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AIR-Pro: Toxicology (Part 1)

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Welcome to the Toxicology (Part 1) AIR-Pro Module. Below we have listed our selection of the 10 highest quality blog posts related to 5 advanced level questions on toxocology topics posed, curated, and approved for residency training by the AIR-Pro Series Board. The blogs relate to the following questions:
  1. Flumazenil in benzodiazepine overdose
  2. Acetaminophen – drawing and timing of levels
  3. Opioid overdoses
  4. Acetaminophen toxicity related to liver transplant
  5. Salicylates and hemodialysis

In this module, we have 6 AIR-Pro’s and 4 Honorable Mentions. To strive for comprehensiveness, we selected from a broad spectrum of blogs identified through FOAMSearch.net and FOAMSearcher.We have a brand new chief resident team and want to thank the out-going team for all of their support!

AIR-Pro Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR-Pro stamp of approval will only be given to posts scoring above a strict scoring cut-off of ≥28 points (out of 35 total), based on our AIR-Pro scoring instrument, which is slightly different from our original AIR Series scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR-Pro Board members as worthwhile, accurate, unbiased and useful to senior residents. Only the posts with the AIR-Pro stamp of approval will be part of the quiz needed to obtain III credit. To decrease the repetitive nature of posts relating to these advanced concepts, we did not always include every post found that met the score of ≥28 points.

Take the quiz at ALiEMU

ALiEMU AIR-Pro Toxicology block quiz
(You will need to create a one-time login account if you haven’t already.)

Toxocology Module (Part 1) 2016: Recommended III credit hours

3 hours (20 minutes per article, 30 minutes for articles with podcasts)

 

Article Title Authors Date Title
EMPharmD: Flumazenil: Friend or Foe? Nadia Awad Nov 7, 2013 AIR-PRO
ALiEM: Utility of Pre-4-Hour Acetaminophen Levels in Acute Overdose Bryan Hayes Aug 5, 2015 AIR-PRO
StEmlyns: Opiate Overdose in the ED Simon Carley Feb 27, 2015 AIR-PRO
EMJClub: Treat and Release vs Observation After Naloxone for Opioid Overdose EMJ Club Nov 24, 2014 AIR-PRO
LIFTL: Liver Transplantation for Paracetamol Toxicity Chris Nickson April 30, 2016 AIR-PRO
ALiEM: 5 Tips in Managing Acute Salicylate Poisoning Kristin Fontes Nov 4, 2013 AIR-PRO
LITFL: Paracetamol/Acetaminophen Overdose Chris Nickson Sept 3, 2010 Honorable Mention
ALiEM: Tricks of the Trade: Naloxone Dilution for Opioid Overdose Bryan Hayes Nov 17, 2014 Honorable Mention
LITFL: Paracetamol Chris Nickson 2015 Honorable Mention
EMDocs: Pearls and Pitfalls of Salicylate Toxicity in the ED Samantha Berman & Josh Bucher Oct 13, 2015 Honorable Mention

 

Author information

Fareen Zaver, MD

Fareen Zaver, MD

Lead Editor/Co-Founder of ALiEM Approved Instructional Resources - Professional (AIR-Pro)
Emergency Physician
University of Calgary Emergency Department

The post AIR-Pro: Toxicology (Part 1) appeared first on ALiEM.


ALiEMU CAPSULES Module 7: Emergency Thyroid Disorders

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We are proud to present CAPSULES module 7: Emergency Thyroid Disorders, now published on ALiEMU. Here is a summary of the key points from this outstanding module by Drs. Craig Cocchio and Colleen Martin.

Course Contributors

Role Team Member Background
Authors Craig Cocchio, PharmD, BCPS
@iEMPharmD
Emergency Medicine Pharmacist, Trinity Mother Frances Hospital
Colleen Martin, PharmD, BCPS
@C0lleen_Martin
Emergency Medicine Pharmacist, Nyack Hospital
PharmD Reviewer and Associate Editor Nadia Awad, PharmD, BCPS
@Nadia_EMPharmD
Emergency Medicine Pharmacist, Robert Wood Johnson University Hospital
Physician Reviewer George Willis, MD
@DocWillisMD
Assistant Professor of Emergency Medicine, University of Maryland
Creator and Lead Editor Bryan Hayes, PharmD, FAACT
@pharmertoxguy
Emergency Medicine Pharmacist, Massachusetts General Hospital
Chief of Design and Development and Co-Founder of ALiEMU Chris Gaafary, MD
@cgaafary
Clinical Assistant Professor, Greenville Health System

Go to ALiEMU module

Summary: Emergency Thyroid Disorders

Thyroid disorders and their emergencies are a challenge to recognize in the clinical setting, offer few evidence-based treatment options and are associated with a high incidence of morbidity and mortality. This CAPSULE will help the reader digest the critical aspects of the pharmacotherapy of these emergencies and provide a springboard into deeper learning through the vast resources of primary literature, textbooks and FOAM. This preview (or loading dose, if you will) highlights a few key CAPSULES in this module.

Thyroid Emergencies

As part of the hypothalamic-pituitary-thyroid axis, the thyroid gland plays critical roles in numerous metabolic processes. The hormones; thyroxine (T4), triiodothyronine (thyronine, or T3), and calcitonin, are critical in both the development and ongoing function of almost every organ system. As a result, derangements in thyroid function can elicit broad non-specific signs and symptoms. However, thyroid disorders may exist on a spectrum including hypo- and hyperthyroid states may elicit manifestations of medical emergencies that may require extreme pharmacologic interventional measures.

Presentation of myxedema coma & thyroid storm may mimic sepsis

The most concerning extreme form of hypothyroidism is myxedema coma. Myxedema coma is, however, a medical misnomer. While referring to a state of decompensated hypothyroidism (DH), myxedema coma does not always involve myxedema (nonpitting edema) or coma. DH presents as an exaggeration of hypothyroid effects; altered mental status, hypothermia, hypotension, hypoventilation, hypoglycemia and hyponatremia.

These widespread generalized signs and symptoms make DH difficult to recognize, but the combination of hypotension, hypothermia, altered mental status should alert clinicians to consider DH.

Levothyroxine (IV or PO) is the drug of choice in acute management of DH.

Thyroid hormone replacement

Ultimately, the goal of treatment once DH is identified is replacement of thyroid hormones. The three categories that have been described include intravenous (IV) T4, oral (PO) T4, and combination therapy with IV/PO T4 and IV/PO T3. The absence of high quality evidence precludes one therapy over another being determined as first line. Thus, treatment recommendations may be based upon consensus or clinician experience.

Oral loading doses of levothyroxine should be double the desired IV loading dose.

Oral loading of levothyroxine has been suggested as an option, particularly in areas where IV levothyroxine is not available. Some references cite low (<50%) bioavailability of levothyroxine oral tablets, modern oral dosage forms of levothyroxine may have a bioavailability of closer to 80%. Despite this, the IV to oral conversion for levothyroxine loading doses should remain as 1:2 since in this clinical scenario, this conversion is not intended to be the final dose but rather a starting point from which the dose will be titrated to desired free T4 and TSH.

Thyroid Storm

Hyperthyroidism is characterized by increased production and release of thyroid hormone by the thyroid gland and can present in a wide spectrum, from sub-clinical, to life-threatening. Thyrotoxicosis is present when there are elevated levels of thyroid hormone in the blood, which may be present in the absence of  hyperthyroidism if thyroid hormone is caused by extrathyroidal sources of hormone or release of preformed thyroid hormone. Thyroid storm, or thyrotoxic crisis, occurs when thyrotoxicosis becomes life-threatening.

Management of thyroid storm should begin immediately due to its reported mortality of 8 – 25%. Treatment of thyroid storm includes all of the following:

  1. Antiadrenergic therapy
  2. Suppression of thyroid hormone formation and secretion
  3. Preventing peripheral conversion of thyroid hormone
  4. Treatment of associated complications or coexisting factors that may have precipitated the storm
  5. Supportive therapy

Propylthiouracil is preferred over methimazole in pregnancy

Suppressing the amount of thyroid hormone in systemic circulation is important in reversal of thyroid storm.  The first-line treatment is the use of  thionamides which inhibit thyroid peroxidase, the enzyme required for thyroid hormone synthesis. Methimazole and propylthiouracil can be administered rectally if the oral route is not feasible as a retention enema.

Thionamide (propylthiouracil or methimazole) should be given prior to iodine

One hour after the administration of a thionamide, iodine should be administered to prevent the release of thyroid hormones.  The time delay is recommended so that the thionamide has had a chance to prevent synthesis of thyroid hormone before providing a large dose of substrate that could used to synthesize additional thyroid hormones.

What is the CAPSULES series?

CAPSULES is a free, online e-curriculum of high-quality, current, and practical pharmacology knowledge for the EM practitioner. About once a month a new course module is released, which has lessons to read about (or watch) and brief quizzes to complete. With each step, your personal dashboard will keep track of what you have completed. The CAPSULES series’ primary focus is bringing EM pharmacology education to the bedside. Our expert team distills complex pharmacology principles into easy-to-apply concepts. It’s our version of what-you-need-to-know as an EM practitioner.

Author information

Bryan D. Hayes, PharmD, FAACT

Bryan D. Hayes, PharmD, FAACT

Associate Editor, ALiEM
Creator and Lead Editor, CAPSULES series, ALiEMU
Clinical Pharmacist, EM and Toxicology, MGH

The post ALiEMU CAPSULES Module 7: Emergency Thyroid Disorders appeared first on ALiEM.

Introducing CME for ALiEM via FOAMbase

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foambase-aliem-logo-sml cmeEver wish you could get Continuing Medical Education (CME) credit for the Free Open Access Meducation (FOAM) you already consume? We are excited to announce that 10 ALiEM articles are now available for AMA PRA Category 1 CME. This is a pilot program in collaboration with FOAMbase and EB Medicine. There is great content on trauma, geriatrics, pediatrics, critical care, and more. We think CME for FOAM is going to be a great way to increase sustainability for FOAM authors while keeping FOAM 100% free and open access.

 

The Bottom Line

  • 10 high quality articles from ALiEM are now available for AMA PRA Category 1 CME (more to come if this pilot is successful)
  • CME units can be obtained via the FOAMbase platform.
  • Each blog post is equivalent to 0.25-0.50 CME units.
  • There is a nominal CME charge ($4-8 per blog post). The revenue is shared between EB Medicine (CME accreditation provider), FOAMbase (centralized CME service for blog posts), and ALiEM/authors. 
  • The blog content remains 100% free for anyone to read, if CME units are not desired.

Blog Posts Available for CME

ALiEM Blog Post Title Category Number of CME Units
5 tips for managing pain in older adults Geriatrics 0.25
Trick of the Trade: Pre-charge the defibrillator Critical Care 0.25
Highlights from the 2015 American Heart Association CPR and ECC guidelines Critical Care 0.25
Synthetic cannabinoid use reaches new heights Toxicology 0.25
Fentanyl: Adding fuel to the fire in the North American opioid epidemic Toxicology 0.5
Traumatic brain injuries in older adults Trauma, Geriatrics 0.5
PEM Pearls: The nonvisualized appendix quandary on ultrasound Pediatrics 0.25
PEM Pearls: Assessing radiation risk in children getting CT imaging Pediatrics 0.25
PEM Pearls: Cardiac causes of pediatric chest pain Pediatrics 0.5
Ultrasound For the Win! Case – 55-year-old man with chest pain Ultrasound 0.25

Background

I remember attending a talk by Mel Herbert at the 2015 Society for Academic Emergency Medicine (SAEM) meeting where he said something that stuck:

“FOAM is not free.”

What he meant is that while FOAM is distributed for free and is a labor of love for the authors, there are costs associated with creating and distributing content. Authors spend unpaid time creating the material, there are web costs for hosting, podcasters need to buy hardware and software tools, etc.

We remember thinking, how can we keep FOAM free and high quality while increasing sustainability for the authors?

Fast forward to 2016 Council of EM Residency Directors (CORD) meeting to one of those fated hallway conversations with Michelle Lin (@M_Lin), Nupur Garg (@NupurGargMD), and myself. We asked ourselves, was there a way to provide CME for ALiEM content? We took up the challenge and built FOAMbase CME to address just that.

Philosophy

  1. We want FOAM to remain free. ALiEM blog posts will always be 100% free and open access to read and learn from. A fee only applies when obtaining CME credit.
  2. We hope revenue-sharing with the blog website and individual authors will help offset the time and material costs of producing high quality educational content.
  3. At the same time, it will give physicians a great new source of high quality CME, allowing them to obtain credit for content that they may already be reading.

