Treatment Pathway for the Management of a Pediatric Patient With Hypothermia January 17, 2020


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

Hypothermia occurs when the core body temperature falls below 35ºC (95ºF) due to primary exposure (eg, environmental exposure) or secondary to other pathologies. Infants, children, and adolescents are at higher risk for primary cold injuries due to a combination of physiologic and cognitive factors, but quick rewarming and appropriate disposition can result in survival and improved neurological outcomes. Treatment for cold injuries is guided by severity and can include passive or active measures.

This clinical pathway will help you improve care in the management of patients who preset with hypothermia. Download now

Treatment Pathway for the Management of a Pediatric Patient With HypothermiaTreatment Pathway for the Management of a Pediatric Patient With Hypothermia

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Click to review Management of Pediatric Hypothermia and Peripheral Cold Injuries in the Emergency Department

Christmas Is The Busiest Air Travel Season. Would You Be Ready In An Emergency Happened Mid-Flight? December 10, 2019


Posted by Andy Jagoda, MD in: Brain Tease , add a comment

A Common Occurrence

More than 4 billion passengers are expected to fly in 2019, and more than 60,000 medical emergencies are expected to occur during commercial flights.1 Emergency clinicians who work with acutely ill patients may have had the experience of boarding an aircraft and wondering what they would do if a medical emergency occurred.

“Should I respond?”

“What kinds of medications and equipment are aboard?”

“Would I be legally protected if something went wrong?”

These questions can be paralyzing and prevent otherwise highly trained medical personnel from delivering life-saving care.

Lifelong Learning, Applied

Megan Carman, NP, encountered one of those 60,000+ inflight medical emergencies just last month. She used the Emergency Medicine Practice issue, “Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls” to familiarize herself with the roles, equipment, and protections available if called upon to respond to an in-flight medical emergency. Little did she know, Carman would be putting that knowledge to use shortly thereafter.

“How helpful that inflight emergency module was! Right after I read it, I was on a flight and a passenger started seizing. I knew to ask for the drugs and which ones they would have and to ask for IV supplies, and when people got upset about why we weren’t going to land, I told them it was a pilot decision and the average cost of landing. Also, when an anesthesiologist, who was also on the plane, was hesitant to help, I was able to tell him there are specific protections for medical providers who assist on planes as long as you are not grossly negligent or acting out of scope… Thank you for all this great info!” -Megan Carman, NP

Carman and many other Emergency Medicine Practice subscribers have specifically noted that they would be more likely to volunteer to assist with an inflight medical emergency after reading this issue.

Review This Issue

To review the issue that helped Carman and other Emergency Medicine Practice subscribers have increased confidence when faced with an inflight medical emergency, click here.

Test your knowledge


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

The correct answer: B.

1. Peterson DC, Martin-Gill C, Guyette FX, et al. Outcomes of medical emergencies on commercial airline flights. N Engl J Med. 2013;368(22):2075-2083. (Retrospective review; 11,920 in-flight medical emergencies)

Test Your Knowledge: Assisting With Air Travel Medical Emergencies November 21, 2019


Posted by Andy Jagoda, MD in: Brain Tease , add a comment

As an emergency clinician, you have special expertise in dealing with acute medical conditions, but when an emergency occurs onboard a commercial aircraft and you raise your hand to help, what are the resources and risks in volunteering? Qualified, active, licensed, and sober providers should volunteer to assist in the event of a medical emergency rather than decline out of fear of medicolegal reprisal.

Test your understanding with a question below.


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

The correct answer: B.

Check out the issue on Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls (Ethics CME) to brush up on the subject. Plus earn CME for this topic by purchasing this issue

Already a subscriber? Earn CME for this topic by logging to take your CME test.

Test Your Knowledge: Nonconvulsive Status Epilepticus in the ED October 3, 2019


Posted by Andy Jagoda, MD in: Brain Tease , add a comment

Nonconvulsive status epilepticus (NCSE) is characterized by persistent change in mental status from baseline lasting more than 5 minutes, generally with epileptiform activity seen on EEG monitoring and subtle or no motor abnormalities. NCSE can be a difficult diagnosis to make in the emergency department setting, but the key to diagnosis is a high index of suspicion coupled with rapid initiation of continuous EEG and early involvement of neurology.

