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December 2015 VOL. 20, NO. 12

AUTHORS

Maria Ortega Tsiu, MD, MBA, Resident Physician, Stanford/Kaiser Emergency Medicine Residency, Department of Emergency Medicine, Stanford School of Medicine, Stanford, CA

Robert L. Norris, MD, Professor, Department of Emergency Medicine, Stanford School of Medicine, Stanford, CA

N. Ewen Wang, MD, Professor of Emergency Medicine, Associate Director of Pediatric Emergency Medicine, Stanford School of Medicine, Stanford, CA

PEER REVIEWER

John Cheng, MD, Pediatric Emergency Medicine Associates, LLC, Atlanta, GA

STATEMENT OF FINANCIAL DISCLOSURE

To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, we disclose that Dr. Dietrich (editor), Dr. Skrainka (CME question reviewer), Dr. Tsiu (author), Dr. Norris (author), Dr. Wang (author), Dr. Cheng (peer reviewer), Ms. Coplin (executive editor), and Mr. Springston (associate managing editor) report no relationships with companies related to the field of study covered by this CME activity.

AHCMedia.com

ED Evaluation and Management of Mammalian Bites, and Snake

and Spider Envenomations“When the dog bites, when the bee stings / When I’m feeling sad, I simply

remember my favorite things, And then I don’t feel so bad.” – Oscar Hammerstein II

Case StudyA 4 year-old girl presents to the emergency department (ED) with a laceration through

her upper lip that was caused by a bite from a stray dog. She is otherwise well-appearing and is playing with a toy. What is your management plan? What medications will you administer? Is the patient at risk for infection?

IntroductionAs a consequence of their playful and curious nature, children not uncommonly

present to the ED with bite injuries; in fact, more than half of bite victims in the ED are children.1 Although envenomations are infrequent, the relatively high dose of venom per body weight in a young child can lead to significant effects. This article will discuss the key clinical features and management of bites from dogs, cats, and humans, as well as envenomations from snakes and spiders. Although not exhaustive, this review will provide a framework for the care of children who have sustained a bite or possible envenomation.

Dog, Cat, and Human BitesEpidemiology. With pet ownership so widespread, the ED provider will fre-

quently care for children with cat or dog bites. Recent sources have cited that 36.5% of households in the United States own at least one dog and 30.4% own at least one cat.1 An estimated 4.5 million dog bite-related injuries occur in the United States each year, and there are approximately 20-30 fatal dog injuries each year.1-3 These dog bite injuries are more common in children, frequently involve the patient’s extremities, and most commonly result from the family pet.1,4 It is estimated that there are approximately 300,000 cat bites per year in the United States.5 Patients are thought to be less likely to seek medical care for cat bites than dog bites.1,6

Human bites are considered to be the third most common mammalian bite, although true incidence is unknown, as it is thought that they are likely under-reported.1,5 In children, human bite injuries have a bimodal distribution — most commonly occurring in toddlers and early teenagers.5 Toddlers may bite other tod-dlers and family members, while school-age children may sustain human bites as a result of play and sports injuries, and adolescents possibly as a part of sexual activ-ity.5 These injuries may also be the result of non-accidental trauma. Approximately 1-3% of human bites are considered to be secondary to child abuse.7 Certain

INSIDE

Financial Disclosure: Author Dorothy Brooks, Managing Editor Leslie Hamlin, Executive Editor Shelly Morrow Mark, and Nurse Planner Diana S. Contino report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Executive Editor James J. Augustine discloses he is a stockholder in EMP Holdings. Caral Edelberg, guest columnist, discloses that she is a stockholder in Edelberg Compliance Associates.