Logistics

  1. Create a new user account at FOAMbase as an “Attending” physician. This will open CME options for you.
  2. Click on FOAM CME to view the list of available CME content, or click on the content-specific links in the table above.
  3. Click the “Get CME” icon next to the blog post. This will launch a guided process on reading and obtaining CME credit for that blog post.

Background

  • FOAMbase is a human curated database of FOAM content. It was built to keep track of high quality FOAM content from around the world and cut down on the noise that exist with FOAM search engines like GoogleFOAM.
  • FOAMbase CME is a custom add-on to FOAMbase with features required for CME administration, including pre-post quizzes, activity survey, certificate issuance, learner tracking, and a CME dashboard.
  • We are working with EB Medicine as the CME accreditation body.

Feedback

Please let use know what you think. All comments are much appreciated. Nupur Garg and I will be at ACEP16 in the InnovatED section demoing the project. Come visit us!

 

Author information

Benjamin Azan, MD

Benjamin Azan, MD

Emergency Physician
Lincoln Medical Center
Founder/Editor of foambase.org

The post Introducing CME for ALiEM via FOAMbase appeared first on ALiEM.

Whipped Cream Charger Abuse: The Toxicologist Mindset

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whipped cream chargerThe Toxicologist Mindset series features real-life cases from the San Francisco Division of the California Poison Control System.

Case: A 39-year-old man, with no significant past medical history, was brought to the emergency department by family members, over three consecutive days, for anxiety, confusion, and ataxia. In the first two visits, his laboratory work-up, including complete blood cell count, chemistry panel, liver function tests, urine drug screen, and non-contrast head CT, were unremarkable. On his third visit, he was profoundly encephalopathic with confusion and poor concentration. He had bilateral lower extremity weakness and ataxia. He was admitted to the neurology service for further work up. Additional history revealed that hundreds of empty canisters of whipped cream chargers were found in his house.

1. Why might this patient be abusing whipped cream chargers?

Whipped cream chargers, colloquially known as “whippits,” “whippets,” or “hippie crack,” is a steel cartridge filled with nitrous oxide (N2O) gas. In whipped cream cans, dissolved nitrous oxide gas from the cartridges helps the cream transform into a frothy, whipped state upon dispensing. Inhalation of N2O produces a state of analgesia, depersonalization, derealization, dizziness, euphoria, and sound distortion.1 Cartridges are generally easy to obtain, either on the internet, in head shops, or on the street.

2. What is the mechanism of myeloneuropathy by nitrous oxide?

Nitrous oxide produces irreversible oxidation of cobalt in vitamin B12, rendering the vitamin B12 molecule functionally inactive. The functional deficiency of vitamin B12 results in an inability to incorporate phospholipids into myelin sheaths, resulting in neuropathy.2 Patients typically present with complaints of numbness, paresthesias, or weakness, and physical exam findings show changes in gait or coordination, difficulty walking, and falls.1 Most case reports describe neurologic sequelae after “chronic” abuse of N2O; however, an exact amount and duration of usage conferring risk has not been well defined.

3. What psychiatric sequelae are associated with nitrous oxide abuse?

In a recent systematic review, 12% of cases of abuse presented with a wide range of psychiatric complaints.1 Symptoms ranged from delirium, confusion, bizarre behavior, agitation, and memory problems. While typical vitamin B12 deficiency is associated with a megaloblastic anemia and neuropsychiatric sequelae, psychiatric symptoms after N2O abuse are not necessarily associated with low mean corpuscular volume. In some cases, delirium may be secondary to concomitant use of illicit substances.1

4. What laboratory or imaging studies could help confirm the diagnosis of nitrous oxide abuse?

There is no formal screening tool for N2O abuse. A detailed patient history is often the key to making the diagnosis.

  • Vitamin B12 levels: May be normal or low
  • Methylmalonic acid (MMA) and/or total serum homocysteine levels (precursors in vitamin B12-dependent pathways): May be elevated
  • T2-weighted MRI images: There have been reports of hyperintense signals in the posterior and/or lateral spinal cord at the cervical and/or thoracic levels.

5. What are some treatment modalities that need to be considered?

The most important intervention is the discontinuation of N2O abuse. Intramuscular and oral vitamin B12 supplementation has also been described. Patients will also require supportive care including an evaluation for fall risks at home due to persistent ataxia. Complete resolution of neuropsychiatric symptoms is variable. In 59 cases of neurologic sequelae after N2O abuse:1

  • Recovered completely: 10/59 cases
  • Symptom improvement: 46/59 cases
  • Psychiatric sequelae
    • Complete resolution: 5/11 cases
    • Improved symptoms: 2/11 cases

Case Outcome

The patient’s mental status and ataxia improved over the course of 3 days. He endorsed using anywhere from 50-100 canisters of nitrous oxide per day. He was diagnosed with chronic nitrous oxide toxicity that was further confirmed by an elevated MMA acid level. He was started on vitamin B12 therapy.

 

This Toxicologist Mindset series features real-life cases from the San Francisco Division of the California Poison Control System. Some elements of the patient’s case may have been altered to help provide additional patient anonymity.

Image credit

1.
Garakani A, Jaffe R, Savla D, et al. Neurologic, psychiatric, and other medical manifestations of nitrous oxide abuse: A systematic review of the case literature. Am J Addict. 2016;25(5):358-369. [PubMed]
2.
Flippo T, Holder W. Neurologic degeneration associated with nitrous oxide anesthesia in patients with vitamin B12 deficiency. Arch Surg. 1993;128(12):1391-1395. [PubMed]

Author information

Kathy Vo, MD

Kathy Vo, MD

Toxicology Fellow
Department of Emergency Medicine
University of California, San Francisco

The post Whipped Cream Charger Abuse: The Toxicologist Mindset appeared first on ALiEM.

52 Articles in 52 Weeks (2nd edition, 2016)

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journal-articles-canstockphoto3359042-200x300Maintaining lifelong learning is challenging, especially when trying to keep up with all of the journal publications in emergency medicine (EM). In 2013, we published a compilation of 52 journal articles, which interns could read over a 52-week period, at an average pace of 1 journal article per week. In the list below, we present an updated compilation for the “52 Articles in 52 Weeks” initiative.

Methodology for Article Selection

Candidate articles were collected via suggestions from U.S. EM residency program directors and assistant program directors via the CORD listserve and from previously existing lists (first edition of the 52 Articles in 52 Weeks List, Colorado Compendium [PDF]1). Articles were then rated by a ‘Selection Committee’ comprised of 9 EM faculty with an academic niche in evidence-based medicine. Each member evaluated the following for each candidate article:

  1. Best Evidence in Emergency Medicine (BEEM) score — a published, validated score to determine how practice-changing an article is (see below table)
  2. Is the article practice-changing in EM?
  3. Should EM graduates know the article?
  4. Should the article be included in the final ’52 Articles in 52 Weeks’ list?

 

Best Evidence in Emergency Medicine (BEEM) Scoring2

Assuming that the results of this article are valid, how much does this article impact on EM clinical practice?
BEEM Score Description
1 Useless information
2 Not really interest, not really new, changes nothing
3 Interesting and new, but doesn’t change practice
4 Interesting and new, has the potential to change practice
5 New and important: this would probably change practice for some emergency physicians (EP’s)
6 New and important: this would change practice for most EP’s
7 This is a “must know for EPs

Results

Evaluations were summarized descriptively, then used to rank the order of most essential knowledge for EM interns. The top-ranked articles are provided below to be consumed throughout the EM intern year.

52

Cardiology

  1. Andersen HR, Nielsen TT, Rasmussen K, Thuesen L, et al; DANAMI-2 Investigators. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med. 2003 Aug 21;349(8):733-42. PMID: 12930925
  2. Backus BE, Six AJ, Kelder JC, Bosschaert MA, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8. PMID: 23465250
  3. McCullough PA, Nowak RM, McCord J, Hollander JE, et al. B-type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure: analysis from Breathing Not Properly (BNP) Multinational Study. Circulation. 2002 Jul 23;106(4):416-22. PMID: 12135939
  4. Nichol G, Leroux B, Wang H, Callaway CW, et al; ROC Investigators. Trial of Continuous or Interrupted Chest Compressions during CPR. N Engl J Med. 2015 Dec 3;373(23):2203-14. PMID: 26550795
  5. Quinn J, McDermott D, Stiell I, Kohn M, Wells G. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med. 2006;47(5):448-54. PMID: 16631985
  6. Sgarbossa EB, Pinski SL, Barbagelata A, Underwood DA, et al; GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. N Engl J Med. 1996 Feb 22;334(8):481-7. PMID: 8559200
  7. Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, et al; Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002 Dec 5;347(23):1825-33. PMID: 12466506

Gastrointestinal

  1. Palamidessi N, Sinert R, Falzon L, Zehtabchi S. Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis. Acad Emerg Med. 2010 Feb;17(2):126-32. PMID: 20370741

Infectious Disease

  1. de Almeida JR, Al Khabori M, Guyatt GH, Witterick IJ, et al. Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. JAMA. 2009 Sep 2;302(9):985-93. PMID: 19724046
  2. de Gans J, van de Beek D; European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med. 2002 Nov 14;347(20):1549-56. PMID: 12432041
  3. Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med. 2012 Aug;40(8):2479-85. PMID: 22809915
  4. Weiss EA, Oldham G, Lin M, Foster T, Quinn JV. Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial. BMJ Open. 2013 Jan 16;3(1). PMID: 23325896
  5. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004 Jul;32(7):1535-41. PMID: 15241098

Musculoskeletal

  1. Stiell IG, Greenberg GH, McKnight RD, Nair RC, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993 Mar 3;269(9):1127-32. PMID: 8433468

Neurosciences

  1. Hacke W, Kaste M, Bluhmki E, Brozman M, et al; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008 Sep 25;359(13):1317-29. PMID: 18815396
  2. Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001 Dec 13;345(24):1727-33. PMID: 11742046
  3. Hypothermia After Cardiac Arrest Study Group. Mild Therapeutic Hypothermia to Improve the Neurologic Outcome after Cardiac Arrest. N Engl J Med. 2002 Feb 21;346(8):549-56. PMID: 11856793
  4. Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007;369(9558):283-92. PMID: 17258668
  5. Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-10. PMID: 19762709
  6. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995 Dec 14;333(24):1581-7. PMID: 7477192
  7. Nielsen N, Wetterslev J, Cronberg T, Erlinge D, et al; TTM Trial Investigators. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013 Dec 5;369(23):2197-206. PMID: 24237006
  8. Perry JJ, Stiell IG, Sivilotti ML, Bullard MJ, et al. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study. BMJ. 2010 Oct 28;341:c5204. PMID: 21030443

Pediatrics

  1. Bjornson CL, Klassen TP, Williamson J, Brant R, et al; Pediatric Emergency Research Canada Network. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med. 2004 Sep 23;351(13):1306-13. PMID: 15385657
  2. Holmes JF, Mao A, Awasthi S, McGahan JP, et al. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med. 2009 Oct;54(4):528-33. PMID: 19250706
  3. Kocher MS, Mandiga R, Zurakowski D, Barnewolt C, Kasser JR. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am. 2004 Aug;86-A(8):1629-35. PMID: 15292409
  4. Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, et al; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70. PMID: 19758692
  5. Pieretti-Vanmarcke R, Velmahos GC, Nance ML, Islam S, et al. Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma. J Trauma. 2009 Sep;67(3):543-9; discussion 549-50. PMID: 19741398
  6. Spiro DM, Tay KY, Arnold DH, Dziura JD, et al. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA. 2006 Sep 13;296(10):1235-41. PMID: 16968847

Pulmonary­

  1. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000 May 4;342(18):1301-8. PMID: 10793162
  2. Bauer TT, Ewig S, Marre R, Suttorp N, Welte T; CAPNETZ Study Group. CRB-65 predicts death from community-acquired pneumonia. J Intern Med. 2006 Jul;260(1):93-101. PMID: 16789984
  3. Brochard L, Mancebo J, Wysocki M, Lofaso F, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1995 Sep 28;333(13):817-22. PMID: 7651472
  4. Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W; Management Strategies and Prognosis of Pulmonary Embolism-3 Trial Investigators. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med. 2002 Oct 10;347(15):1143-50. PMID: 12374874
  5. Kline JA, Courtney DM, Kabrhel C, Moore CL, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008 May;6(5):772-80. PMID: 18318689
  6. Masip J, Roque M, Sánchez B, Fernández R, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis. JAMA. 2005 Dec 28;294(24):3124-30. PMID: 16380593
  7. Wells PS, Anderson DR, Rodger M, Stiell I, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: Management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Annals Intern Med 2001;135:98-107. PMID: 11453709

Resuscitation

  1. De Backer D, Biston P, Devriendt J, Madl C, et al; SOAP II Investigators. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010 Mar 4;362(9):779-89. PMID: 2020038
  2. Jones AE, Shapiro NI, Trzeciak S, Arnold RC, et al; Emergency Medicine Shock Research Network (EMShockNet) Investigators. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010 Feb 24;303(8):739-46. PMID: 20179283.
  3. ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014 May 1;370(18):1683-93. PMID: 24635773.
  4. Rivers E, Nguyen B, Havstad S, Ressler J, et al; Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368-77. PMID: 11794169.

