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

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

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

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

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

Dosing Information for Antihypertensive Medications March 16, 2019

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

For children with severe acute hypertension without further evidence of end-organ damage, initiation of oral agents may be recommended to lower blood pressure. Based on the available studies, aggressive bolus dosing of antihypertensive agents should be avoided in the younger child; careful initiation of a drip for children who are symptomatic is a safer strategy. The therapeutic window for all medications is wider for adolescent children and, likely, none of the oral agents will cause inadvertent hypotension or side effects. For the school-age child, a careful discussion with a specialist will help guide decisions. See Table 3 for dosing recommendations.

Download the table for yourself and check out more content like this at www.ebmedicine.net/topics.

Dosing Information for Antihypertensive Medications

Clinical Pathway for Emergency Department Management of Abnormal Uterine Bleeding in Adolescent Patients February 18, 2019

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

In the emergency department, gynecologic complaints are common presentations for adolescent girls, who may present with abdominal pain, pelvic pain, vaginal discharge, and vaginal bleeding. The differential diagnosis for these presentations is broad, and further complicated by psychosocial factors, confidentiality concerns, and the need to recognize abuse and sexual assault.

This clinical pathway will help you improve care in the management of abnormal uterine bleeding in adolescent patients. Download now.

Clinical Pathway for Emergency Department Management of Abnormal Uterine Bleeding in Adolescent Patients

Clinical Pathway for Emergency Department Management of Subarachnoid Hemorrhage February 17, 2019

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

Headache is the fourth most common reason for emergency department encounters, accounting for 3% of all visits in the United States. Though troublesome, 90% are relatively benign primary headaches –migraine, tension, and cluster headaches. The other 10% are secondary headaches, caused by separate underlying processes, with vascular, infectious, or traumatic etiologies, and they are potentially life-threatening.

This clinical pathway will help you improve care in the management of patients with subarachnoid hemorrhage. Download now.


Treatment Pathway for Emergency Department Management of Nausea and Vomiting of Pregnancy January 17, 2019

Posted by Andy Jagoda, MD in : Feature Update , 2comments

Timely management of patients presenting to the ED while in their first trimester of pregnancy can improve outcomes for both the patient and the fetus. Common obstetric problems encountered include vaginal bleeding and miscarriage, ectopic pregnancy and pregnancy of undetermined location, and nausea and vomiting of pregnancy, including hyperemesis gravidarum.

This clinical pathway will help you improve care in the management of patients who preset with nausea and vomiting in the first trimester. Download now

Treatment Pathway for Emergency Department Management of Nausea and Vomiting of PregnancyTreatment Pathway for Emergency Department Management of Nausea and Vomiting of Pregnancy

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10 Risk Management Pitfalls in the Management of Suspected Bioterrorism in the Pediatric Patient December 19, 2018

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10 Risk Management Pitfalls in the Management of Suspected Bioterrorism in the Pediatric Patient

1. “This isn’t New York City or Washington, DC; we don’t live in a target area. Bioterrorism preparedness is not a high priority for my practice.” Bioterrorism events often occur without warning—at any time, in any place. Many bioterrorism agents are highly contagious and can spread to remote areas of the country, due to travel of infected persons or wide dispersal of aerosolized agents. It is every emergency clinician’s obligation to become familiar with bioterrorism agents.

2. “If a bioterrorism patient shows up, I will be able to rely on the infectious disease and infection control teams for recommendations.” Recognizing suspicious illness patterns is an important responsibility of front-line emergency clinicians. While infectious disease and infection control specialists provide specific expertise, the protection of patients and staff depends on adherence to recommended protocols as early as possible.

3. “There are so many different agents that could be biological weapons. Trying to prepare for all the possibilities is overwhelming.” Many resources in print and online can support the emergency clinician. The CDC publishes clinical guidelines and manages electronic applications to support clinical decision making. The AAP also provides online resources for bioterrorism issues pertaining to children. (See Table 2.)