When a patient presents to the ED with new-onset altered mental status or unusual behavior without visible convulsive activity, how can you tell if it is nonconvulsive status epilepticus?

Can you get it right?


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

The correct answer: D.

Check out the issue on Nonconvulsive Status Epilepticus: Overlooked and Undertreated (Pharmacology CME) to brush up on the subject. Plus earn CME for this topic by purchasing this issue.

What’s Your Diagnosis? Nonconvulsive Status Epilepticus: Overlooked and Undertreated September 30, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 1 comment so far

But before we begin, check out if you got last month’s case, on assistance with air travel emergencies, right. Click here to check out the answer!

Case Presentation: An 81-year-old woman presents with 1 day of behavioral changes

An 81-year-old woman presents with 1 day of behavioral changes. On examination, she is disoriented, with no focal neurologic findings and no evidence of seizure activity. Her medical history is remarkable for anxiety, arthritis, and hypertension; she has no history of stroke, trauma, or immunocompromise. Her medications include furosemide, lorazepam, and acetaminophen. After an extensive workup in the ED including ECG, CBC, CMP, UA, and
brain CT, all of which were normal, she was admitted to the floor.

You wonder: Is there something you forgot to consider in your differential diagnosis?

Case Conclusion

The 81-year-old woman with AMS was evaluated by a neurologist on the floor. Her EEG showed irregular, rhythmic, generalized 2.0–2.5 Hz sharp-and-slow wave complexes that ceased after 10 mg of IV diazepam. Later, her husband noted that her daily lorazepam had recently been discontinued abruptly due to a change in insurance. The patient was diagnosed with NCSE. NCSE can develop in a patient with or without underlying epilepsy, and should be included in the differential of unexplained AMS, especially in the setting of chronic benzodiazepine use. A high level of suspicion is essential for early diagnosis, but urgent confirmatory EEG is required.

Review the issue to find out more about the authors’ recommendation.

Not a subscriber? You can find out the conclusion and if you got it right, next month when a new case is posted, so stay tuned!

Click to review this Emergency Medicine Practice Issue

What’s Your Diagnosis? Assisting With Air Travel Medical Emergencies August 29, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 3 comments

But before we begin, check out if you got last month’s case, on assess anticoagulation status, right. Click here to check out the answer!

Case Presentation: a 53-year-old female passenger in the economy section has become “unresponsive.”

You are flying from London Heathrow Airport to New York JFK on British Airways when a flight attendant makes a request over the intercom for medical personnel to respond to an ill passenger. Among the responders is a Basic Life Support-trained EMT, a nurse intensivist, a psychiatrist, and yourself, an emergency medicine physician. The flight attendant informs you that a 53-year-old female passenger in the economy section has become “unresponsive.” Her husband says that she has a history of diabetes, hypertension, and coronary artery disease; has 2 stents; and is currently taking insulin, aspirin, clopidogrel, and metoprolol. On physical exam, she is initially diaphoretic, pale, and lethargic, but quickly regains consciousness and is able to provide some history, and she reports feeling lightheaded prior to losing consciousness. She reports ongoing general weakness and presyncope. She is bradycardic at 35 beats/min but she is alert, with no increased work of breathing. Her neurological exam is nonfocal, and she has a soft abdomen and thready peripheral pulses.

Case Conclusion

For your diabetic patient with weakness and loss of consciousness, you were able to access the AED and could see that she was bradycardic with a ventricular escape rhythm. Her husband retrieved her glucometer from her carry-on luggage, and her glucose measured at 45 mg/dL. She was able to drink some juice, and her glucose improved to 100 mg/dL and her heart rate improved to 60 beats/min, with improved mental status and peripheral pulses. She reported improving symptoms. The flight attendant connected you to the medical control officer employed by the airline, and you were able to describe the situation to her. Given the patient’s improving condition and the current location over the Atlantic Ocean, she recommended continuing to your final destination. The patient did well for the remainder of the flight, and was transported to an ED by EMS upon landing.