Toxicology

  1. Weaver LK, Hopkins RO, Chan KJ, Churchill S, et al. Hyperbaric oxygen for acute carbon monoxide poisoning. N Engl J Med. 2002 Oct 3;347(14):1057-67. PMID: 12362006

Trauma

  1. Bickell WH, Wall MJ Jr, Pepe PE, Martin RR, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994 Oct 27;331(17):1105-9. PMID: 7935634
  2. CRASH-2 trial collaborators, Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010 Jul 3;376(9734):23-32. PMID: 20554319
  3. Hendey GW, Wolfson AB, Mower WR, Hoffman JR; National Emergency X-Radiography Utilization Study Group. Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma. Lancet J Trauma. 2002 Jul;53(1):1-4. PMID: 12131380
  4. Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998 Oct;32(4):461-9. PMID: 9774931
  5. Karounis H, Gouin S, Eisman H, Chalut D, et al. A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures. Acad Emerg Med. 2004 Jul;11(7):730-5. PMID: 15231459
  6. Moore EE, Knudson MM, Burlew CC, Inaba K, et al; WTA Study Group. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. J Trauma. 2011 Feb;70(2):334-9. PMID: 21307731
  7. Stiell IG, Wells GA, Vandemheen KL, Clement CM, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17;286(15):1841-8. PMID: 11597285
  8. Stiell IG, Wells GA, Vandemheen K, Clement C, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001 May 5;357(9266):1391-6. PMID: 11356436

Ultrasound

  1. Melniker LA, Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med. 2006 Sep;48(3):227-35. PMID: 16934640
  2. Nagdev AD, Merchant RC, Tirado-Gonzalez A, Sisson CA, Murphy MC. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. Ann Emerg Med. 2010 Mar;55(3):290-5. PMID: 19556029

Urology

  1. Smith-Bindman R, Aubin C, Bailitz J, Bengiamin RN, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med. 2014 Sep 18;371(12):1100-10. PMID: 25229916

Vascular

  1. Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000 Feb 16;283(7):897-903. PMID: 10685714

 

1.
Druck J, Pearson D, Claud J. The colorado compendium: an article-based literature review program. West J Emerg Med. 2009;10(1):21-22. [PubMed]
2.
Worster A, Kulasegaram K, Carpenter C, et al. Consensus conference follow-up: inter-rater reliability assessment of the Best Evidence in Emergency Medicine (BEEM) rater scale, a medical literature rating tool for emergency physicians. Acad Emerg Med. 2011;18(11):1193-1200. [PubMed]

Author information

Emily Junck, MD

Emily Junck, MD

Helicopter EMS Fellow
Auckland City Hospital
Auckland, New Zealand

The post 52 Articles in 52 Weeks (2nd edition, 2016) appeared first on ALiEM.

Magnesium for Rapid Atrial Fibrillation Rate-Control in the ED

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magnesium-ivWe love magnesium in the Emergency Department. It’s been said that magnesium is second-line for everything (kind of like doxycycline). But what about rate/rhythm control in atrial fibrillation (AF)? The 2014 AHA/ACC/HRS guideline for the management of patients with AF don’t mention magnesium at all.1 Dr. Josh Farkas (@PulmCrit) wrote about magnesium infusions for atrial fibrillation and torsade last year. His post looked at its use for cardioversion, rhythm-control, and rate-control in critically-ill patients. Our post will focus specifically on the IV magnesium data for rate-control in ED-related settings.

Over the years, IV magnesium has been studied for the treatment of rapid AF in several clinical situations, most prominently in post-cardiac surgery patients. However, there are also studies in ED and cardiology patients, both as a primary therapy and as an adjunct. In fact, two meta-analyses from 2007 evaluated the data (mostly the same studies).2,3 Both concluded that magnesium is safe and effective in controlling ventricular rate in rapid AF compared to placebo, the latter in patients also receiving digoxin. A closer look at the meta-analyses reveals that the positive rate control effect for magnesium seems to be driven by the placebo-controlled trials.4 Similarly, the positive benefit of magnesium in rhythm control is largely derived from trials versus placebo or traditional rate-control medications (e.g., beta-blockers or calcium channel blockers) rather than amiodarone or other rhythm-control agents. Of the 11 studies cited in the meta-analyses, only five reported rate-control data in ED-related settings. 

Rate-control with IV magnesium in ED-related settings

Citation Setting/Design Comparison Result
Chiladakis 20015 Cardiology department / prospective, randomized Diltiazem (n = 23): 25 mg IV over 15 min, then 12.5 mg/h infusion for 6 h
Magnesium (n = 23): 2.5 g IV over 15 min, then 7.5 g over 6 h
Similar efficacy in reducing ventricular rate at 1 hr (P <0.05)
Davey 20056 ED / prospective, randomized, double-blind, placebo-controlled Control (n = 97): 100 mL 5% dextrose, IV digoxin at the discretion of treating physician
Magnesium (n = 102): 2.5 g over 20 min then 2.5 g over2 h, IV digoxin at the discretion of treating physician
Magnesium more likely than placebo to achieve a HR <100 bpm (65% vs 34%, RR 1.89; 95% CI 1.38 to 2.59; P <0.0001)
Joshi 19957 ICU / prospective, controlled Verapamil (n = 45): 5 mg IV verapamil and repeat if no response after 15 min
Magnesium (n = 41): 2 g and repeat if no response after 15 min
Verapamil more likely to achieve HR <100 bpm (55.6% vs 19.5%) p < 0.0001
Hays 19948 ED / prospective, randomized, double-blinded, placebo-controlled Control (n = 8): placebo (not defined), 0.5 mg IV digoxin after first 30 min
Magnesium (n = 7): 2 g over 1 min, then 1 g/h for 4 h, IV 0.5 mg digoxin after first 30 min
At 5 minutes, ventricular rates decreased 16 +/- 7% (P <0.02) with MgSO4; this was comparable with rate control with digoxin (18 +/- 9%) at 4 hours
Gullestad 19939 Unclear / prospective, randomized Verapamil (n = 20): Verapamil 5 mg IV over 5 min, repeat 5 mg if no response after 10 min, followed by 0.1 mg/min infusion
Magnesium (n = 15): 1.2 g over 5 min, repeat if no response after 10 min, followed by infusion 0.04 mmol (0.01 g)/min
Verapamil more likely to achieve HR < 100 bpm at 4 hrs (48% vs 28%) p <0.05

One ED trial has been published since the meta-analyses.10 Twenty-four patients were randomized in a double-blinded, placebo-controlled fashion to receive either magnesium sulfate 2.5 gm (10 mmol) IV or 0.9% saline over 15 minutes.

  • Baseline heart rate (mean +/- standard deviation [SD])
    • Saline group: 140 +/- 21 beats/min
    • MgSO4 group: 125 +/- 24 beat/min
  • Heart rate at 2 hours
    • Saline group: 114 +/- 31 beats/min
    • MgSO4 group: 116 +/- 30 beats/min
  • The heart rate decrease across time did not differ between groups (p=0.124).

Dose

Based on the available date, the magnesium dose should be 2 gm IV over 15 minutes. Repeat boluses or continuous infusions were used in some trials and may be considered. To keep intracellular magnesium levels higher, infusions are theoretically necessary. But, it may not be logistically feasible to maintain a continuous magnesium infusion in the ED, especially considering there is not much supporting data to this point.

Adverse Effects

The primary adverse effects of IV magnesium administration across the trials were flushing and slight hypotension. All reactions were mild and self-limiting.

Magnesium Deficiency

Hypomagnesemia is often found in patients with rapid AF, but data is conflicting on whether the magnesium level matters.11,12 One study found no difference in magnesium’s effect on heart rate between magnesium deficient and non-deficient patients with rapid AF.

Chronic Atrial Fibrillation

Magnesium does not seem to have an effect on heart rate in patients with chronic AF.13

Bottom Line

Magnesium seems to be safe and moderately effective for reducing heart rate in rapid AF. Even in the studies where magnesium was less effective than an active comparator, it still demonstrated some reduction in HR. Therefore, consider administering 2 gm of IV magnesium as an adjunctive therapy while you are choosing between a calcium channel blocker or beta blocker as the primary agent.

Photo

1.
January C, Wann L, Alpert J, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):e1-76. [PubMed]
2.
Ho K, Sheridan D, Paterson T. Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta-analysis. Heart. 2007;93(11):1433-1440. [PubMed]
3.
Onalan O, Crystal E, Daoulah A, Lau C, Crystal A, Lashevsky I. Meta-analysis of magnesium therapy for the acute management of rapid atrial fibrillation. Am J Cardiol. 2007;99(12):1726-1732. [PubMed]
4.
Nair G, Morillo C. Magnesium in the acute management of atrial fibrillation: noise or music? Pol Arch Med Wewn. 2007;117(10):446-447. [PubMed]
5.
Chiladakis J, Stathopoulos C, Davlouros P, Manolis A. Intravenous magnesium sulfate versus diltiazem in paroxysmal atrial fibrillation. Int J Cardiol. 2001;79(2-3):287-291. [PubMed]
6.
Davey M, Teubner D. A randomized controlled trial of magnesium sulfate, in addition to usual care, for rate control in atrial fibrillation. Ann Emerg Med. 2005;45(4):347-353. [PubMed]
7.
Joshi P, Deshmukh P, Salkar R. Efficacy of intravenous magnesium sulphate in supraventricular tachyarrhythmias. J Assoc Physicians India. 1995;43(8):529-531. [PubMed]
8.
Hays J, Gilman J, Rubal B. Effect of magnesium sulfate on ventricular rate control in atrial fibrillation. Ann Emerg Med. 1994;24(1):61-64. [PubMed]
9.
Gullestad L, Birkeland K, Mølstad P, Høyer M, Vanberg P, Kjekshus J. The effect of magnesium versus verapamil on supraventricular arrhythmias. Clin Cardiol. 1993;16(5):429-434. [PubMed]
10.
Chu K, Evans R, Emerson G, Greenslade J, Brown A. Magnesium sulfate versus placebo for paroxysmal atrial fibrillation: a randomized clinical trial. Acad Emerg Med. 2009;16(4):295-300. [PubMed]
11.
Singh R, Manmohan M, Dube K, Singh V. Serum magnesium concentrations in atrial fibrillation. Acta Cardiol. 1976;31(3):221-226. [PubMed]
12.
Eray O, Akça S, Pekdemir M, Eray E, Cete Y, Oktay C. Magnesium efficacy in magnesium deficient and nondeficient patients with rapid ventricular response atrial fibrillation. Eur J Emerg Med. 2000;7(4):287-290. [PubMed]
13.
Frick M, Ostergren J, Rosenqvist M. Effect of intravenous magnesium on heart rate and heart rate variability in patients with chronic atrial fibrillation. Am J Cardiol. 1999;84(1):104-108, A9. [PubMed]

Author information

Bryan D. Hayes, PharmD, FAACT

Bryan D. Hayes, PharmD, FAACT

Associate Editor, ALiEM
Creator and Lead Editor, CAPSULES series, ALiEMU
Clinical Pharmacist, EM and Toxicology, MGH

The post Magnesium for Rapid Atrial Fibrillation Rate-Control in the ED appeared first on ALiEM.

