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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

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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.

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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

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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. 

It is Stroke Awareness Month! May 16, 2019

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10 Risk Management Pitfalls For Cervical Artery Dissections

Cervical artery dissections involve the carotid or vertebral arteries. Although the overall incidence is low, they remain a common cause of stroke in children, young adults, and trauma patients. Symptoms such as headache, neck pain, and dizziness are commonly seen in the emergency department, but may not be apparent in the obtunded trauma patient. A missed diagnosis of cervical artery dissection can result in devastating neurological sequelae, so emergency clinicians must act quickly to recognize this event and begin treatment as soon as possible while neurological consultation is obtained.

Use these risk management pitfalls to avoid unwanted outcomes when performing cervical artery dissections. Download now.

1. “This patient has a left temporal headache that radiates into his left ear. His examination is benign, except his pupil is smaller on that side. I did a noncontrast CT head and it’s negative. The headache is probably just due to a hard game of basketball yesterday. I’m going to give him some IV ketorolac and send him out.”

Dissections can occur spontaneously or as a result of minor trauma, even from a basketball game. Failure to consider the diagnosis will result in a missed diagnosis. Headaches in carotid artery dissections can be nonspecific, but are mostly located in the frontal or temporal regions; the radiation to the ear is also characteristic. His examination is also concerning for a partial Horner syndrome. Both of those are suspicious for carotid artery dissection and warrant further vascular imaging.

2. “She has a history of migraines, and she says that this one is different from what she usually feels, but it definitely sounds like a migraine because it is unilateral, pulsatile, and she had a visual aura. I’m going to give her the usual migraine cocktail and see how she does.”

Not suspecting cervical arterial dissection in the beginning of the evaluation results in a significant delay to diagnosis. It can be many hours by the time she has a couple of migraine cocktails before you realize her headache isn’t better and you need to rethink your plan. Due to the risk of early stroke in these patients, a delay in diagnosis could lead to long-term neurological sequelae. Headaches in carotid dissections can be unilateral, pulsatile, and with an aura. Any time a patient with a history of migraines states that the symptoms are not typical, take note.

3. “A 35-year-old woman was attacked by her boyfriend. He hit her on the right side of the neck near her jaw, causing her head to snap around to the left. Her neurological examination is completely normal. She is in a great deal of pain, but it seems to be related to the soft-tissue injury from the hit, because her noncontrast CT head and c-spine are negative. I’m going to treat her pain and see how she feels.”

Pain due to the trauma could mask specific signs or symptoms of dissection. In these patients, relying on the history to identify high-risk factors is important. Due to the location of the blow, it may have caused a hyperextension and rotation of her head in addition to direct trauma, which could have caused a dissection. Patients with risk factors should have advanced vascular imaging (CTA or MRA).

4. “I couldn’t do a neurological examination because she was in too much pain. I’ll treat her headache and then try again later.”

Although it seems kind to give patients a little time to obtain comfort before performing an examination, a prompt neurological examination is absolutely necessary in order to determine any findings that need to be addressed immediately, such as an acute stroke.

5. “A 12-year-old boy fell off of his bike after running into a parked car, and then he had a seizure. The noncontrast CT head and c-spine were normal. He is still in some pain, but I don’t see anything abnormal on his neuro examination, so I’m going to clear his c-spine.”

Pediatric patients with dissection have different symptoms from adults; seizure has been shown to be a presenting symptom in 12.5% of cases. The seizure, along with the mechanism, should prompt vascular imaging to assess for a cervical artery dissection before the cervical collar is removed.

6. “I really thought that patient with the headache, anterolateral neck pain, and partial Horner syndrome had a carotid dissection, but the CTA was read as negative, so I guess I was wrong. I’ll just treat her pain and send her home.”

CTA is an excellent screening tool, but it is not 100% sensitive and can miss small intimal flaps, intramural hematomas, or a slight fusiform dilatation of the vessel. In patients for whom there is a high suspicion of dissection and a negative or equivocal CTA or MRA, further imaging with MRI or digital subtraction angiography is indicated.

7. “The CTA showed a dissection, so I gave him an aspirin and called neurology. However, he now says he doesn’t want to wait and wants to go home. His neuro examination is normal, so I was thinking of sending him out on aspirin.”

Sending the patient home in the acute setting without consultation is not a good idea. Due to high risk of stroke in the first 24 hours and the high incidence of progression of lower-grade dissections, these patients warrant close monitoring and early follow-up imaging to determine the need for escalation of care.

