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Brain Teaser: Do you know which of the following patients meets the criteria for anaphylaxis? June 24, 2019

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Test your knowledge and see how much you know about recognition and treatment of anaphylaxis in pediatric patients.

Did you get it right? Click here to find out!

The correct answer: A.

Earn CME for this topic by logging to take your CME test.

From the author of the very first issue of Emergency Medicine Practice June 24, 2019

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Stephen Colucciello, MD, FACEP
Professor of Emergency Medicine, University of North Carolina School of Medicine-Charlotte Campus,
Charlotte, NC

When we first published Emergency Medicine Practice 20 years ago, emergency clinicians were becoming skeptical of established dogma, which was often based on an “expert” who defined best practices; otherwise known as “eminence-based” medicine. For example, abdominal pain patients were never to get opioids, oral contrast should always be used for abdominal CT scans and the rectal exam was essential in the abdominal pain workup.

Instead of blindly accepting such “textbook facts”, we created Emergency Medicine Practice to advance an evidence-based approach. Evidence-based medicine depends upon the best available evidence, while incorporating personal experience and individual patient values. The size and quality of the study, the research methodology, and the reproducibility of results matters in assessing practice validity.

For Emergency Medicine Practice’s 20th anniversary, we turn back to our roots and revisit and revive our very first issue on abdominal pain. I understand from EB Medicine that hundreds – if not thousands – of emergency clinicians have said this course has aided them in their training and practice in the 20 years since its publication. The editors tell me it is oft-referenced even to this day.

Abdominal pain is one of the complaints seen most frequently in the ED, and the degree of pathology runs from the mundane to catastrophic. Unfortunately, the severity of illness is easily overlooked, especially in the elderly and immunosuppressed. Identifying the high-risk patient is crucial to avoiding a life-threatening diagnostic mistake.

There are many changes in best practices for assessing patients with abdominal pain compared to 20 years ago. Bedside ultrasound by the emergency provider is certainly revolutionizing ED practice. Radiation-reduction strategies are also becoming more commonplace. MRI is a growing modality, especially in pregnant women with suspected appendicitis. In the past two decades, we have learned that oral contrast provides no additional benefit to IV contrast in abdominal CT scans (with some exceptions). We also have seen a dramatic decrease in abdominal plain films and a corresponding increase in abdominal CT scans, especially in the elderly.

In the end, all the thinking, research, peer reviewing, and thought-provoking discussions that go into each issue of Emergency Medicine Practice are to ensure that every topic makes a difference in your diagnostic or treatment routine. I would be honored if you change your daily practice after reading this new edition of “Assessing Abdominal Pain In Adults.”

Sincerely,
Stephen Colucciello MD

Click here to read the updated version of our inaugural issue prepared specifically for our 20th anniversary this June!

For two decades, we have helped emergency medicine clinicians like you, who are committed to lifelong learning, providing excellent patient care, and saving lives, with the resources and information you need to do the things that you do best. Tap here to take advantage of the 20th anniversary sale!

It’s our way of saying thank you for helping us reach this significant landmark in our company’s history, which is your history, too. Here’s to 20 more!

Managing pediatric patients in the ED June 11, 2019

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During a busy shift in the ED, an adolescent girl is wheeled back from triage. Her right arm is resting on the arm of the wheel chair, and she is holding her head. Her eyes are downcast, and she appears weak. She saw her doctor the day before with complaints of fever, nausea without vomiting, and generalized muscle aches. Her pediatrician diagnosed her with a flu-like illness and recommended plenty of fluids and ibuprofen.

Earlier that morning when her parents went to check on her, she was weak and could barely get out of bed. Her vital signs in the ED are: temperature, 39.4°C: heart rate, 141 beats/min; and blood pressure, 80/30 mm Hg. You begin examining the patient as a nurse inspects her upper extremities for a site to place a peripheral IV line. She has a generalized erythematous non­palpable rash, a slightly red posterior oropharynx, supple neck, clear lung fields, tachycardia with an otherwise normal cardiac examination, lower abdominal tenderness without peritoneal signs, and extremities with 1+ peripheral pulses, 2+ central pulses, and a capillary refill time of 4 to 5 seconds. You ask the respiratory therapist to provide her oxygen by facemask, and now that the nurse has established an IV line, you ask for a rapid bolus of fluid and start to consider antibiotics.