ED Charting and Coding: Review of Systems (ROS)

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review of systems medical-chart-canstockphoto13003631-ros

The Review of Systems (ROS) was the most frustrating aspect of charting as an intern. Documenting at least 10 elements from systems seemingly unrelated to the chief complaint took as long as a physical exam and was much harder to remember. For efficiency, many of us include any pertinent positives and negatives in the history of present illness (HPI) and use an ROS caveat such as “10/14 Review of Systems completed and is negative except as stated above in HPI (Systems reviewed: Const, Eyes, ENT, Resp, CV, GI, GU, MSK, Skin, Neuro)” or “A complete Review of Systems was obtained and is negative except as stated in HPI.

This obviates documenting 10 or more separate systems, but what if you’re at a site where the coders won’t accept a blanket phrase? Should you keep your lengthy HPI and then chart the same info again? Or can we devise a ROS that is at a minimum not redundant, and perhaps even helpful?

CMS Definition & Requirements

The ROS is “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced”. CMS recognizes the following organ systems* for ROS (1995 E/M Documentation Guidelines, PDF):

  1. Constitutional
  2. Eyes
  3. Ears, Nose, Mouth, Throat
  4. Cardiovascular
  5. Respiratory
  6. Gastrointestinal
  7. Genitourinary
  8. Musculoskeletal
  9. Integumentary (skin and/or breast)
  10. Neurological
  11. Psychiatric
  12. Endocrine
  13. Hematologic/Lymphatic
  14. Allergic/Immunologic

*Organ systems: A complete ROS must document systems, not regions of the body. This is an important distinction, e.g. Eyes and ENMT count separately, but Head and HEENT don’t count.

You can document 4 types of ROS, depending on how many of the possible 14 systems are reviewed:

ros-table-em-level

Work Smarter, Not Harder: Resuscitating ROS

How do you make this section useful?

  • Offload pertinent positives and negatives from the HPI into ROS.
  • Organize your history with HPI first, then ROS, and PFSH last (mimicking how CMS arranges the E/M guidelines) so you can document a concise HPI statement and move directly to ROS. This will make your charting efficient, yet effective and billable.
  • Use the ROS as a cognitive backstop. As a junior resident documenting ROS, I often realized I had forgotten certain history questions, did not have enough information to exclude an item on my differential, or that something the patient said did not fit with the rest of the picture, prompting me to re-evaluate my differential.
  • Have a quick, rehearsed set of ROS questions to cover any systems not included in the history. For example: Fevers? Vision/hearing changes? Sore throat? Chest pain? Shortness of breath? Vomiting or diarrhea? Painful urination? Rashes? Joint pain or swelling? Numbness or tingling? Changes in mood? Heat or cold intolerance? Bleeding or bruising? Allergic reactions? Tailor this question set to your practice setting and specific patients.

Final Tips

  • One item– positive, negative, or normal– will suffice for each system.
  • If you use dot phrases or macros, have a 2-4 system ROS for most patients and a complete ROS for patients that will reach E/M level 5. Consider also having a separate pediatric ROS.
  • Always document at least 2 systems to prevent downcoding to an E/M level 2-3.
  • ROS can be obtained by ancillary staff or by patient questionnaire, as long as the physician reviews and discusses any pertinent positives or negatives with the patient. Be sure to notate this in your documentation: “I have reviewed the ROS questionnaire and discussed the pertinent positives and negatives with the patient.” Also, initial any physical forms, e.g. patient questionnaires, which you have reviewed.
  • A complete ROS can be a hybrid, listing pertinent positives and negatives by system, and then a notation indicating “All other systems are negative.”
  • Both caveats used in the introduction are valid examples per CMS. If you give a number of systems in your caveat, you must list that number of systems afterwards, so the second version is more straightforward.

 

Author information

Bjorn Watsjold, MD

Bjorn Watsjold, MD

Emergency Medicine Chief Resident
Division of Emergency Medicine
University of Washington

The post ED Charting and Coding: Review of Systems (ROS) appeared first on ALiEM.

PV Card: Algorithm for acute bronchiolitis management

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baby-cough-canstockphoto5283520Bronchiolitis is a common lower respiratory tract infection in children less than 2 years old, and especially in those 3-6 months old. In a collaboration with the American Academy of Pediatrics’ (AAP) Section on Emergency Medicine Committee on Quality Transformation, we present a PV card summarizing the Section’s “Clinical Algorithm for Bronchiolitis in the Emergency Department Setting” (reproduced with permission).1 Dr. Shabnam Jain sums it up best in her expert peer review below: “In bronchiolitis, less is more.”

How to use the Bronchiolitis Algorithm

Scope

  • Does not apply if severe or atypical presentation

Inclusion Criteria

  • Children, 1‐12 months of age, presenting with symptoms and signs suggestive of a clinical diagnosis of bronchiolitis, such as upper respiratory tract infection such as rhinitis and coughing, progressing to lower respiratory symptoms including wheezing, crackles, and/or tachypnea that may result in difficulty breathing and/or difficulty feeding

Exclusion Criteria

  • Full‐term infants that are <28 days old
  • Premature infants that are <48 weeks post‐conception
  • Patients with hemodynamically significant cardiac or significant pulmonary disease (such as bronchopulmonary dysplasia or asthma) or other major chronic conditions (such as immunodeficiency and neuromuscular disease)

aap-bronchiolitis-1

 

[Download the PV card]

 

(AAP) Section on Emergency Medicine Committee on Quality Transformation: Bronchiolitis Content Expert Team

  • Shabnam Jain, MD | Champion (Children’s Healthcare of Atlanta)
  • Anne Stack, MD | Co‐Champion (Boston Children’s Hospital)
  • Marc Baskin, MD (Boston Children’s Hospital)
  • Laura Chapman, MD (Hasbro Children’s Hospital)
  • Peter Dayan, MD (Morgan Stanley Children’s Hospital)
  • Mark Meredith, MD (Le Bonheur Children’s Hospital)
  • Graham Thompson, MD (Alberta Children’s Hospital)
  • Joseph Zorc, MD (Children’s Hospital of Philadelphia)

Note: This algorithm does not represent AAP policy and was not reviewed or approved by the AAP Board of Directors.


(c) Can Stock Photo / 800

1.
Ralston S, Lieberthal A, Meissner H, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-502. [PubMed]

Author information

Michelle Lin, MD

ALiEM Editor-in-Chief
Academy Endowed Chair of EM Education
Professor of Clinical Emergency Medicine
University of California, San Francisco

The post PV Card: Algorithm for acute bronchiolitis management appeared first on ALiEM.


ED Charting and Coding: Physical Exam (PE)

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medical-chart-canstockphoto13003631- physical exam“What do I see, hear, and smell when I walk into the room?” While the oral boards challenge you to perform the physical exam in a certain way, the day to day examination of patients can vary dramatically. Centers for Medicare and Medicaid Services (CMS), however, has physical exam guidelines for billing that conform to neither the exam you learned as a medical student nor the one you’ve refined as a resident. These disparities between what you do and how you’re asked to document it can lead to charts that are frequently down-coded or at risk if audited. The following discussion tries to unravel some of these twisted regulations and will provide tips and tricks on how to improve your physical exam documentation for coding and billing.

Double Standards

“There are no straight backs, no symmetrical faces, many wry noses, and no even legs. We are a crooked and perverse generation.” – Sir William Osler

There are 2 very different standards used to bill CMS and/or insurance companies: the 1995 and 1997 CMS guidelines. Overall, 1995 is too vague, 1997 is too specific, and the responsibility to choose one or the other falls on your coding department.

The 1995 guidelines identify Body Areas and Organ Systems as a framework for documenting the physical exam, but do not say what to chart under either.

The 1997 guidelines define mandatory physical exam elements and called them Bullets. A comprehensive exam requires all bulleted items to be examined, and at least 2 per system to be documented. The full list of bullets is in the appendix at the end of this post. These guidelines also describe Single Organ System examinations, which focus on a primary organ system but require bullets from other systems. Don’t bother looking these up– in general, a comprehensive single organ system examination is more complicated to perform and document than a comprehensive multi-system exam.

physical-exam-em-level

* 1995 guidelines allow a combination of systems & body areas for PF, EPF, & Detailed exams.  ** 1997 multi-system exam requires specific bullets for each system.

Work Smarter, Not Harder: Resuscitating the Physical Exam

  • Develop a structured, comprehensive exam that you can perform on nearly any patient, and use the normal findings for this exam as your documentation template. If your department uses the 1997 guidelines, read through the bullets and pick 2 per system to include in your exam.
  • Your examination is part of your decision making. The chief complaint will indicate certain positive or negative findings to be documented.
  • With many EMRs, vital signs are usually automatically pulled into your note. In addition to reviewing all vitals as part of good patient care, include a statement in your documentation that the recorded vital signs were reviewed.

Sample template for normal comprehensive physical exam

Vital Signs: P / BP / RR / SpO2 / T [1]
I have reviewed the triage vital signs.

  1. Const: Well-nourished, Well-developed (WNWD), Young/Middle-Aged/Elderly Male/Female appearing stated age [2].
  2. Eyes: PERRL [1], no conjunctival injection [2], and symmetrical lids [3].
  3. ENMT: Atraumatic external nose and ears [1]. Moist MM [2].
    * Neck: Symmetric, trachea midline [1], No thyromegaly [2].
  4. CVS: +S1/S2, No murmurs or gallops [1]. Peripheral pulses 2+ and equal in all extremities [2].
  5. RESP: Unlabored respiratory effort [1]. Clear to auscultation bilaterally (CTAB) [2].
  6. GI: Nontender/Nondistended (NTND) [1], No hepatosplenomegaly (HSM) [2].
  7. MSK: Normocephalic/Atraumatic (NC/AT) [1], Extremities w/o deformity or ttp [2]. No cyanosis or clubbing [3]
  8. Skin: Warm, Dry [1]. No rashes or lesions [2].
  9. Neuro: CNs II-XII grossly intact [1]. Sensation grossly intact [2].
  10. Psych: Awake, Alert, & Oriented (AAO) x3 [1]. Appropriate mood and affect [2].

The 10 listed items are for both the 1995 and 1997 guidelines. The bracketed red numbers are the bullets for the 1997 guidelines. The * counts as a system/area in the 1997 guidelines.

Final Tips

  • Although technically acceptable under 1995 guidelines, avoid charting only “normal” or “abnormal” under a system, instead list specific abnormal or pertinent normal findings.
  • Find out which guidelines your coders use: the list of organ systems is mostly the same, but the 1997 rules require far more specific information.
  • From an ethical and medical legal perspective, if you document it, examine it! Tailor your smart phrases or macros to a list of normals you reliably perform on every patient, every time, and include placeholders for you to add patient-specific information.
  • If your department utilizes scribes (or incorporates medical student notes), take an extra second to review their documentation for completeness and accuracy.

Additional Reading

Appendix: Full list of Organ Systems and Body Areas

Author information

Ted Fan, MD

Ted Fan, MD

Emergency Medicine Chief Resident
Department of Emergency Medicine
George Washington University

The post ED Charting and Coding: Physical Exam (PE) appeared first on ALiEM.

PV Card: Hip Injuries | Quick Reference Guide

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hip-dislocation-posterior-drawing hip injuriesOrthopedic injuries are commonly managed in the emergency department. Often a quick bedside reference card is needed to remind the clinician about the acute management decisions. This is the second of a series of orthopedic quick reference cards written by a team from the 2015-16 ALiEM Chief Resident Incubator. The first was on ankle and hindfoot fractures, and this card set covers hip injuries, such as hip dislocations and femur fractures. These cards were expert reviewed by Dr. Scott Sherman, co-editor of the Emergency Orthopedics textbook (Amazon), and illustrations were created by Dr. Mary Haas.

PV Card: Hip Injuries

hip-injuries-1-pv
 hip-injuries-2-pv

 [Download this PDF]

See other Paucis Verbis cards.

Author information

Layla Abubshait, MD

Layla Abubshait, MD

Faculty Development and Medical Education Fellow
Department of Emergency Medicine
Beth Israel Deaconess Medical Center
Harvard Medical School

The post PV Card: Hip Injuries | Quick Reference Guide appeared first on ALiEM.

ED Charting and Coding: Medical Decision Making (MDM)

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In this ED Charting and Coding Series, we have covered Introduction to ED Charting and Coding (PV Card); the History of Present Illness & Past Medical, Family, Social History; the Review of Systems; and the Physical Exam. At last we arrive at the crux of the chart: Medical Decision Making (MDM). In this final section, you show your work and your thought process.