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MAY 2015 Vol. 27, No. 5; p. 49-60

Protocol shows early promise in trimming costs and LOS for low-risk chest pain patients . . . . . . . . . . . . . . . . . . . . . cover

Hospital moves to leverage smartphone technology to improve post-ED follow-up, bring hospital-level care to some patients in their homes . . . . . . . . . . . . . 53

New tool is designed to speed appropriate care to medically complex children who present to the ED . Get the details . . . . . . . . . . . . . . . . . . . . 56

Emergency providers are accustomed to seeing patients with chest pain. In fact, it is the second most common complaint in the ED. However, while more than half of these patients are either admitted or

Early data suggest new protocol to risk-stratify chest pain patients, potentially preserving resources without compromising safety

Serial troponin tests improve sensitivity of a risk-score system developed in Europe

EXECUTIVE SUMMARY

Early data from the study of a new protocol suggest there may be a more efficient

way to risk-stratify patients presenting to the ED with chest pain so that lower-risk

patients can be safely discharged rather face longer hospital stays and expensive

tests . The approach, dubbed the HEART Pathway, involves using the HEART score, a

clinical decision tool developed in the Netherlands, along with slight modifications

including a second blood test for troponin levels .

• Experts say that the United States spends $10 to $13 billion per year for workups

on chest pain patients when fewer than 10% are actually having an acute coronary

syndrome .

• In a single-center randomized controlled trial, investigators found that when

compared to usual care, use of the HEART Pathway resulted in 12% fewer cardiac

tests, shorter lengths-of-stay, and 21% more early discharges . No patients in either

group experienced a major cardiac complication within 30 days of their ED visit .

• Larger studies of the HEART Pathway approach are being implemented with more

robust findings expected within a year .

Vol. 10, Issue 6, August 2015www.AHCMedia.com

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Evidence-Based Information for HospitalistsIntensivists, and Acute Care Physicians

Financial Disclosure: Hospital Medicine Alert’s Physician Editor, Kenneth P. Steinberg, MD, Peer Reviewer Rachael Safyan, MD, Managing Editor Jill Drachenberg, Associate Managing Editor Dana Spector, and Authors Dr. Samuel Nadler, MD, PhD, Dean L. Winslow, MD, FACP, FIDSA, and Matthew E. Fink, MD have no relevant relationship related to the material presented in this issue. Dr. Richard R. Watkins, MD, MS, FACP receives research support from Forest Pharmaceuticals.

ABSTRACT & COMMENTARY

Inferior Vena Cava Filters and Recurrent Pulmonary EmbolismBy Samuel Nadler, MD, PhD

Critical Care, Pulmonary Medicine, The Polyclinic Madison Center, Seattle, WA

Dr. Nadler reports no financial relationships relevant to this field of study.

SYNOPSIS: Placement of retrievable inferior vena cava filters in individuals with concurrent deep vein thrombosis does not reduce the risk of recurrent pulmonary embolism.

SOURCE: Mismetti P, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism: A randomized clinical trial. JAMA 2015;313:1627-1635.

Inferior vena cava (IVC) filters have increasingly been used as add-on therapy in patients with pulmonary embolism (PE), particularly if there is an additional clot burden in the legs, leading to concern that an additional embolism would be life-threatening. However, there are no data from randomized, controlled trials to support this intervention.

The PREPIC2 study is a randomized, open-label, blinded endpoint trial that specifically addresses this question. From August 2006 to January 2013, 399 patients with acute symptomatic PE associated with persistent lower limb venous thrombosis who

were at high risk for clinical decompensation were randomized to retrievable IVC filter placement for 3 months, plus systemic anticoagulation for 6 months vs anticoagulation alone. High risk was defined as having, in addition to the PE, one of the following: active cancer, chronic cardiac or respiratory insufficiency, ischemic stroke within the last 6 months, deep venous thrombosis (DVT) within the iliocaval segment or bilateral DVTs, signs of right ventricular strain or myocardial injury, and age > 75 years.

Exclusion criteria included: previous IVC filter placement, inability to place an IVC filter, full dose

VTE Occurs Frequently in Patients with Sepsis

page 43

Duration of Antibiotic Treatment for Vertebral Osteomyelitis

page 44

Antibiotics for Intraabdominal Infections: Less Is More

page 45

Vol. 23, Issue 9, December 2015AHCMedia.com

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Financial Disclosure: Critical Care Alert’s editor Betty Tran, MD, MSc, nurse planner Jane Guttendorf, DNP, RN, CRNP, ACNP-BC, CCRN, peer reviewer William Thompson, MD, executive editor Leslie Coplin, and associate managing editor Jonathan Springston report no financial relationships relevant to this field of study.