The nurse asks, “What type of fluid and how fast?” You think to yourself, “Which antibiotic should I use, and what will I do if her condition continues to decline?” Then you recall that you didn’t ask when her last menstrual period occurred.

There may be nothing more anxiety-provoking for a clinician than caring for a previously healthy infant or young child who presents in shock. Once a child’s condition has progressed to this point, it can be very difficult to determine the exact cause. Shock is a common pathway for a multitude of life-threatening illnesses and injuries. As the child’s condition worsens, the similarities among the clinical presentations of the divergent causes of shock overwhelm the differences. Fortunately, there are fundamental principles applicable to multiple causes of shock in children.

The first fluid bolus given to the adolescent girl was provided rapidly using a liter of normal saline, a 60-ml syringe, and a 3-way stopcock. You ordered a dose of vancomycin, ceftriaxone, and clindamycin because of your concern for tampon-related toxic-shock syndrome. A brief gynecologic examination revealed a retained tampon, which was removed. A second and third normal saline bolus was given.

You asked the nurse to prepare dopamine to be given peripherally, if the patient continued to demonstrate signs of shock. Her blood pressure improved, but she still had signs of poor peripheral perfusion, such as delayed capillary refill, so you started her on a dopamine infusion. She was then transferred to the PICU for further management.

Catch up on best practices in cases such as this and for treating pediatric rashes, shock, chest pain, and viral challenges at the pediatric sessions in Ponte Vedra, FL, at the 18th Annual Clinical Decision Making in Emergency Medicine conference.

Enjoy the sea breeze and welcoming sun while earning CME in Ponte Vedra, FL – June 26-29, 2019.

Clinical Pathway for Diagnosis of Anaphylaxis in Pediatric Patients June 7, 2019

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Anaphylaxis is a time-sensitive, clinical diagnosis that is often misdiagnosed because the presenting signs and symptoms are similar to those of other disease processes. An allergic reaction is an overreaction of the immune system to a foreign substance (allergen). Anaphylaxis is a type of an allergic reaction that is an
acute, severe systemic hypersensitivity reaction that can rapidly lead to death.

The signs and symptoms of anaphylaxis are similar to other common illnesses, which can make diagnosis challenging. Atypical anaphylaxis can be even more difficult to diagnose, because some of the typical signs of anaphylaxis are not present.

This clinical pathway will help you diagnose pediatric patient with anaphylaxis. Download now.

Get access to more pathways with an individual or group subscription. Visit www.ebmedicine.net/EMPinfo to find out more!

Need more information?
Click here to review the issue!

Clinical Pathway for Patients Aged < 50 Years With Abdominal Pain June 7, 2019

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The management of abdominal pain has changed significantly in the past 20 years, with increasing emphasis on identifying patients who are at high risk for occult pathology and worse outcomes. With abdominal pain still the most common chief complaint seen in the emergency department, a new look at the evolution of assessment strategies is in order.

After an extensive workup, patients with severe pain may prove to have gastroenteritis, while those with a seemingly benign belly are hiding a surgical catastrophe.

This clinical pathway will help you improve care in the management of patients with abdominal pain and recognize a surgical abdomen. Download now.

Clinical Pathway for Patients Aged < 50 Years With Abdominal Pain

Get access to more pathways with an individual or group subscription. Visit www.ebmedicine.net/EMPinfo to find out more!

Need more information?
Click here to review the issue!

68-year-old woman presents with severe abdominal pain May 31, 2019

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Case Recap:
As you begin your shift, a 68-year-old woman presents with severe abdominal pain. She requires 4 mg of morphine before you can even talk to her. Surprisingly, her abdomen is soft, and not particularly tender. She is tachycardic to the 120s, and her pulse feels irregular. Her blood pressure is 100/50 mm Hg. It seems strange that her pain is so incongruent with her exam, and you wonder: What is the best imaging study to help clarify things?