CMS Assessment of Medical Decision Making

The Centers for Medicare & Medicaid Services (CMS) evaluates MDM based upon the highest 2 of the following 3 elements:

  1. The number of diagnostic and management options to be considered
  2. The complexity of data analyzed, including charts, tests, and other sources (family, EMS)
  3. The risk of complications, morbidity, and mortality associated with the presenting problem(s) and subsequently with the procedures and management options for them.

These elements are presented qualitatively in the following table. See each section below for more quantitative scoring systems.

mdm-em-level

Let’s work through a sample case, and discuss how each section is documented and then scored.

Diagnostic and Management Options

Begin your MDM section with a summary statement of the patient encounter and list your differential diagnosis:

Ms. Example is a 25-year-old woman with a history of prior ectopic pregnancy who presents with acute RLQ pain concerning for ectopic pregnancy, PID, ovarian torsion, appendicitis, or other acute ovarian or abdominal pathology.

This case involves a new, acute problem with a broad differential including several high-risk diagnoses. These will apply to both the number and nature of problems and later to evaluation of risk.

Scoring the number of diagnostic and treatment options is accomplished in most places using the “Marshfield Clinic Scoring Tool,” which is not officially part of the E/M guidelines nor endorsed by CMS or the AMA. The tool tries to infer complexity from the nature of the problem and the effort it will take to address it. The following tables show the tool and the most common conversion from Marshfield “problem points” to the E/M guidelines element for number of diagnostic and management options.

marshfield-scoring-mdm-em-level

The tool was developed for clinic appointments, but the American College of Emergency Physicians (ACEP) has recommendations to adapt it to the emergency department (ED) setting. The first distinction is new vs established problems. In the ED, most patients present with problems that are new to the examiner, so unless you are caring for a patient on a planned return visit, your cases will either be minor, self-limited problems (1 point for each problem) or new medical problems that require consideration, guidance for care, and often some kind of workup (3 or 4 points for each problem). Contrasted to the clinic setting, where testing is typically done between visits, in the ED we order, perform, and interpret most of our tests during the visit. So any new problem you can diagnose and manage by history and physical exam alone will score 3 points, and those requiring testing to guide diagnosis and management will score 4 points, as in the case of Ms. Example.

Ms. Example’s case should score 4 points for Extensive diagnostic and management options, because of her new abdominal pain requiring further imaging.

Data Review

The body of your MDM will describe how you work through your differential. Decisions based upon your history and exam require minimal additional information, but cases that require chart review, tests, and images are credited for increasing complexity.

To score your data review, you may use a table to calculate “data points” for the different kinds of testing, interpretation, and record review. In the table below, note that different kinds of testing score separately, and if you are providing your own read (even if you have a radiologist, cardiologist, or pathologist also on record) you get credit for that work. It’s important to include your interpretation of test results, both as part of your thought process and because your input counts.

As a side note, ECG interpretation must include ≥3 of 6 elements:

  1. Rate/rhythm
  2. Axis
  3. Intervals
  4. ST-segment changes
  5. Comparison to prior
  6. Summary of the patient’s clinical condition

You may also interpret the telemetry monitor recordings, which should include a mention of rate and rhythm.

data-points-complexity

I have ordered a CBC, BMP, and urinalysis with urine HCG. I will add a serum HCG if this is positive, in which case we will follow with US, or if negative I plan to proceed to CT scan of the abdomen. I also reviewed Ms. Example’s visit with Dr. Gyn 6 weeks ago, which showed that Ms. Example had negative UPT, gonorrhea, and chlamydia testing as well as a benign examination and unremarkable wet prep at that visit.

We will treat Ms. Example’s pain with IV morphine, and nausea with ondansetron.

On reevaluation, Ms. Example’s pain and nausea are significantly improved and she is resting comfortably, but she continues to have RLQ rebound tenderness. I have reviewed her laboratory results, which show an elevated WBC, normal hematocrit, and platelets. Her electrolytes and renal function are all normal. Her urinalysis shows no sign of infection, and urine HCG is negative, making ectopic unlikely. I have ordered a CT scan of the abdomen after discussing the above results with the patient.

I have reviewed the CT scan, which demonstrates a distended appendix with surrounding fat stranding that are concerning for appendicitis without perforation. I discussed with the radiologist the appearance of the right ovary and uterine tube, which are normal. I then consulted Dr. Jen Surgeon, who will admit the patient, and requested IV cefoxitin preoperatively. Ms. Example was informed of the CT scan results and consultation, and is amenable to the plan for admission and likely appendectomy. She will be kept NPO.

This gives us 1 for lab tests, 1 for radiology, 2 for your personal review of the CT scan, and 2 for your review and summation of old records (the OB visit), for a total of 6 data points. This indicates an extensive amount and complexity of data reviewed.

Risk

We can also address the level of risk involved for the presenting problem, testing, and treatment plan. The following table gives examples for risk, based upon the categories of presenting problems, testing required, and treatment plans. Important to note: the highest single item in any category determines the level of risk (CMS Evaluation and Management Services Guide, PDF).

risk-levels

The differential diagnosis for RLQ pain in a 25-year-old woman includes causes at each level of risk, and you should tailor both your differential and your workup appropriately to the presenting problem. Failure to account for higher-risk diagnoses, perform adequate testing, and appropriately escalate care are major areas of potential liability for EM providers. For Ms. Example, if you limited your workup to cystitis and ovarian cysts, this would be minimal to low risk. Considering pelvic inflammatory disease (PID) or other serious infection is moderate risk. Being appropriately concerned for appendicitis, peritonitis, and ovarian torsion reaches high risk. Non-invasive testing (labs and radiology) is considered low risk, but use of IV opioids to treat pain places the management level at high risk (drug therapy requiring monitoring).

Our sample case demonstrates High Complexity MDM based upon extensive diagnostic and management options, extensive data review and analysis, and high risk. It was quite thoroughly documented, but the scoring could be accounted for with just two items: a new problem requiring testing and pain treated with IV narcotics.

mdm-em-level-arrows

 

Work Smarter, Not Harder: Show Your Effort

The MDM is arguably the most important section of the patient’s record. There are many styles of documentation depending on your system, our example reflects the style we have adopted since using computer dictation, and many will be much shorter. Regardless, every MDM should include 3 core elements:

  1. Explain the complexity of the diagnostic and management options available to you by giving a brief summary of your patient’s presentation followed by your differential diagnosis, no matter how short.
  2. Describe and interpret the data that you obtained and reviewed. Be sure to use a phrase such as, “on my interpretation,” when you independently interpret radiographs or ECGs and briefly summarize prior visits that you reviewed.
  3. Be sure to mention the risk the patient is at due to their underlying pathology, the testing that is required to make a diagnosis, and the treatments that you administer or prescribe.

This example demonstrates the core elements of the MDM up to the point of admission for billing purposes, but leaves out the greater proportion of charts you will write: discharges. Documentation of discharge planning, return precautions, and unplanned discharges including those leaving against medical advice (AMA) and risk-minimizing measures will be covered in a future post.

Author information

Bjorn Watsjold, MD

Bjorn Watsjold, MD

Emergency Medicine Chief Resident
Division of Emergency Medicine
University of Washington

The post ED Charting and Coding: Medical Decision Making (MDM) appeared first on ALiEM.

PV Card: Knee Injuries | Quick Reference Guide

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patella-dislocation knee injuriesOrthopedic injuries are commonly managed in the emergency department. Often a quick bedside reference card is needed to remind the clinician about the acute management decisions. This is the third of a series of orthopedic quick reference cards written by a team from the 2015-16 ALiEM Chief Resident Incubator. The first two were on ankle and hindfoot fractures and hip injuries. This card set covers knee injuries, specifically patella fractures, patella dislocation, and knee dislocation. These cards were expert reviewed by Dr. Scott Sherman, co-editor of the Emergency Orthopedics textbook (Amazon), and illustrations were created by Dr. Mary Haas.

PV Card: Knee Injuries


See other Paucis Verbis cards.

Author information

Layla Abubshait, MD

Layla Abubshait, MD

Faculty Development and Medical Education Fellow
Department of Emergency Medicine
Beth Israel Deaconess Medical Center
Harvard Medical School

The post PV Card: Knee Injuries | Quick Reference Guide appeared first on ALiEM.

PV Card: LVAD Complications

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lvad-image-from-mayo

Patients with left ventricular assist devices (LVAD) often cause much anxiety amongst providers in the emergency department. This is understandable with all of the hardware, diminished or absent peripheral pulses at baseline, and potential for complications. To add to the already helpful reviews about LVADs at REBELEM and emDocs, this is a PV card set providing a methodical approach to troubleshooting LVAD complications, including a reproduction of an algorithm for managing the LVAD patient with altered mental status from EMCrit.1–3


[Download PDF]

Thumbnail LVAD image use approved by Mayo Foundation for Medical Education and Research

1.
Partyka C, Taylor B. Review article: ventricular assist devices in the emergency department. Emerg Med Australas. 2014;26(2):104-112. [PubMed]
2.
Andersen M, Videbaek R, Boesgaard S, Sander K, Hansen P, Gustafsson F. Incidence of ventricular arrhythmias in patients on long-term support with a continuous-flow assist device (HeartMate II). J Heart Lung Transplant. 2009;28(7):733-735. [PubMed]
3.
Greenwood J, Herr D. Mechanical circulatory support. Emerg Med Clin North Am. 2014;32(4):851-869. [PubMed]

Author information

Nicolas Stadlberger, MD

Nicolas Stadlberger, MD

Emergency Medicine Resident
Dartmouth-Hitchcock Medical Center

The post PV Card: LVAD Complications appeared first on ALiEM.

Ultrasound For The Win! Case – 40F with Fever, Chest Pain, Shortness of Breath

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Welcome to another ultrasound-based case, part of the “Ultrasound For The Win!” (#US4TW) Case Series. In this case series, we focus on a real clinical case where point-of-care ultrasound changed the management of a patient’s care or aided in the diagnosis. In this case, a 40-year-old woman presents with a fever, chest pain, shortness of breath, cough, and generalized weakness.

Case Presentation

A 40-year-old woman presents to the Emergency Department (ED) for evaluation of multiple complaints including fever, chest pain, shortness of breath, cough, and generalized weakness. She denies any known sick contacts or recent travels, and denies any significant past medical history. Her review of systems is otherwise unremarkable. On social history, she endorses intravenous (IV) drug abuse.

Vitals

  • BP 93/56 mmHg
  • P 109 bpm
  • RR 24 breaths/min
  • O2 93% room air
  • T 38.0 C

Differential Diagnosis

  • Acute Coronary Syndrome (ACS)
  • Endocarditis
  • Influenza-Like Illness (ILI)
  • Myocarditis
  • Pericarditis
  • Pneumonia
  • Pulmonary Embolism (PE)
  • Sepsis

She is placed in an isolation room. On physical examination, you find a woman who appears older than stated age. She is in moderate respiratory distress and diaphoretic. On auscultation, her heart is tachycardic and regular without murmurs or rubs. She has coarse breath sounds throughout. Examination of the skin reveals track marks on bilateral ventral forearms, with no other sores, petechiae, or lesions noted.

Fluid resuscitation is started via two large-bore IVs, and initial laboratory studies including blood cultures are drawn. While awaiting a portable chest x-ray, the emergency physician performs a point-of-care echocardiogram.

Workup

Point-of-Care Ultrasound

image-1-endocarditis

Figure 1. Apical-4-chamber cardiac view revealing vegetations on the tricuspid valves concerning for right-sided infective endocarditis.

 

image-2-endocarditis

Figure 2. Large vegetations (arrows) are identified on the tricuspid valves (*). RA = right atrium, RV = right ventricle, LA = left atrium, LV = left ventricle

image-3-endocarditis

Figure 3. Trans-thoracic echo revealing vegetations on the tricuspid valves.

image-4-endocarditis

Figure 4. Vegetation (arrow) on the tricuspid valve

Given the concern for infective endocarditis, broad-spectrum antibiotics are started. At this point, the chest x-ray is performed:

image-5-cxr-pulm-infarct-endocarditis

Figure 5. Chest x-ray revealing a new cavitary mass (3.9 cm) in the left upper lobe. Differential considerations include septic embolus, cavitary pneumonia (tuberculosis/fungal), and abscess.