8. “The intubated trauma patient had his noncontrast CT head and c-spine and the radiologist just called and said there is a temporal bone fracture through the carotid canal. I’m going to pass it along and let the trauma service finish the workup after he gets to the intensive care unit.”

This will lead to a significant delay in diagnosis, which could be devastating for the patient. Due to its sensitivity and availability in the ED, a CTA should be performed prior to the patient being transported upstairs, so treatment can be started immediately.

9. “The CTA showed a vertebral artery dissection on that patient from the roller coaster ride, so I consulted the neurology service for admission. Her neuro examination is normal, so I’m going to wait to treat her and see what they recommend.”

An antithrombotic agent for stroke prevention needs to be started on this patient and can be started in the ED to avoid treatment delays. Studies in this population have not shown superiority of one over the other, so the choice of aspirin or heparin depends on patient factors. For uncomplicated dissections, antiplatelet agents are sufficient, and heparin is preferred in patients with an acute thrombus or high risk for thromboembolic events if no contraindications exist.

10. “The patient is a 42-year-old man presenting with an acute onset of right-sided hemiplegia and global aphasia that started 1 hour ago while at the grocery store. His CT head was negative for hemorrhage, but the CTA showed a dissection in his left carotid artery with about 50% vessel occlusion. Unfortunately, that excludes him from treatment with rtPA due to the risk of hemorrhage or intramural hematoma expansion.”

Data have shown rtPA to be as safe in patients with cervical dissections as with patients with strokes due to other causes. Therefore, this patient should be treated with rtPA as soon as possible if there are no contraindications. Endovascular treatment should also be considered if there are contraindications to IV rtPA or if he does not improve after treatment.

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Clinical Pathway for Management of Sexually Transmitted Diseases in the Emergency Department April 15, 2019

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Sexually transmitted disease can cause severe outcomes for patients, their partners, and their unborn babies, and swift and accurate diagnosis and treatment is essential to reduce morbidity and minimize the potential public health risks.

Sexually transmitted diseases are a growing threat to public health, but are often underrecognized, due to the often nonspecific (or absent) signs and symptoms, the myriad diseases, and the possibility of co-infection. Emergency clinicians play a critical role in improving healthcare outcomes for both patients and their partners. Optimizing the history and physical examination, ordering appropriate testing, and prescribing antimicrobial therapies, when required, will improve outcomes for men, women, and pregnant women and their babies.

This clinical pathway will help you improve care in the management of patients with sexually transmitted diseases. Download now.

Clinical Pathway for Management of Sexually Transmitted Diseases in the Emergency Department

Clinical Pathway for Management of Pediatric Patients With Community-Acquired Pneumonia April 15, 2019

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A significant challenge in the management of pediatric community-acquired pneumonia is identifying children who are more likely to have bacterial pneumonia and will benefit from antibiotic therapy while avoiding unnecessary testing and treatment in children who have viral pneumonia.

Worldwide, pneumonia is the most common cause of death in children aged < 5 years. Distinguishing viral from bacterial causes of pneumonia is paramount to providing effective treatment but remains a significant challenge. For patients who can be managed with outpatient treatment, the utility of laboratory tests and radiographic studies, as well as the need for empiric antibiotics, remains questionable.

Clinical Pathway for Management of Pediatric Patients With Community-Acquired Pneumonia

This clinical pathway will help you improve care in the management of pediatric patients with community-acquired pneumonia. Click here to download yours today.

Clinical Pathway for Management of Emergency Department Patients With Suspected Blunt Cardiac Injury March 16, 2019

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

Blunt cardiac injury describes a range of cardiac injury patterns resulting from blunt force trauma to the chest. Due to the multitude of potential anatomical injuries blunt force trauma can cause, the clinical manifestations may range from simple ectopic beats to fulminant cardiac failure and death. Because there is no definitive, gold-standard diagnostic test for cardiac injury, the emergency clinician must utilize an enhanced index of suspicion in the clinical setting combined with an evidence-based diagnostic testing approach in order to arrive at the diagnosis. This review focuses on the clinical cues, diagnostic testing, and clinical manifestations of blunt cardiac injury as well as best-practice management strategies.

This clinical pathway will help you improve care in the management of patients with suspected blunt cardiac injury. Download now 

Clinical Pathway for Management of Emergency Department Patients With Suspected Blunt Cardiac Injury

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Last Modified: 06-16-2019
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