jump to navigation

Ultrasound Assessment for Skull Fractures August 15, 2019

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

The use of ultrasound at the point of care by emergency clinicians, as well as by other specialists, has become increasingly common over the last 25 years. Emergency POCUS can be used as a diagnostic test and also to visualize anatomy for procedural guidance. It allows the emergency clinician to rapidly rule in or rule out disease processes and guide ongoing investigation and management of patients in the ED.

Pediatric emergency ultrasound has been slower to progress than adult emergency ultrasound. However, the use of emergency ultrasound for pediatric patients has recently begun to formalize.

The pediatric patient is arguably more suited for emergency ultrasound than the adult patient. Children generally have a smaller body habitus than adults and, therefore, less tissue for the ultrasound beams to penetrate. This often leads to clearer images of the different organ systems, which should yield better diagnostic accuracy.

Ultrasound can be used in the evaluation of children with blunt head trauma to assess for skull fractures. (See Figure Below) The presence of a skull fracture increases the risk of traumatic intracranial hemorrhage 4- to 6-fold.

While the absence of a skull fracture does not rule out the presence of intracranial injury, assessment for skull fracture has been used to risk stratify.

Skull Fracture on Ultrasound

Patients with blunt head trauma. In a meta-analysis published in 2000, skull x-rays had a sensitivity of 38% and a specificity of 95% when interpreted by radiologists. Given this poor sensitivity, skull x-rays have been falling out of favor for assessment of skull fracture. However, there has been a renewed interest in skull ultrasound as perhaps a better tool to assess for skull fracture and to risk stratify patients with blunt head trauma.

Technique
Skull ultrasound is performed with a high-frequency linear array probe. The probe should be placed on the area of the skull with maximal tenderness, hematoma, or other sign of possible fracture. It should be scanned in 2 planes, looking for disruptions in the cortex. Sutures can be differentiated from fractures by following the cortical break to a fontanelle and by scanning the contralateral side for comparison. Additionally, the cortical break in a fracture will appear ragged, with sharp margins, while a suture will have a smooth appearance.

Several prospective studies have evaluated bedside ultrasound for skull fractures in children. Rabiner et al pooled data from previous trials along with their own data. They reported a sensitivity of 94% and specificity of 96% for ultrasound detection of skull fractures. Parri et al performed another study not captured in the Rabiner et al study, and showed a sensitivity of 100% and a specificity of 95%, with 1 false-positive result. A limitation of these studies was that the ultrasounds were performed on patients for whom a CT scan was planned. Therefore, the study population was already determined to be at higher risk for injury as compared to the entire spectrum of head trauma patients presenting to the ED. Nonetheless, it can be concluded that the diagnostic accuracy of skull ultrasound is superior to that of skull x-ray.

Future Applications
The current trend in the evaluation and risk stratification of pediatric head trauma is the incorporation of clinical decision rules, with the PECARN pediatric head injury prediction rule being the most sensitive and most commonly used in the United States.56 An area of future research is the incorporation of skull ultrasound in conjunction with a clinical decision rule to better risk stratify patients and possibly further decrease the number of CT scans being performed.

To read more about the PECARN Pediatric Head Injury Prediction Rule, go to: www.ebmedicine.net/PECARN-head-rule

Need more information?
Click here to review the issue!

Clinical Pathway for Emergency Department Management of Patients With Bariatric Surgery Complications August 14, 2019

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

As bariatric procedures have become more common, more of these patients present to the emergency department postoperatively.

The most common complaints in these patients are abdominal pain, nausea, and vomiting, though each of the surgical procedures will present with specific complications, and management will vary according to the surgical procedure performed. Computed tomography is often the primary imaging modality, though it has it limits, and plain film imaging is appropriate in some cases.

This clinical pathway will help you improve care in the management of patients with bariatric surgery complications. Download now.

Clinical Pathway for Emergency Department Management of Patients With Bariatric Surgery Complications

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!