Laboratory Investigations

Laboratory studies return and are unremarkable:

  • WBC 7.9 x10³/µL
  • Lactate 1.1 mg/dL
  • Hemoglobin 9.2 g/dL
  • Three (3) sets of blood cultures are sent and pending

Ultrasound Image Quality Assurance (QA)

Infective endocarditis (IE) has been historically diagnosed clinically with the aid of the Duke Criteria; however, the requirements for diagnosis are not typically met in the ED as they require a prolonged hospitalization. Thus, the Duke Criteria is largely irrelevant in the ED, making IE a particularly challenging diagnosis for emergency physicians. Fortunately, point-of-care trans-thoracic echocardiogram (TTE) is readily available in most EDs, and can be considered the initial imaging study of choice to look for vegetations.

Vegetations on echocardiogram are visualized as mobile masses on the cardiac valves that move independently from the valves themselves. Vegetations as small as 6 mm can be seen with TTE.1 The identification of right-sided vegetations in particular can be difficult to visualize with a parasternal view. A subxiphoid or apical-4-chamber view may be needed to better visualize these vegetations which highlights the importance of obtaining multiple views when performing a point-of-care echocardiogram.

Valvular incompetence can be evaluated when vegetations are identified or suspected, and has been found to be both diagnostic and prognostic.1 Assessing for tricuspid or mitral regurgitation involves the use of Color Doppler in the apical-4-chamber view. A regurgitant jet is identified with color flow moving away from the probe when the valves close. Additionally, atrial enlargement may be associated with regurgitation.

Abscesses can also be associated and identified with IE (albeit difficult with TTE) as a thickened region with an associated heterogenous echogenic area.

Is TEE sensitive enough to rule out endocarditis in the Emergency Department?

Studies comparing the test characteristics of TTE vs. TEE in the identification of vegetations reveal sensitivities of 30-65% for TTE compared with sensitivities of 87-100% for TEE.2,3 However for right-sided endocarditis, there is an improved sensitivity with TTE, and TEE may not be necessary if clear vegetations are visualized with TTE.3 Of course, the size of a vegetation is a large determinant in its ability to be visualized with TTE. One study revealed that 25% of vegetations <5 mm in size were identified by TTE, 70% of those between 6-10 mm were identified, and 84% of vegetations >10 mm were identified with TTE (Figure 6).1

Figure 6. Identification of vegetations with trans-thoracic echocardiography based on size of vegetation. Adapted from Seif et al.

The data from Figure 6 above can prove particularly useful for emergency physicians as larger vegetations (i.e. >10 mm) or vegetations with severe mobility are independent prognostic factors that are associated with a higher risk of complications (including septic emboli) and mortality.1,4 If these higher-risk patients can be identified by emergency physicians by TTE, more aggressive management and consultation can be initiated earlier, potentially decreasing patient morbidity and mortality.

Thus the utility for the use of TTE in patients with suspicion for infective endocarditis in the ED may be in the ability to risk-stratify patients who are at higher risk for complications such as embolic events and death.

Disposition and Case Conclusion

The visualization of vegetations on the tricuspid valves on point-of-care trans-thoracic echocardiogram helped confirm the diagnosis of right-sided infective endocarditis. The patient was admitted to the ICU for continued IV antibiotics and medical management, in consultation with cardiothoracic surgery during her hospitalization.

A transesophageal echocardiogram was performed during her admission the following day, which revealed:

Multiple large tricuspid valve vegetations (20 mm and 10 mm) attached to both the anterior and posterior leaflets of the tricuspid valve. Mild tricuspid regurgitation. No abscess cavity. Mitral, aortic, pulmonic valves appear normal. Normal biventricular systolic function. No pericardial effusion.

Blood cultures grew gram positive cocci, confirmed to be methicillin-resistant staphylococcus aureus (MRSA), sensitive to vancomycin.

After a prolonged hospitalization, the patient was discharged to home in stable condition with no complications.

Infective Endocarditis

Infective endocarditis (IE) is an uncommon and life-threatening disease with significant morbidity and mortality.1 There are an estimated 10,000 to 15,000 new cases of IE in the United States annually.5 The most common presenting symptoms of IE are non-specific and include fever, anorexia, weight loss, and night sweats.6 The classic physical exam findings including cardiac murmurs, petechiae, Janeway lesions, and Osler’s nodes are relatively rare and may not be evident in cases of IE.6 In fact, a study by Pathak et. al. revealed that tricuspid regurgitation could only be identified 12-33% of the time via cardiac auscultation by Internal Medicine residents and Cardiology fellows.5

Risk factors for IE include patients with prosthetic heart valves, structural heart disease, and intravenous drug use.5 As compared to left-sided endocarditis, right-sided endocarditis tends to affect patients who are younger, have a history of IV drug abuse, and tend to have larger vegetations.3

Complications from IE include septic shock and embolic events. The mortality rate of IE is high (up to 40%) with the most common causes of death being septic shock and multi-organ failure.4,6,7 Thus, a high index of suspicion with early recognition and diagnosis with aggressive early management is needed.

Treatment of IE includes aggressive resuscitation, broad spectrum IV antibiotics that cover the most common organisms (staphylococci and streptococci), which may include vancomycin + gentamicin.8 Cardiothoracic surgery consultation can be considered for potential valvulectomy.6 The indications for valvulectomy include persistent fever, large vegetations, severe right-sided heart failure, or recurrent pulmonary emboli.8

Trans-Esophageal Echocardiography (TEE) in the ED

While not yet widespread, TEE is becoming increasingly used in EDs by emergency physicians, primarily in patients with cardiac arrest. A great online resource for learning more about TEE is the Virtual Transesophageal Echocardiography Simulator by the Toronto General Hospital, Department of Anesthesia.

Take Home Points

  1. Infective endocarditis (IE) is a life-threatening disease with a high morbidity and mortality that often presents with non-specific symptoms. This challenging diagnosis requires a high-index of suspicion by the emergency physician.
  2. Trans-thoracic echocardiogram, while not as sensitive as trans-esophageal echocardiogram, can be used to risk stratify patients at high risk for complications of IE including septic emboli.
  3. Vegetations appear as mobile masses on the valves that move independently from the valves themselves. Vegetations as small as 6 mm can be visualized with TTE.
  4. Management of IE includes aggressive medical management including broad spectrum antibiotics, hospital admission, and consideration for cardiothoracic surgery consultation.
1.
Seif D, Meeks A, Mailhot T, Perera P. Emergency department diagnosis of infective endocarditis using bedside emergency ultrasound. Crit Ultrasound J. 2013;5(1):1. [PubMed]
2.
San R, Vilacosta I, López J, et al. Role of transthoracic and transesophageal echocardiography in right-sided endocarditis: one echocardiographic modality does not fit all. J Am Soc Echocardiogr. 2012;25(8):807-814. [PubMed]
3.
Reynolds H, Jagen M, Tunick P, Kronzon I. Sensitivity of transthoracic versus transesophageal echocardiography for the detection of native valve vegetations in the modern era. J Am Soc Echocardiogr. 2003;16(1):67-70. [PubMed]
4.
Thuny F, Di S, Belliard O, et al. Risk of embolism and death in infective endocarditis: prognostic value of echocardiography: a prospective multicenter study. Circulation. 2005;112(1):69-75. [PubMed]
5.
Pathak N, Ng L, Saul T, Lewiss R. Focused cardiac ultrasound diagnosis of right-sided endocarditis. Am J Emerg Med. 2013;31(6):998.e3-4. [PubMed]
6.
Nunes M, Gelape C, Ferrari T. Profile of infective endocarditis at a tertiary care center in Brazil during a seven-year period: prognostic factors and in-hospital outcome. Int J Infect Dis. 2010;14(5):e394-8. [PubMed]
7.
Kini V, Logani S, Ky B, et al. Transthoracic and transesophageal echocardiography for the indication of suspected infective endocarditis: vegetations, blood cultures and imaging. J Am Soc Echocardiogr. 2010;23(4):396-402. [PubMed]
8.
Hecht S, Berger M. Right-sided endocarditis in intravenous drug users. Prognostic features in 102 episodes. Ann Intern Med. 1992;117(7):560-566. [PubMed]

Author information

Jeffrey Shih, MD, RDMS

Director, Emergency Ultrasound Fellowship Program,
The Scarborough Hospital
Lecturer,
University of Toronto
Assistant Editor, Ultrasound for the Win Series,
Academic Life in Emergency Medicine

The post Ultrasound For The Win! Case – 40F with Fever, Chest Pain, Shortness of Breath appeared first on ALiEM.

AIR Series: Infectious Disease Module (2016)

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Welcome to the Infectious Disease Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index the ALiEM AIR Team is proud to present the highest quality procedure content. Below we have listed our selection of the 18 highest quality blog posts within the past 12 months (as of August 2016) related to Infectious Disease emergencies, curated and approved for residency training by the AIR Series Board. More specifically in this module, we identified 2 AIRs and 16 Honorable Mentions. We recommend programs give 6 hours (about 20 minutes per article) of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have two subsets of recommended resources. The AIR stamp of approval will only be given to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Take the quiz at ALiEMU:
ALiEMU AIR Infectious Disease block quiz

Interested in taking the quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a one-time login account if you haven’t already.

Highlighted Quality Posts on Infectious Diseases

Article Title Author Date Label
EMLyceum: Diarrhea, “Answers” Salil Bhadari, MD November 2, 2015 AIR
EMCrit: PulmCrit- Neurocritical care of the comatose meningitis patient Josh Farkas, MD December 21, 2015 AIR
EMCrit: Evidence-based treatment for severe community-acquired pneumonia Josh Farkas, MD August 16, 2016 Honorable Mention
EMCrit: PulmCrit: Which patients admitted for pneumonia need MRSA coverage? Josh Farkas, MD July 18, 2016 Honorable Mention
First10EM: Articles of the month Special Edition: Pediatric UTI Justin Morgenstern, MD February 2, 2016 Honorable Mention
PedsEMMorsels: UTI Empiric Antibiotics Sean Fox, MD April 15, 2016 Honorable Mention
PedsEMMorsels: Sickle Cell Disease and Fever Sean Fox, MD March 18, 2016 Honorable Mention
ALiEM: Zika Virus: What emergency department providers need to know Lauren Pike, MD and Julian Villar, MD February 15, 2016 Honorable Mention
PEMBlog: The Febrile Infant – University of Cincinnati Emergency Medicine Collaboration Brad Sobolewski, MD March 1, 2016 Honorable Mention
EMDocs: Blood Cultures: When Do They Make a Meaningful Impact on Clinical Care Desiree Brooks, MD April 23, 2016 Honorable Mention
CoreEM: Spinal Epidural Abscess Latrice Triplett, MD December 30, 2015 Honorable Mention
EMDocs: Fever in the Returning Traveler Nazanin Meshkat, MD, Matthew Muller, Keerat Grewal, MD, Anton Helman MD April 2015 Honorable Mention
EMDocs: Lactate in Sepsis: Pearls & Pitfalls Erik Hofmann, MD March 6, 2016 Honorable Mention
REBEL EM: Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses? Salim Rezaie, MD March 10, 2016 Honorable Mention
EMDocs: Updates on Recommendations For STI Treatments & Empiric Therapy: When to Treat and What to Treat Depending on your Patient Adrianna Levesque, MD March 3, 2016 Honorable Mention
EMCrit: Steroids in septic shock: Four misconceptions and one truth Josh Farkas, MD July 12, 2015 Honorable Mention
PedsEMMorsels: Bulging Fontanelle Sean Fox, MD March 4, 2016 Honorable Mention

If you have any questions or comments, please contact us!

Author information

Andrew Grock, MD

Andrew Grock, MD

Lead Editor/Co-Founder of ALiEM Approved Instructional Resources (AIR)
Assistant Professor of Emergency Medicine
UCLA Emergency Medicine Department

The post AIR Series: Infectious Disease Module (2016) appeared first on ALiEM.


PV Card: Elbow Injuries

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elbow injuries

Elbow injuries are a common presentation to the Emergency Department. This pocket card reviews some the imaging, acute management, and some pearls for the following injuries: elbow dislocation, radial head subluxation, supracondylar fractures (such as the xray on the right), radial head fracture, epicondylitis, condyle fractures, and olecranon fracture. Thanks to Dr. Jonathon Hancock (Doctor’s Hospital orthopedist) for the expert peer review.

PV Card: Elbow Injuries

View other PV Cards.

 

Author information

Melody Glenn, MD

Melody Glenn, MD

2016-2018 EMS and Disaster Medicine Fellow
University of California San Francisco

The post PV Card: Elbow Injuries appeared first on ALiEM.

