randomized, crossover, non-inferiority trial to determine if YEARS plus age-adjusted could be used to rule out PE, age 18 or older, not pregnant - Sample size: 1414 patients within 18 EDs, PERC positive - Outcome: PE diagnosed in 100 patients, no missed PEs with patients with YEARS score of "0", - Among ED patients with suspected PE, the use of the YEARS rule combined with the age-adjusted D-dimer threshold in PERC-positive patients, compared with a concential diagnostic strategy, did not result in an inferior rate of thromboembolic events.

Study #6: Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial

- Randomized, single masked study (providers were masked), controlled clinical trial, non-inferiority study design, single center study - Participants: children - aged 8 weeks to 3 years, moderately dehydrated (dehydration score greater than 3, but less than 7) - Outcomes: Successful rehydration at 4 hours, hospitalization rate, time to initiation of treatment, repeat ED visits within 72 hrs -Results: no difference between the groups with succesful rehydration at 4 hours - Limitations: small sample size - Oral rehydration therapy (ORT) is as good as intravenous fluid therapy (IVF) in rehydration of moderately dehydration children due to gastroenteritis. In addition, the study found that less time was required to intiate ORT when compared with IVF in the ED. Patients treated with ORT had fewerer hospitalizations. Results of the study suggested that ORT be the initial treatment of choice for moderately dehydrated children less than three years old with gastroeneritis.

Thanks to Dr. Lucas Dingman and Dr. Cady Welch for their knowledge and contribution to this podcast.

Please check out the additional show notes for more information/resources.