Most Common Risk Stratification Criteria for Management of Febrile Young Infants July 18, 2019

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

Due to an immature immune system and pathogens often specific to the age group, the young infant (generally aged < 60-90 days, depending on the specific study or review) is at high risk for serious bacterial infections (SBIs); in particular, urinary tract infection (UTI), bacteremia, and bacterial meningitis. Consequently, the febrile young infant with a rectal temperature ≥ 38°C (100.4°F) is commonly encountered in the emergency department (ED). The incidence of SBI in febrile infants aged < 90 days is 8% to 12.5%, and it is nearly 20% in neonates (aged ≤ 28 days). The incidence of potentially life-threatening bacteremia and/or bacterial meningitis (ie, invasive bacterial infection [IBI]) is approximately 2%.

Due to their lack of social responsiveness (eg, social smile) and verbal cues, even well-appearing febrile young infants may harbor an SBI, in contrast to well-appearing febrile older infants and children who are at lower risk for IBI. Multiple studies have demonstrated that both observation scales and clinician suspicion for SBI are poorly predictive of bacterial infection in febrile infants. Additionally, bacterial meningitis is the most common diagnosis involved in pediatric medical malpractice claims in the emergency department (ED).

Over 2 decades ago, several risk stratification criteria were created to identify febrile young infants at low risk for SBI, and the criteria have been utilized to potentially avoid hospitalization of certain low-risk patients. More recently, newer risk stratification algorithms that incorporate biomarkers such as procalcitonin (PCT) and C-reactive protein (CRP) have been developed and validated in febrile infants.

Among well-appearing febrile infants, neonates have the highest prevalence of SBI and IBI and the least reliable clinical examination. These infants should undergo a full sepsis evaluation, including CSF testing. While the Rochester criteria and the recently published PECARN prediction rule do not include routine CSF testing in this age group (see table below), infants classified as low-risk by any criteria may still have bacterial meningitis, so CSF testing is generally recommended for all infants aged ≤ 28 days. Consideration should be given to testing for HSV in the neonate aged ≤ 21 days, even in the absence of vesicles or maternal history of HSV infection.

This table will help you predict the risk stratification criteria for management of febrile young infants. Download now.

Table 4. Most Common Risk Stratification Criteria for Management of Febrile Young Infants

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!

Intravenous Thrombolysis in Acute Ischemic Stroke July 17, 2019

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

Stroke is the fifth leading cause of death in the United States and an important cause of long-term disability. Approximately 795,000 people suffer from stroke each year (610,000 primary strokes and 185,000 recurrent strokes),1 with ischemic stroke representing the vast majority of all stroke types (87%).

The cornerstone of acute ischemic stroke treatment relies on rapid clearance of an offending thrombus in the cerebrovascular system. Advanced neuroimaging and clinical trials, together with continuous adjustments of inclusion/exclusion criteria, have helped emergency clinicians to rapidly and more accurately identify the patients who will benefit from acute stroke treatment.

Inclusion and Exclusion of Intravenous Thrombolysis: A Changing Landscape

The American Heart Association (AHA) recently published updated guidelines for stroke management. Table 1, summarizes the updated 2018 AHA indications and contraindications for treatment with IVT. Every patient presenting with symptoms of acute stroke within 4.5 hours of last known well or usual state should be triaged for potential IVT. Patients should be evaluated with computed tomography (CT) scan of the brain and systolic blood pressure (SBP) should be maintained at < 185 mm Hg and diastolic blood pressure (DBP) at < 110 mm Hg. Every eligible patient should receive IVT without delay. Changes and adjustments of inclusion/exclusion criteria (in order to minimize the risk of any complication) have been made and are discussed in following sections.

Table 1. Eligibility Criteria and Exclusion Criteria for Intravenous Thrombolysis
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!

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

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

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

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

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

Posted by Andy Jagoda, MD in : Feature Update , 1 comment so far

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

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

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!

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.

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.

 

About EB Medicine:

Products:

Accredited By:

ACCME ACCME
AMA AMA
ACEP ACEP
AAFP AAFP
AOA AOA
AAP AAP

Endorsed By:

AEMAA AEMAA
HONcode HONcode
STM STM

 

Last Modified: 08-25-2019
© EB Medicine