AIR-Pro: Toxicology (Part 2)

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Welcome to the Toxicology (Part 2) AIR-Pro Module. Below we have listed our selection of the 12 highest quality blog posts related to 5 advanced level questions on toxicology topics posed, curated, and approved for residency training by the AIR-Pro Series Board. The blogs relate to the following questions:

  1. One-pill-could-kill ingestions for pediatrics patients
  2. Decontamination techniques
  3. Physostigmine
  4. Alcohol Withdrawal
  5. High dose insulin therapy

In this module, we have 8 AIR-Pro’s and 4 Honorable Mentions. To strive for comprehensiveness, we selected from a broad spectrum of blogs identified through FOAMSearch.net and FOAMSearcher.

AIR-Pro Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR-Pro stamp of approval will only be given to posts scoring above a strict scoring cut-off of ≥28 points (out of 35 total), based on our AIR-Pro scoring instrument, which is slightly different from our original AIR Series scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR-Pro Board members as worthwhile, accurate, unbiased and useful to senior residents. To decrease the repetitive nature of posts relating to these advanced concepts, we did not always include every post found that met the score of ≥28 points.

Take the quiz at ALiEMU
ALiEMU AIR-Pro Toxicology block quiz

Toxicology Module (Part 2) 2016: Recommended III credit hours

4 hours (20 minutes per article, 30 minutes for articles with podcasts)

Article Author Date Label
ALiEM: PV Card – Pediatric Ingestion Dose Thresholds for ED Referral Bryan D. Hayes Jul 9, 2014 AIR-Pro
Core EM: Hyperinsulinemia Euglycemia Therapy Jenny Beck-Esmay & Daniel Lugassy Sept 5, 2015 AIR-Pro
Dr. Smith’s ECG Blog: Delirium and Physostigmine Steve Smith Mar 7, 2015 AIR-Pro
EMCrit: Phenobarbital monotherapy for alcohol withdrawal  Josh Farkas Oct 18, 2015 AIR-Pro
EM Docs: Alcohol Withdrawal  Drew Long & Brit Long Jun 28, 2016 AIR-Pro
EM Docs: Physostigmine for Management of Anti-Cholinergic Toxidrome Sahaphume Srisuma & James Dazhe Cao May 5, 2015 AIR-Pro
EM Docs: The Approach to the Poisoned Patient Levi Kitchen Jul 9, 2015 AIR-Pro
LITFL: Enhanced Elimination Mike Cadogan Nov 21, 2016 AIR-Pro
CoreEM: Anti-Cholinergic Poisoning Anand Swaminathan & Jenny Beck-Esmay May 23, 2016 Honorable Mention
JEMS: Assessing & Treating Pediatric Poisonings Caused by One Dose of Adult Medication Chelsea White & Gabriel De Baltz Sept 4, 2015 Honorable Mention
REBEL EM: Benzodiazepine Refractory Alcohol Withdrawal Darrel Hughes April 28, 2016 Honorable Mention
The Poison Review: Must-read: review of single-dose activated charcoal Leon Gussow Nov 17, 2015 Honorable Mention

 

Author information

Fareen Zaver, MD

Fareen Zaver, MD

Lead Editor/Co-Founder of ALiEM Approved Instructional Resources - Professional (AIR-Pro)
Champion, 2016-17 ALiEM Chief Resident Incubator
Board Member, 2016-17 ALiEM Wellness Think Tank
Clinical Lecturer, Emergency Physician
University of Calgary Emergency Department

The post AIR-Pro: Toxicology (Part 2) appeared first on ALiEM.

Trick of the Trade: A cleaner way to apply dental cement for a tooth fracture

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dental cement for tooth fracture The management of a dental fracture is a core skill of the emergency physician.1 When the enamel is violated and the underlying dentin is exposed (i.e. Ellis Class II or greater), the dental pulp becomes at risk.2Protecting the exposed dentin in a timely manner, therefore, is paramount. This is best accomplished through the use of dental cements.

The application of dental cement to a fractured tooth, while a relatively rare procedure, is one often fraught with difficulties. With many of the formulations requiring the rapid application of a fast-drying cement, time for accurate and clean application is limited. This often clumsy, haphazard spackling of the patient’s tooth with cement rarely feels smooth or confidence-instilling. Isn’t there a better way?

Trick of the Trade:

Syringe and Angiocatheter Application of Dental Cement

Using materials easily found in the emergency department, this trick is an easy, slick way to apply dental cement where you need it… and only where you need it.

Equipment

  1. 3 mL syringe
  2. 18 gauge angiocatheter
  3. Dental cement, paper, and stem for mixing

Steps

  • Gather all of your materials before mixing your cement and familiarize yourself with the technique. This will prevent your cement from prematurely drying in your syringe before application.
  • Remove the plastic 18 gauge catheter tip from the angiocatheter and screw it into your syringe.
  • Mix your dental cement. For ease of getting it into your syringe, mix slightly more than you may typically.
  • Remove the plunger from your syringe and scrape the cement into the back end. Re-insert the plunger and press until the cement engages the angiocatheter.
  • Apply the dental cement to your patient via this clean and targeted method.

Tips

  • Be sure to have all your materials gathered before you start mixing. The syringe method does not alter drying times.
  • Mix slightly more cement than you anticipate using, as some volume is lost in transfer from paper to syringe.
  • As with any dental cement application procedure, strategically insert gauze and dental pledgets in the patient’s mouth to create a dry environment before application.

(c) Can Stock Photo / focalpoint

1.
Counselman F, Borenstein M, Chisholm C, et al. The 2013 Model of the Clinical Practice of Emergency Medicine. Acad Emerg Med. 2014;21(5):574-598. [PubMed]
2.
Beaudreau R. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, Seventh Edition (Book and DVD). (Tintinalli J, Stapczynski J, Ma O John, Cline D, Cydulka R, Meckler G, eds.). Mcgraw-hill; 2010.

Author information

Jason Hine, MD

Jason Hine, MD

Attending Physician
Emergency Department
Southern Maine Health Care

The post Trick of the Trade: A cleaner way to apply dental cement for a tooth fracture appeared first on ALiEM.

Trick of the Trade: Warfarin tablet strength identification

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warfarinMedical providers commonly encounter patients in the emergency department who state they are anticoagulated with warfarin, but they have no idea what dose they are taking. “I know that I take two pills of warfarin daily.” Dosing becomes critically important especially when continuing their medication as an inpatient, refilling their medications, or adjusting their outpatient dose because of an inappropriately high or low INR level. How can you determine the patient’s warfarin dose?

Trick of the Trade

Ask about the color of his/her warfarin tablets

In the United States, manufacturers of both brand and generic warfarin have agreed to make each strength a consistent color. While the colors do NOT change, the shape and shade may vary.

Helpful Mnemonics

To aid your memory recall of the colors, you can use this mnemonic

Please Let Granny Brown Bring Peaches To Your Wedding”

Alternatively, @scepticalemdoc from Queensland, Australia offered an EM-related mnemonic:

Probably Leaves Granny Bleeding Bloody Profusely, Thank You Warfarin”

Mnemonic Warfarin Tablet Color Tablet Strength
Probably Pink 1 mg
Leaves Lavender 2 mg
Granny Green 2.5 mg
Bleeding Brown 3 mg
Bloody Blue 4 mg
Profusely Peaches 5 mg
Thank Teal 6 mg
You Yellow 7.5 mg
Warfarin White 10 mg

Safety Considerations

While this color-coding scheme holds true for warfarin dispensed in the United States, it may not apply in other countries as pointed out by @laurajanebroad. Also be cautious of patients with deuteranopia (color-blindness), who may mistakenly report the wrong tablet color.

Another trick using colors

Color-coded eye drop bottles

Author information

Samantha Boartfield, PharmD

Samantha Boartfield, PharmD

PGY-1 Pharmacy Practice Resident
Banner University Medical Center – Phoenix

The post Trick of the Trade: Warfarin tablet strength identification appeared first on ALiEM.

Top 8 Must-Know EM Pharmacotherapy Articles of 2016

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Top 8 must-know EM pharmacotherapy articles of 2016For the third consecutive year, we provide a quick summary of some important Emergency Medicine pharmacotherapy articles from the last 12 months. We have tried to focus on articles you may have missed, but are potentially high-impact for improving clinical practice in the ED. Without further ado, we present the 8 must-know EM pharmacotherapy articles of 2016.

Top 8 EM EM Pharmacotherapy Articles of 2016

1. Vancomycin Loading Doses in ED Not Associated with Increased Nephrotoxicity2. Ketamine for Prehospital Agitation3. Does Succinylcholine Increase Mortality in Severe TBI Patients?4. Predicting Hemodynamic Response to Ketamine in Prehospital RSI5. Esmolol for Refractory Ventricular Fibrillation6. The Ceiling Effect of IV Ketorolac7. Piperacillin/Tazobactam and Risk of Acute Kidney Injury with Vancomycin8. Utility of Pre-4-Hour Acetaminophen Levels in Acute Overdose

Guidelines recommend loading doses of vancomycin (15-20 mg/kg, up to 30 mg/kg in critically ill patients), but the risk of nephrotoxicity is unknown. A new retrospective cohort study aimed to compare nephrotoxicity in ED sepsis patients who received vancomycin at high doses (>20 mg/kg) versus lower doses (20 mg/kg).

What They Found

  • 1,330 patients had 3 serum creatinine values assessed for the primary outcome
  • High-dose initial vancomycin was actually associated with a lower rate of nephrotoxicity (5.8% vs 11.1%)
  • After adjusting for age, gender, and initial serum creatinine, the risk of high dose vancomycin compared to low dose was decreased for the development of nephrotoxicity (RR=0.60; 95% CI: 0.44, 0.82)

Application to Clinical Practice

It appears initial loading doses of vancomcyin >20 mg/kg do not cause increased risk of nephrotoxicity.

Reference

1.
Rosini J, Davis J, Muenzer J, et al. High Single-dose Vancomycin Loading Is Not Associated With Increased Nephrotoxicity in Emergency Department Sepsis Patients. Acad Emerg Med. 2016;23(6):744-746. [PubMed]

Originally posted Apr 2, 2016 as University of Maryland (UMEM, @UMEmergencyMed) pearl.

Ketamine is gaining traction as a prehospital option for managing severe agitation or excited delirium syndrome. Previous reports have mostly been case series, but a new prospective study adds some important information that may help delineate ketamine’s role in this setting. [1] An accompanying commentary was published in the same issue. [2]

What They Did

Open-label before-and-after prospective comparison of haloperidol (10 mg IM) versus ketamine (5 mg/kg IM) for the treatment of acute undifferentiated agitation.

What They Found

  • Ketamine demonstrated a statistically and clinically significant difference in median time to sedation compared to haloperidol, 5 min vs. 17 min (p < 0.0001, 95% CI: 9 15)
  • Complications: ketamine, 49%; haloperidol, 5%
    • Ketamine complications: hypersalivation (38%), emergence reaction (10%), vomiting (9%), and laryngospasm (5%)
  • Intubation rate: ketamine, 39%; haloperidol, 4%

Application to Clinical Practice

  • Ketamine works for prehospital agitation (and more rapidly)
  • Ketamine has a higher complication and intubation rate
  • Though this study did not find a dose relationship between ketamine and intubations, future studies should evaluate further and potentially use lower ketamine doses
  • At our institution, we start with 2-3 mg/kg IM and repeat if necessary after 5 min. Most patients have not required a second dose and none have been intubated. This allows time to place an IV line and initiate additional treatment.

References

1.
Cole J, Moore J, Nystrom P, et al. A prospective study of ketamine versus haloperidol for severe prehospital agitation. Clin Toxicol (Phila). 2016;54(7):556-562. [PubMed]
2.
Hayes B. Ketamine for agitation: a key cog in the prehospital treatment armamentarium wheelhouse. Clin Toxicol (Phila). 2016;54(7):545-546. [PubMed]

Originally posted June 9, 2016 as UMEM pearl.

An interesting new study was published looking at in-hospital mortality in traumatic brain injury (TBI) patients who received succinylcholine or rocuronium for RSI in the ED.