4. “Yes, he triggered the screening tool, but we have no rooms to isolate this patient. Besides, it is very unlikely that this is bioterrorism.” Failure to properly isolate patients can put other patients and staff at risk for any contagious illness. It is important to put safety first.

5. “Where would a child get anthrax? I haven’t heard anything in the news.” Children have particular physiologic and developmental vulnerabilities that put them at higher risk of being victims of bioterrorism agents. Therefore, children may show symptoms before public officials are aware that there has been an outbreak.

6. “Managing a surge from a bioterrorism event is similar to managing a mass casualty. We should be able to use similar protocols” Bioterrorism agents are often highly contagious and require public health support beyond the scope of any single healthcare facility. Specific protocols are important to best recognize and respond to the threat of bioterrorism.

7. “All children should receive postexposure pro-phylaxis after exposure to a bioterrorism agent. It’s the right thing to do.” Apply the recommended guidelines for PEP as recommended by the CDC. Not all medications or vaccines are safe for children and they should be considered in the context of the potential risks to the child.

8. “Yes, there has been a spike in pneumonic tularemia in the ED, but it’s endemic to this area, so that shouldn’t be cause for concern.” Any unusual cluster of presentations of Category A bioterrorism agents should be cause for concern. The inhalational form of any Category A illness should also be a red flag, as the aerosolized form of these agents is the most likely mechanism used for a bioterrorism attack.

9. “I don’t know how I would be able to tell if a cluster of patients had these unusual symptoms. There are at least 8 other hospitals in this city. I don’t have time to call them all to find out if they are seeing similar presentations.” Coordination with your local public health resources is essential in rare disease outbreaks. Since 2001, biosurveillance systems have been used to track unusual outbreaks and serve as a resource for health systems.

10. “Even though I have suspicions that this case could be due to a bioterrorism agent, I don’t want to cause the laboratory staff to panic. I’ll just send the culture and wait for the results.” Laboratory personnel are at high risk for exposure from the highly contagious bioterrorism agents. Most Category A agents require special reagents and tests only available in secured public health laboratories. Communicating concerns early and using appropriate personal protective gear consistently are essential to prevent further outbreak of a highly contagious illness.

 

Treatment Pathway for Managing a Patient Who Presents to the ED With an Influenza-Like Illness December 17, 2018

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Patients presenting to the ED with “influenza-like illness” (cough, sore throat, fever) are typical in the fall and winter. How can you tell whether a patient might have influenza and infect others with a potentially dangerous strain?  Influenza can present with a wide range of nonspecific clinical signs and symptoms, making ED management challenging.

This clinical pathway will help you improve care in the management of patients who preset with an influenza-like illness. Download now.

Clinical Pathway for Managing a Patient Who Presents to the ED With an Influenza-Like Illness

 

10 Risk Management Pitfalls in the Management of Pediatric Patients With Bacterial Meningitis November 19, 2018

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

The presentation of bacterial meningitis can overlap with viral meningitis and other conditions, and emergency clinicians must remain vigilant to avoid delaying treatment for a child with bacterial meningitis. Here are 10 risk management pitfalls to avoid and 3 time- and cost-effective strategies for when you’re managing pediatric patients with bacterial meningitis.

10 Risk Management Pitfalls in the Management of Pediatric Patients With Bacterial Meningitis

1. “The patient is sleeping. I don’t want to wake her up to perform a neurological examination.”

The neurologic assessment of the young child can be difficult, even under optimal circumstances. If you are performing this evaluation when a child is fearful or when they should be sleeping, it can be even more challenging and requires patience and, frequently, a dedicated period of observation for reassessment. Efforts should also be made to provide distraction to reduce the amount of fear or inhibition caused by the hospital environment to allow the most accurate examination possible. This distraction can be provided by family interaction with the child or by having the child play independently with a toy.

2. “The patient has inflamed tympanic membranes. The fever and irritability are likely due to otitis media. It’s not meningitis.”