Case Conclusion:
You recognized that she needed pain control and fluids along with a full sepsis workup, including lactate, ECG, CT abdominal angiography, and an almost-certain surgical consult. Her ECG showed atrial fibrillation, and the CT angio confirmed the diagnosis. She was emergently taken to the OR, where a dead bowel segment was resected and she had a surprisingly good recovery, thanks to your rapid mobilization of specialty care.

Did you get it right?

Brush up on most recent best practices in evaluating patients with abdominal pain in the ED with our 20th anniversary Emergency Medicine Practice issue, Assessing Abdominal Pain in Adults: A Rational, Cost-Effective, and Evidence-Based Strategy.

P.S. Emergency Medicine Practice celebrates its 20th anniversary this month! Click here to check out our story, our plans and our great anniversary sale!

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A 3-year-old girl with a known peanut allergy May 31, 2019

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Case Recap:
A 3-year-old girl with a known peanut allergy arrives to your ED via EMS. The girl was given a cookie by a classmate and immediately developed a generalized urticarial rash. EMS personnel gave her 12.5 mg of oral diphenhydramine and transported her to the ED. On examination, the patient has a heart rate of 160 beats/min with normal oxygenation and perfusion. She has bilateral periorbital swelling, without respiratory distress, wheezing, vomiting, or diarrhea. The accompanying daycare teacher tells you that the girl has previously been admitted to the intensive care unit for anaphylaxis.

You call the girl’s parents for more information and wonder what to do in the meantime. Is diphenhydramine sufficient treatment for this patient? Are corticosteroids indicated? Is this just an allergic reaction or could it be an anaphylactic reaction? What are the criteria for diagnosis of anaphylaxis? What are the indications for administering epinephrine in patients with anaphylaxis?

Case Conclusion:
The parents of the 3-year-old girl stated that the girl’s previous anaphylactic reaction began with urticaria and facial swelling that progressed, resulting in a critical care admission for airway compromise due to angioedema. You administered epinephrine 0.01 mg/kg IM for suspected anaphylaxis and observed the patient in the ED for 4 hours. The girl had complete resolution of the facial swelling and urticarial rash. You reviewed the signs and symptoms of anaphylaxis with the parents, discussed allergen avoidance, and demonstrated appropriate use of an epinephrine autoinjector. You discharged the patient with a prescription for 2 epinephrine autoinjectors and an anaphylaxis action plan.

Did you get it right?

Brush up on most recent best practices in evaluating and treating pediatric patients with anaphylaxis in the ED with the latest issue of Pediatric Emergency Medicine Practice issue, Anaphylaxis in Pediatric Patients: Early Recognition and Treatment Are Critical for Best Outcomes.

P.S. Emergency Medicine Practice celebrates its 20th anniversary this month! Click here to check out our story, our plans and our great anniversary sale!

Sign up for our email list below to get updates on future blog posts!

EB Medicine Celebrates 20 Years Of Evidence-Based Emergency Medicine Publishing May 31, 2019

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June 7, 2019 – Atlanta, GA – EB Medicine, the premier provider of cutting-edge, evidence-based emergency medicine content, is celebrating their 20th anniversary this year. The company is using the opportunity to celebrate client contributions over the years with an anniversary sale and special offers for current subscribers.
EB Medicine is known for their evidence-based clinical content, including the Emergency Medicine Practice and Pediatric Emergency Medicine Practice journals.

The History of EB Medicine

EB Medicine was founded in 1999 by Dr. Stephen Colucciello, an emergency physician at Carolinas Medical Center, who saw a need for a high-quality, evidence-based journal that would analyze and summarize all of the available evidence on a given topic and present the best recommendations based on the evidence.

Before EB Medicine, doctors found it challenging to stay up to date on the latest information. With thousands of new studies being published every year, how could one doctor comb through all of this information to make sure he is at the cutting edge of his practice? Unlike today when there are dozens of websites, blogs, podcasts, and newsletters that discuss recent findings or spur point-counter point internet debates, there were almost no resources to help emergency physicians stay current with new treatments and protocols 20 years ago. The resources that were available were not evidence-based, but more like textbooks whose dogma proclaimed a standard of care that due to years-long publication cycle was out of date by release date.