What They Did

  • Retrospective cohort study
  • 233 patients (149 received succinylcholine, 84 received rocuronium)
  • Groups were well matched overall (roc group was older, more hypotension in sux group)
  • Within the two groups, patients were separated based on head Abbreviated Injury Score (scores of 4 or 5 were considered severe)
  • The authors controlled for a lot of confounding factors

What They Found

  • Overall, mortality was the same in each group (23%)
    • Mortality within the roc group was the same irrespective of head AIS
    • Mortality within the sux group was significantly higher in the subset of patients with higher head AIS (OR 4.1, 95% CI 1.18-14.12, p = 0.026)

Application to Clinical Practice

  • Succonylcholine may increase mortality in severe TBI patients undergoing RSI in the ED compared to rocuronium.
  • The confidence interval was wide and these findings need to be confirmed in a prospective study
  • Though the patients were well matched and the authors controlled for many variables, it still is difficult to pinpoint one intervention as the cause for mortality in critically ill patients (eg, etomidate + sepsis).
  • With proper rocuronium dosing, intubating conditions are similar to succinylcholine. So if there is a potential for increased mortality in severe TBI patients with sux, rocuronium seems to provide a safer alternative.

Reference

1.
Patanwala A, Erstad B, Roe D, Sakles J. Succinylcholine Is Associated with Increased Mortality When Used for Rapid Sequence Intubation of Severely Brain Injured Patients in the Emergency Department. Pharmacotherapy. 2016;36(1):57-63. [PubMed]

Originally posted Feb 6, 2016 as UMEM pearl.

Ketamine is often thought to be the induction agent least associated with hypotension in the peri-intubation period. However, reports of hypotension following ketamine do exist, including 2 cases of cardiac arrest [1]. There are limited objective means to predict which patients may have an adverse hemodynamic response.

New Study

A new prospective observational study followed 112 patients in the prehospital setting who received ketamine for rapid sequence intubation. 81 had a low shock index [< 0.9], 31 had a high shock index [2].

Shock index = HR / SBP

What They Found

Patients with a high shock index were more likely to experience hypotension (SBP < 90 mm Hg) in the peri-intubation period compared to those with a low shock index (26% vs 2%).

Application to Clinical Practice

  • This is the first study to evaluate a potential objective predictor for which patients may experience hypotension after RSI with ketamine. But, even with a high shock index, the majority of patients did not develop hypotension.
  • These findings should not lead to avoidance of ketamine in these situations, as other induction agents are equally or more likely to cause adverse hemodynamic effects.
  • It has been suggested to use lower induction doses in patients at risk for hypotension (with the same or higher paralytic dose). Patients with a high pre-RSI shock index may be the population in which to consider that approach.

References

1.
Dewhirst E, Frazier W, Leder M, Fraser D, Tobias J. Cardiac arrest following ketamine administration for rapid sequence intubation. J Intensive Care Med. 2013;28(6):375-379. [PubMed]
2.
Miller M, Kruit N, Heldreich C, et al. Hemodynamic Response After Rapid Sequence Induction With Ketamine in Out-of-Hospital Patients at Risk of Shock as Defined by the Shock Index. Ann Emerg Med. 2016;68(2):181-188.e2. [PubMed]

Originally posted May 7, 2016 as UMEM pearl.

Up until two years ago, beta blocker use for refractory ventricular fibrillation (VFib) had only been studied in animal models with sporadic human case reports. Two studies in humans have now been published and may provide some guidance in managing this difficult-to-treat condition.

First Human Study

In 2014, Dr. Steven Smith’s (@smithECGBlog) group published a retrospective evaluation of 25 patients with refractory VFib; 6 patients received esmolol during cardiac arrest and 19 patients did not [1]. Comparing the patients that received esmolol to those that did not: 67% and 42% had sustained return of spontaneous circulation (ROSC); 66% and 32% survived to intensive care unit admission; 50% and 16% survived to hospital discharge; and 50% and 11% survived to discharge with a favorable neurologic outcome, respectively.

New Human Study

In the October 2016 issue of Resuscitation, a new study from the Republic of Korea evaluated a similar cohort [2]. 41 patients were included in this single center, retrospective analysis: 16 patients received esmolol and 25 patients did not. Comparing the patients that received esmolol to those that did not: 56% vs. 16% (p = 0.007) had sustained ROSC; 56% and 16% (p = 0.007) survived to ICU admission; 19% and 8% survived to 30 days, 3 months, and 6 months (p = 0.36); and 19% and 8% had a good neurologic outcome at 30 days, 3 months, and 6 months (p = 0.36), respectively.

Application to Clinical Practice

  • Both studies used similar inclusion criteria: VFib that was resistant to ≥3 defibrillations, 3 mg of epinephrine, and 300 mg of amiodarone (Lee et al added no ROSC after >10 min of CPR).
  • Though there are several limitations (namely single center, retrospective cohorts with small sample sizes), both studies demonstrated the potential for esmolol to increase the chance of neurologically good outcome in patients with refractory VFib.
  • Not all of the comparisons reached statistical significance (small sample sizes). However, the potential clinical significance of improved neurologically intact outcomes from a relatively benign therapy (esmolol) could be profound.
  • Based on these two small data sets, it may be reasonable to consider esmolol in refractory VFib cases earlier in the resuscitation (ie, before 10 minutes of CPR has transpired and before 3 doses of epinephrine).

References

1.
Driver B, Debaty G, Plummer D, Smith S. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation. Resuscitation. 2014;85(10):1337-1341. [PubMed]
2.
Lee Y, Lee K, Min Y, et al. Refractory ventricular fibrillation treated with esmolol. Resuscitation. 2016;107:150-155. [PubMed]

For acute pain in the ED, parenteral ketorolac is generally administered as 30 mg IV or 60 mg IM. Dr. Chris Bond (@socbmobem) has written about the ‘ceiling effect’ of NSAIDS. The question is: are we using too much ketorolac without getting additional pain benefit?

Hot-off-the-press is a new randomized, double-blind trial from Dr. Sergey Motov’s group (@painfreeED) that addresses this exact question.

What they did

240 patients with acute pain in a 711-bed urban community teaching hospital ED were randomized to receive 10 mg, 15 mg, or 30 mg of IV ketorolac as a single-dose.

  • Age 18 to 65 years
  • Acute flank, abdominal, musculoskeletal, or headache pain with an intensity of 5 or greater on a standard 0 to 10 numeric rating scale
  • Patients who would routinely be treated with IV ketorolac
  • Pain scores, vital signs, and adverse effects were recorded at baseline and 15, 30, 60, 90, and 120 minutes
  • Subjects still desiring pain medication 30 min after study drug administration were offered IV morphine 0.1 mg/kg as a rescue

Outcome

The primary outcome was reduction in numeric rating scale pain score at 30 minutes from medication administration.

What they found

  1. There was no difference in reduction of pain scores between the groups: 10 mg – 7.7 to 5.2; 15 mg – 7.5 to 5.1; 30 mg – 7.8 to 4.8
  2. There were no differences between the groups with respect to use of rescue morphine analgesia at any time
  3. There were no clinically concerning changes in vital signs and no clinically significant adverse effects related to the study medication at any dose

There was no placebo group and the box plot (Figure 2) revealed wide variability in all of the treatment arms.

Implications for Clinical Practice

This is a well-conducted study demonstrating no difference in pain score reduction for various doses of IV ketorolac. Doses of 10 mg or 15 mg are just as effective as 30 mg and should be used preferentially over higher doses. Higher doses can cause more adverse effects, especially if more than one dose is administered.

Reference

1.
Motov S, Yasavolian M, Likourezos A, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. December 2016. [PubMed]

A full review of this topic was covered in a previous ALiEM post and is updated as new articles are published. Previous (and subsequent) studies on this topic have largely been retrospective. This is the first prospective study to evaluate the observed incidence of AKI.

What They Did

Prospective, open label cohort study at a community academic medical center involving adult patients who received either:

  • the combination of pip-tazo + vancomycin OR
  • the combination of cefepime or meropenem + vancomycin for greater than 72 hours

AKI was defined using specific criteria introduced by Kidney Disease: Improving global outcomes (KDIGO) acute kidney injury work group in 2012.

What They Found

  • 85 patients were enrolled (59 in the pip-tazo + vancomycin group)
  • Incidence of AKI was significantly higher in the pip-tazo + vancomycin group (37.3%) compared with the cefepime or meropenem + vancomycin group (7.7%; χ2 = 7.80, P = .005)
  • Importantly, there was no difference in mean of steady state vancomycin trough levels between groups

Limitations

  • The study did not reach the projected sample size of 120 patients and there were disproportionately more patients in the pip-tazo group, both decreasing the power of the study’s findings
  • Development of AKI was strictly by KDIGO definition and patients were not followed for the clinical significance of the AKI

Application to Clinical Practice

  • It seems time to acknowledge there is an association between pip-tazo and risk of AKI (with vancomycin). There have been 12 different groups with internal medicine, pediatric, and ICU patients (including this prospective study) demonstrating this adverse effect. Three meta-analyses, with 963 patients, 3,528 patients, and 3,549 patients, drew the same conclusion.
  • The prospective study supports the association, even with vancomycin trough levels the same in each group.
  • In ICU patients specifically, the results have been conflicting. All 3 ICU studies reported a high rate of AKI with vanc + pip-tazo (21.2-40.5%). Two of the ICU studies showed a significantly higher rate in the combo group compared with vancomycin alone; the other did not demonstrate a difference when pip-tazo was replaced with cefepime. A prospective study in ICU patients is needed.
  • Proposed mechanisms for pip-tazo induced AKI include acute interstitial nephritis or toxic effects on the renal tubule.
  • To me, this adds one more reason to at least think twice before reflexively ordering pip-tazo for every sick patient, especially when combined with vancomycin. The AKI association should be taken into account when creating sepsis order sets and treatment plans.

Further Reading

Dr. Josh Farkas (@PulmCrit) tackles the question ‘Is Piperacillin-Tazobactam Nephrotoxic?‘ on his blog at EMCrit.

Reference

1.
Peyko V, Smalley S, Cohen H. Prospective Comparison of Acute Kidney Injury During Treatment With the Combination of Piperacillin-Tazobactam and Vancomycin Versus the Combination of Cefepime or Meropenem and Vancomycin. J Pharm Pract. February 2016. [PubMed]

A full review of this topic was covered in a previous ALiEM post.

What They Did

  • The authors examined serum APAP concentrations obtained less than 4 hours post-ingestion, and again 4 or more hours post-ingestion.
  • They specified a cutpoint of 100 mcg/mL (662 micromol/L) obtained between 2 and 4 hours and a subsequent 4 to 20 hour APAP concentration above the nomogram treatment line of 150 mcg/mL (993 micromol/L).

What They Found

  • Almost 2,500 patients were evaluated.
  • Concentrations drawn between 2-4 hours post-ingestion demonstrated a sensitivity of 0.96 [95% CI; 0.94, 0.97] and a negative likelihood ratio of 0.070 [0.048, 0.10]. Coingested opioids reduced this sensitivity to 0.91 [0.83, 0.95], and antimuscarinics to 0.86 [0.72, 0.94].
  • Only very low to undetectable APAP concentrations prior to 4 hours reliably excluded a subsequent concentration over the treatment line.
  • They concluded that applying an APAP concentration cutpoint of 100 mcg/mL (662 micromol/L) at 2-4 hours after an acute ingestion as a threshold for repeat testing and/or treatment would occasionally miss potentially toxic exposures.
  • Importantly, their data validated the practice of not retesting when the first post-ingestion APAP concentration is below the lower limit of detection.

Application to Clinical Practice

  1. The Rumack-Matthew nomogram is to be utilized starting at 4 hours after an acute APAP ingestion.
  2. Pre-4 hour APAP levels, if not repeated, can lead to unnecessary treatment, admissions, and adverse effects.
  3. If an APAP level is drawn before 1 hour, a second APAP level must be drawn again at the 4-hour mark.
  4. If an APAP level is drawn between 1-4 hours, and the level is:
    Undetectable –> you can stop additional APAP testing
    Detectable –> you should redraw a second APAP level at the 4-hour mark
  5. The current data supports waiting until 4 hours after ingestion to draw a level, but optimally less than 7 hours (to allow an hour to start acetylcysteine if needed).

Reference

1.
Yarema M, Green J, Sivilotti M, et al. Can a serum acetaminophen concentration obtained less than 4 hours post-ingestion determine which patients do not require treatment with acetylcysteine? Clin Toxicol (Phila). October 2016:1-7. [PubMed]

Previous Annual Summaries

Author information

Bryan D. Hayes, PharmD, FAACT

Bryan D. Hayes, PharmD, FAACT

Associate Editor, ALiEM
Creator and Lead Editor, CAPSULES series, ALiEMU
Clinical Pharmacist, EM and Toxicology, MGH

The post Top 8 Must-Know EM Pharmacotherapy Articles of 2016 appeared first on ALiEM.

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