Is Less More or More Less?

page 67

Optimizing Respiratory Muscle Function During Mechanical Ventilationpage 68

Nutrition in the ICU: The Controversy Continues

page 69

Atrial Fibrillation in the ICU

page 71

ABSTRACT & COMMENTARY

Reducing Daily Chest Radiographs in the ICUBy Samuel Nadler, MD, PhD

Critical Care, Pulmonary Medicine, The Polyclinic Madison Center, Seattle

Dr. Nadler reports no relationships relevant to this field of study.

SYNOPSIS: Quality improvement protocols can reduce the number of chest radiographs in the ICU without compromising care.

SOURCE: Sy E, et al. Implementation of a quality improvement initiative to reduce daily chest radiographs in the intensive care unit. BMJ Qual Saf 2015 Sept 8 [Epub ahead of print].

Routine, daily chest radiographs (CXRs) are often ordered on all patients in the ICU, particularly on mechanically ventilated patients. However, several studies have called into question the utility of this practice. In 2003, Krivopal et al randomized patients to routine vs non-routine CXR and demonstrated no difference in duration of mechanical ventilation, ICU length of stay (LOS), and total LOS despite a 36% reduction in the number of radiographs in the non-routine group.1 Graat et al performed a prospective, non-randomized study requiring a clinical indication and new order for radiographs.2 The number of studies dropped by 56% without a change in length of ICU stay, ICU readmission, and hospital

mortality.2 A 2010 meta-analysis included these studies, demonstrating that elimination of routine CXRs had no effect on hospital or ICU mortality.3 More recently, the American College of Radiology changed its recommendations to state that CXRs should be ordered “for clinical indications only,” even in mechanically ventilated patients.4 However, ICUs continue ordering millions of routine CXRs.

This study is a before-after design that sought to reduce the number of routine CXRs in the ICU. Between June 2014 and 2015, data were collected as the pre-intervention baseline in a 350-bed, tertiary, teaching hospital with a 15-bed mixed medical-surgical ICU. Patients with trauma, thoracic surgery,

NOVEMBER 29, 2015 VOL. 36, NO. 25

AUTHORS

Jonathan Glauser, MD, FACEP, Faculty, MetroHealth/Cleveland Clinic Residency Program, Emergency Medicine; Professor, Emergency Medicine, Case Western Reserve University, Cleveland, OH.

Nathan Eikhoff, MD, Emergency Medicine Resident, MetroHealth Medical Center/Cleveland Clinic, Case Western Reserve University, Cleveland, OH.

PEER REVIEWER

Steven M. Winograd, MD, FACEP, St. Barnabas Hospital, Core Faculty, Bronx, NY; Emergency Medicine Residency, Clinical Assistant Professor, Emergency Medicine, NYiTCOM.

STATEMENT OF FINANCIAL DISCLOSURE

To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guide-lines, we disclose that Dr. Farel (CME question reviewer) owns stock in Johnson & Johnson. Dr. Stapczynski (editor) owns stock in Pfizer, Johnson & Johnson, AxoGen, Walgreens Boots Alliance Inc., and Bristol Myers Squibb. Ms. Mark’s spouse (executive editor) works for a company that creates advertising for Uroplasty. Dr. Schneider (editor), Dr. Eikhoff (author), Dr. Glauser (author), Dr. Winograd (peer reviewer), Mr. Landenberger (editorial and continuing educa-tion director), and Jonathan Springston (associate managing edi-tor) report no financial relationships with companies related to the field of study covered by this CME activity.

www.AHCMedia.com

Meningitis UpdateMissed meningitis is every emergency physician’s worst nightmare, especially in

a child. We all know the explanations of why it may be missed. First of all, it is uncommon; how many lumbar punctures (LPs) have you done that were “negative”? Second, there are much more common causes of fever, headache, and irritability. And third, performing an LP in a combative patient is not easy. So, it is easy to talk yourself out of doing one. This issue of EM Reports should provide you with enough reasons to stick with your first instinct and do the LP.