Perhaps, even more importantly, the resources that were available focused on the treatment, and assumed that the diagnosis had already been made. Dr. Colucciello recognized this information gap. He focused on importance of presenting the information from a chief-complaint perspective rather than from a diagnosis. We rarely get ED patients who tells us: “I’m having a myocardial infarction.” Most likely, it’s a chest pain complaint.
Dr. Colucciello, an emergency physician with 18 years of experience, and Robert Williford, a medical publisher with more than 25 years of experience, aimed to address these challenges by creating Emergency Medicine Practice and published the first issue in June 1999.

The inaugural issue on assessing abdominal pain is still used by physician educators around the country to train emergency medicine residents on the proper way to work-up and manage patients with abdominal pain.
Over the next few years, based on industry needs and at the request of customers, EB Medicine expanded to pediatric-focused content. As is often said in the ED: Kids aren’t just little adults; they require different tests, different treatment, and different care. In 2004, EB Medicine launched Pediatric Emergency Medicine Practice to address this need.

Read the full story here.

 

EB Medicine Celebrates 20 Years Of Evidence-Based Emergency Medicine Publishing May 31, 2019

Posted by Andy Jagoda, MD in : Feature Update , add a comment

June 7, 2019 – Atlanta, GA – EB Medicine, the premier provider of cutting-edge, evidence-based emergency medicine content, is celebrating their 20th anniversary this year. The company is using the opportunity to celebrate client contributions over the years with an anniversary sale and special offers for current subscribers.

EB Medicine is known for their evidence-based clinical content, including the Emergency Medicine Practice and Pediatric Emergency Medicine Practice journals.

EB Medicine Today

Today, EB Medicine has 11 full-time employees, over 50 physician editorial board members, and more than 2,000 physician authors and reviewers. Board members, authors, and reviewers are carefully selected by physician Editors-in-Chief Andy Jagoda, MD, FACEP; Ilene Claudius, MD; and Tim Horeczko, MD based on their experience and expertise in a given topic area; EB Medicine contributors are recognized leaders in their field and have frequently published original research and review articles, presented at national conferences, and educated other physicians. They are committed to providing the very best educational content and truly believe in the value and importance of what EB Medicine does every day.

What started out as one print journal, Emergency Medicine Practice, has evolved into a multimedia resource that goes beyond its flagship print publication; it now includes a podcast, an online digest/summary, a supplement that reviews and links to relevant calculators and risk scores that can be used in real time, and more. Last year, EB Medicine launched an all-new mobile responsive website that makes it easier for clients to access the information they need even while they’re on shift.

“Over the years, we’ve continued to develop resources to meet the needs of our customers. Our goal is to help them improve decision making and patient care, and we will continue to create products to fulfill that goal,” said EB Medicine CEO Stephanie Williford.

EB Medicine continuously partners with other forward-looking organization and associations to make sure they continue to evolve and stay relevant to the customers they serve. They have also created an Emerging Leaders Council, which is made up of 12 young leaders in the field of emergency medicine who have joined EB Medicine to make sure they stay up to date with various industry needs and deliver relevant education to emergency clinicians at all levels of their careers.

Click here to read the full story.

 

May is Trauma Awareness Month! May 16, 2019

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Clinical Pathway For Management In The Emergency Department Of Pediatric Patients With Suspected Cervical Spinal Cord Injury

Spinal injuries from blunt trauma are uncommon in pediatric patients, representing only about 1.5% of all blunt trauma patients. However, the potentially fatal consequences of spinal injuries make them of great concern to emergency clinicians.

Clinical goals in the emergency department are to identify all injuries using selective imaging and to minimize further harm from spinal cord injury. Achieving these goals requires an understanding of the age-related physiologic differences that affect patterns of injury and radiologic interpretation in children, as well as an appreciation of high-risk clinical clues and mechanisms.

Clinical Pathway For Management In The Emergency Department Of Pediatric Patients With Suspected Cervical Spinal Cord Injury

This clinical pathway will help you improve care in the management of pediatric patients with suspected cervical Spinal cord injury. Click here to download yours today. 

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Last Modified: 06-25-2019
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