Review the issue to find out more recommendations.

Not a subscriber? You can find out the conclusion and if you got it right, next month when a new case is posted, so stay tuned!

Click to review this Emergency Medicine Practice Issue

Should you give antivenom again? — ED Management of North American Snake Envenomations April 11, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 2 comments

Case Recap:
A 26-year-old man arrives to the ED via private vehicle with his arm in a makeshift sling. He reports that his pet rattlesnake bit him on his right index finger about 45 minutes ago. His hand and wrist are swollen. He reports that he has no past medical history besides his 3 previous visits for snakebites. He reports having a “reaction” to the snakebite antidote during his last visit. You wonder whether the patient is immune . . . or should you give antivenom again?

Case Conclusion:
The 26-year-old man with 3 prior rattlesnake bites was at risk for significant morbidity related to this fourth snakebite, including impaired use of his dominant hand. Additionally, his initial lab values showed a developing coagulopathy. You decided to administer 6 vials of antivenom, but you ordered pretreatment with IV corticosteroids and antihistamines. You moved the patient to your resuscitation area for administration of antivenom and admitted him to the ICU for continued monitoring; fortunately, there were no side effects with the initial dose of antivenom.

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Secondary hypothermia in patients with sepsis and trauma — Brain Teaser. Do you know the answer? January 26, 2019


Posted by Andy Jagoda, MD in: Brain Tease , add a comment

Test your knowledge and see how much you know about treating and managing hypothermia and peripheral cold Injuries in pediatric patients.

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

The correct answer: C.

Earn CME for this topic by purchasing this issue. 

Skiing with no gloves. How do you handle these cold injuries? — Management of Pediatric Hypothermia January 14, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , add a comment

Case Recap:
A 17-year-old boy comes into your ED complaining of numbness and hardening of his fingers. He is a previously healthy foreign exchange student who is staying with a host family. The symptoms started yesterday after he went snow skiing for the first time. He says he wore gloves, but he was having a hard time holding the ski poles, so he took them off midway through the day. On examination, the fingertips on both of his hands are firm to the touch, have a dark discoloration, and are without sensation. The firmness and discoloration extend only to the distal interphalangeal joint in most of the fingers, but to the proximal interphalangeal joint in the middle finger of his left hand. The thumb on his right hand has a sizeable blister. As you step out of the room, you contemplate the next steps.

How do you classify the severity of his cold injuries? Does his thumb need debridement? Should you consult a hand surgeon and/or the burn center? What is the long-term prognosis for his injuries?

Case Conclusion:
The hands of the 17-year-old boy who did not wear gloves while skiing were placed in a warm water bath at 38°C (100.4°F) and gently rewarmed for 30 minutes. The pain did increase in his hand secondary to reperfusion, and all of his tissues softened except for his thumbs. You left his thumb blister intact, as it was not causing any restriction in movement and was filled with clear fluid. You placed aloe vera gel on all of his digits and loosely wrapped his hands in nonadhesive dressing. You gave him instructions to follow up at the burn center for continued outpatient therapy. He did not lose any digits, but the decreased sensation in his left thumb remained.

Skiing with no gloves. How do you handle these cold injuries? — Management of Pediatric Hypothermia January 7, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 3 comments

A 17-year-old boy comes into your ED complaining of numbness and hardening of his fingers. He is a previously healthy foreign exchange student who is staying with a host family. The symptoms started yesterday after he went snow skiing for the first time. He says he wore gloves, but he was having a hard time holding the ski poles, so he took them off midway through the day. On examination, the fingertips on both of his hands are firm to the touch, have a dark discoloration, and are without sensation. The firmness and discoloration extend only to the distal interphalangeal joint in most of the fingers, but to the proximal interphalangeal joint in the middle finger of his left hand. The thumb on his right hand has a sizeable blister. As you step out of the room, you contemplate the next steps.

How do you classify the severity of his cold injuries? Does his thumb need debridement? Should you consult a hand surgeon and/or the burn center? What is the long-term prognosis for his injuries?

Come back on Jan 14th to see if you got it right!