— J. Stephan Stapczynski, MD, Editor

IntroductionMeningitis is inflammation of the meninges lining the brain, that if allowed

to progress, causes impaired absorption and distribution of cerebrospinal fluid (CSF), vasodilation, and disruption of the blood-brain barrier, ultimately lead-ing to increased intracranial pressure.1 Infectious organisms gain access to this space either through hematologic spread, usually from the upper respiratory tract, or directly through infections of adjoining structures such as otitis media, mastoiditis, or sinusitis. Encephalitis, defined as inflammation of the brain parenchyma, causes alterations in mental status or other neurologic patholo-gies, whereas these features are technically absent in meningitis. These disease processes often coexist in the entity sometimes called meningoencephalitis. This update will refer to the term meningitis in the broad sense, with the implication that concomitant encephalitis may or may not be present.

Meningitis is usually classified as either bacterial or aseptic. Aseptic menin-gitis is defined as meningitis with CSF cultures that produce no growth with routine bacterial culture; it includes viral, fungal, tuberculous, and neoplastic meningitides. Other rare etiologies of meningitis, such as drug-induced and autoimmune meningitides, are diagnoses of exclusion and less pertinent to the practice of emergency medicine, and so they will not be part of this discussion.

Bacterial MeningitisEpidemiology The epidemiology of bacterial meningitis has drastically changed due to

vaccines against the most common bacterial pathogens.2 Cases of meningitis due to H. influenzae type b have decreased by more than 90% in the United States after the introduction of the conjugate vaccine in 1990. In developing countries, where few patients have access to this vaccine, it continues to be a major cause of pediatric meningitis, causing more than 100 cases per 100,000 children per year in some countries.2 Vaccines against Streptococcus pneumoniae have led to a 59% reduction in pediatric meningitis in the United States due to that pathogen.2 One of the most common bacterial causes of meningitis

JULY/AUGUST 2015 VOL. 16, NO. 4

AUTHORS

Jason R. Pickett, MD, FACEP, Assistant Professor, Department of Emergency Medicine, Wright State University, Dayton, OH.

Tyler Kallsen, MD, Wright State Emergency Medicine Residency, Dayton, OH.

Eric Schott, MD, Wright State Emergency Medicine Residency, Dayton, OH.

PEER REVIEWER

Jay Menaker, MD, FACEP, Associate Professor, Department of Surgery; Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD.

STATEMENT OF FINANCIAL DISCLOSURE

To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, we disclose that Executive Editor Ms. Mark’s spouse works for a company that creates advertising for Uroplasty. Dr. Dietrich (editor in chief), Dr. Pickett (author), Dr. Kallsen (author), Dr. Schott (author), Dr. Menaker (peer reviewer), Ms. Behrens (nurse reviewer), and Mr. Landenberger (continuing education and editorial director) report no relationships with companies related to this field of study.

www.ahcmedia.com

Damage Control ResuscitationDamage control resuscitation is critical for patients with massive hemorrhage.

Ideally, the first step is termination of the blood loss, then replace fluids and control the lethal triad of acidosis, hypothermia, and coagulopathy. This resuscitative tech-nique is valuable in the trauma setting, but also may be useful in any patient with massive hemorrhage such as a GI bleed or ruptured AAA. Damage control resuscita-tion is important for all trauma sites, beginning in the prehospital arena, rural hos-pitals, or Level 1 trauma center.

Adjuncts such as point-of-care testing may further assist with individualizing patient care. Damage control resuscitation continues to be an active area of research, and its management principles continue to be refined to offer our patients the optimal therapy.