Many young children with bacterial meningitis can have concomitant inflammation in other areas on physical examination or diagnostic study. Otitis media and upper respiratory tract infections are common enough conditions that their presence can lead the emergency clinician to “explain away” the child’s more serious symptoms as being due to those pathophysiologic findings. Anchoring on a simpler, less severe diagnosis can result in missing or delaying the correct diagnosis.

3. “The patient likely had a febrile seizure. I can’t get a neurological examination in his postictal state.”

Delay during decision-making can result in harmful diagnostic or therapeutic delay. A high-risk scenario can develop while waiting for a postictal child to awaken from a febrile seizure to perform a thorough neurologic examination and determining the need for a lumbar puncture or empiric antibiotics. The large majority of patients with simple febrile seizure are going to awaken to a baseline neurologic state within 1 to 2 hours after the seizure. Is the patient who is still “sleeping” 2 to 3 hours after a febrile seizure postictal, or is the patient progressing to a state of unresponsiveness? Patients who behave in this manner after a complex febrile seizure can be particularly concerning, and a lower threshold of lumbar puncture should be considered.

4. “This patient’s neck stiffness or meningismus is likely due to pharyngitis or ‘flu-like’ symptoms.”

Pharyngitis and other viral illnesses can also give a clinical presentation of neck stiffness. Meningismus is not specific to meningitis. Emergency clinicians can be inundated with patients presenting with neck stiffness during the winter months, and it is important to be vigilant for any other clues that seem disproportionate to a normal viral illness.

5. “The patient has a normal WBC count, so I don’t need to be worried about meningitis.”

In isolation, the absence of leukocytosis or leukopenia is an inadequate tool by which to make clinical management decisions. The peripheral blood absolute neutrophil count can be used in combination with other elements of the bacterial meningitis score to guide initial decision-making while awaiting results of CSF culture.

6. “The patient likely has viral meningitis, so we don’t need to get a lumbar puncture.”

The notion that emergency clinicians can distinguish the difference between viral and bacterial meningitis based on the history and physical examination is not supported by the available evidence. The clinical overlap of these conditions is substantial, particularly early in the course of illness. Diagnosis should not be made based on the history and physical examination alone.

7. “I did not consider group B Strep in my differential for this perinatal infant.”

GBS infection must be considered in any febrile infant in the first 2 months of life, even after maternal treatment of colonization.

8. “We need to wait for a CT scan and lumbar puncture before we can give antibiotics, as they can cause sterilization of CSF.”

When caring for a patient with a presumptive diagnosis of bacterial meningitis, do not delay administration of appropriate antibiotics for the completion of a CT scan or lumbar puncture or for the results of these studies. Although antibiotics may obscure the ultimate bacteriologic diagnosis, this is a small clinical price to pay to prevent further bacterial proliferation and inflammation within the CNS.

9. “We don’t need to consider tuberculosis or fungal meningitis.”

Meningitis due to atypical pathogens such as Mycobacterium tuberculosis can be notoriously insidious and indolent in presentation. Consider these pathogens, particularly in patients with immunodeficiency, patients traveling from high-risk parts of the world, or, in the case of tuberculosis, those with prolonged contact with an infected individual.

10. “My patient has a positive urinalysis. This is clearly just a UTI. I don’t need to consider any other diagnoses.”

While concomitant UTIs are rare, they do occur. In a recent study involving 1737 infants aged 29 to 60 days, concomitant UTI with bacterial meningitis occurred 0.2% of the time, and was more prevalent in infants aged 0 to 28 days.90

3 Time- And Cost-Effective Strategies For Pediatric Patients With Bacterial Meningitis

Reference:

90. Thomson J, Cruz AT, Nigrovic LE, et al. Concomitant bacterial meningitis in infants with urinary tract infection. Pediatr Infect Dis J. 2017;36(9):908-910. (Retrospective study; 1737 infants)

 

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Last Modified: 04-22-2019
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