— Ann M. Dietrich, MD, Editor

Introduction Damage control resuscitation is the replacement of lost fluids while control-

ling the lethal triad of acidosis, hypothermia, and coagulopathy in a patient with massive hemorrhage. Exsanguinating hemorrhage is one of (if not the) most common preventable cause of death after trauma. It causes approximately one-third of the almost six million trauma deaths per year, and is the lead-ing cause of life years lost throughout the world.1-3 Of the majority of trauma deaths occurring within the first 24 hours, 50% of these are due to hemor-rhage.4 Unfortunately, those patients who do survive a massive resuscitation have a significantly increased risk of sepsis, multi-organ failure, longer hospital stays, and higher healthcare costs.5 About half of the total mortalities occur before the patient reaches the hospital. All civilian and military trauma systems face the challenge of ensuring that bleeding patients receive timely and effec-tive hemorrhage control.

Early strategies (development of trauma practices in the Vietnam War until the 1990s) revolved around early fluid administration with crystalloid solu-tions in large quantities if required. As the practice of mass transfusion with red blood cells (RBCs) began to develop, it became evident that large amounts of crystalloids were contributing to coagulopathy through dilution. Protocols began adding relatively small volumes of blood component therapy (in addition to RBCs) as a reactionary correction to the resulting coagulopathy.6 Recent literature analyzing the experience with hemorrhage in the Iraq/Afghanistan conflicts emphasizes early anticipation and management by administering fresh frozen plasma (FFP), platelets, and cryoprecipitate before progression of the coagulopathy cascade. This strategy of early blood component therapy in conjunction with “permissive hypotension” until hemorrhage control has been achieved has led to dramatic improvements in mortality and morbidity.7 This

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Financial Disclosure: The following individuals disclose that they have no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study: Arthur R. Derse, MD, JD, FACEP (Physician Editor), Director and Professor, Center for Bioethics and Medical Humanities, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI; Stacey Kusterbeck (Contributing Editor); Shelly Morrow Mark (Executive Editor); and Leslie Hamlin (Managing Editor). Kay Ball, RN, PhD, CNOR, FAAN, Consultant/ Educator, K&D Medical Inc., Lewis Center, OH (Nurse Planner) is a speaker for AORN and a stockholder for STERIS, Inc.

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MAY 2015 Vol. 26, No. 5; p. 49-60

TM

Is Parent Signing Child Out AMA in Your ED? Hostility Can Lead to Lawsuit . . . . . . . . . . . . 52

Could EP Defendant Be Held to Inappropriate Standard of Care? . . . 54

“If the EP Had Only Told Me, I Would Have ...” When Consultant Says This, Can You Prove Otherwise? . . . . . . . . . 56

Physician reviewers at The Doctor’s Company, a Napa, CA-based medical malpractice insurer, recently analyzed 332 emergency medicine claims that closed from 2007 to 2013.1

“The motivation for the study was to identify risks to patients in emergency medicine,” says Darrell Ranum, JD, CPHRM, vice president of patient safety and risk management at The Doctor’s Company. “The value of data from a large number of physicians is to learn from their experiences.”

The hope is that as emergency physicians (EPs) review the findings of this study, they will scrutinize their own systems and processes. “They should determine whether the weaknesses identified in the study exist in their organization,” says Ranum.

Even though 39% of the claims were filed because of a patient’s death,

only about one in five claims resulted in a judgment or settlement against an emergency medicine physician. Other injuries included infections, loss of mobility, the need for surgery, hemorrhages, cardiac or brain infarction, and cardiac or pulmonary arrest.

The most common allegation was failure, delay, or wrong diagnosis. “Because of this diagnostic focus, we were surprised at the number of cases (173) in which our physician reviewers identified an issue with patient assessments,” says Ranum. It appeared that incomplete assessments were conducted. “In some cases, the assessment may have been thorough, but that was difficult to determine because the documentation was not detailed,” notes Ranum.

Patients with viral flu-like symptoms had bacterial pneumonia and were not treated with antibiotics; no lab tests,

Surprising New Data on Closed ED Claims: Incomplete Assessments Are Factor in Many Med/Mal Suits“A common path to lawsuits” against emergency physicians

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