EM Foundations: 2/22/2018

Welcome to the next installment of our 18 month longitudinal integration of the EM Foundations curriculum! EM Foundations uses a flipped classroom model that includes a guided independent review of EM core content to capable adult learners followed by in-person meeting time that is reserved for active, case-based, small group learning and focused critical teaching points. EM Foundations consists of two levels of case-based curricula and two levels of EKG courses that we will incorporate. If you have not done so already, please review the Guidelines for Learners which reviews all the details of how the curriculum works. Check out the residency calendar to see when EM Foundations are scheduled! Below is the assigned material with your choice of learning pathways for your independent review prior to our session scheduled for 2/22/18 at 8:30AM.

 

EM Foundations 1 + EKG I Course (PGY1 + PGY2 residents):

EMF 1 Unit Topics & Framework Traditional Textbook High-Yeld Text Multimedia
Tox II Toxidromes and Poisoning II

Approach to Toxidromes

Rosen’s: APAP 1960-1964, Cardiovascular Drugs, Caustics 1982-1998, Iron/Metals, Hydrocarbons, Inhaled Toxins 2024-2043, Pesticides, Mushrooms/Plants 2057-2075 River’s: APAP, Fe, HC, Caustics, OP, Mushrooms, CN, Dig, BB, CCB, CO, Mercury, Sulfonylurea p570-583 Hippo Videos:
Calcium Channel
Tintinalli’s: APAP 1269-1276, Dig, BB, CCB, AntiHTN 1284-1301, Fe, Hydrocarbons, Caustics, Pesticides 1307-1326, Metals, Industrial Toxins 1329-1341, Mushrooms 1419-1424, CO 1437-1441 Tintinalli Manual: APAP 523-526, Cardiac Meds 533-544, Fe, Hydrocarbons, Caustics, Pesticides, Metals, Industrial Toxins/CN 549-571, CO, Mushrooms 617-625 FOAMed:
EMRAP: Acetaminophen

EKG I Course Unit Unit Summary Challenge EKG #
Unit III Approach to Syncope Challenge EKG 10

EM Foundations 2 + EKG II Course (PGY3 residents):

EMF 2 Unit General Topics Text-Based (ALL) Multimedia (FOAMed)
Tox II Toxic Bradycardia, Classic Toxidromes Hardwood-Nuss:
Ch 323 p1402-1405
Ch 324 p1406-1409
Ch 338 p1444-1448
Ch 340 p1451-1453
Ch 343 p1460-1463
FOAMed:
NMS and SS (EM Docs)

BB overdose (LIFTL)

Bradycardia in OD (EM Docs)

Critical Care Literature:
Ch 68 p1205-1210
Ch 69 p1230-1235
Hippo Videos: (optional)
Enviro- Marine Enven, Gases, etc
Primary Literature:
Article 1

Article2

Article 3

Article 4

Article 5

EKG II Course Unit Unit Summary Challenge EKG #
Unit IX Miscellaneous Ischemic EKGs Challenge EKG 34

The post EM Foundations: 2/22/2018 appeared first on Bold City Emergency Medicine.

Empiric Antibiotic Considerations for Infective Endocarditis

There have been two recent FOAMed posts on the topic of endocarditis by REBEL EM and EMDocs. Both posts do a great job discussing risk factors, pathophysiology, signs and symptoms, and the diagnosis of endocarditis. However, we believe a more in-depth review of appropriate empiric antibiotic selection is prudent. As the ED pharmacist, we are ultimately responsible for making sure our patients get the most appropriate antibiotics. Additionally, whatever regimen is started downstairs is commonly continued upstairs. Therefore, if a patient is started on inappropriate therapy in the ED, it’s likely to continue until ID is able to see the patient, which may not be until the next day. Aside from decreased efficacy, inappropriate empiric antibiotics can also result in harm (e.g., AKI with aminoglycosides in native valve patients). We’re only giving one dose of antibiotics in the ED, so you’ve got one chance to get it right.

The 2016 IDSA Infective Endocarditis Guidelines(1) separate antimicrobial treatment recommendations into categories based on the causative pathogen(s) and the patient’s valve status (native versus prosthetic). Often empiric therapy for endocarditis is initiated in the ED because a patient is considered unstable. Unfortunately for us, this means we don’t regularly have culture results to guide therapy and therefore must choose empiric regimens to cover all of the most likely pathogens.When considering which empiric antibiotics to use, we have always found it useful to split patients into two categories much the same way the IDSA guidelines do: native valve versus prosthetic valve as the pathogens differ slightly between these groups.

Native Valve
The IDSA recommendation for empiric antimicrobial therapy for native valve endocarditis in patients with acute presentation is cefepime + vancomycin. Cefepime provides coverage of aerobic gram-negative bacilli, Streptococcus spp., and superior methicillin-susceptible Staphylococcus aureus (MSSA) coverage when compared to vancomycin. Vancomycin primarily provides coverage of methicillin-resistant Staphylococcus aureus (MRSA) and Enterococcus spp. when used in this regimen. Aminoglycosides are omitted from these empiric regimens as no benefit has been found with their addition in regards to clinical response, overall cure, or mortality for Staphylococcal endocarditis; although increased rates of nephrotoxicity were seen(2).

Prosthetic Valve
The IDSA recommendation for prosthetic valve endocarditis is cefepime + vancomycin + gentamicin + rifampin. Gentamicin is added for synergistic activity against Staphylococcus spp., Streptococcus spp. and Enterococcus spp., and rifampin is used to diminish Staphylococcal biofilms. Gentamicin is the preferred empiric aminoglycoside as some Enterococcus spp. possess an aminoglycoside acetyltransferase that confers high-level resistance to tobramycin and amikacin.

Dosing considerations
Cefepime— 2 g IV; aggressive dosing is warranted in this high bacterial burden infection.

Rifampin— 300 mg IV/PO; primarily studied at a dose of 900 mg/day divided in 3 separate does (i.e., 300mg q8 hours) in endocarditis, a dosing scheme unique to this disease state.

Gentamicin— 1 mg/kg IV (based on ideal body weight, unless total body weight > 120% ideal body weight, then adjusted body weight). This is not extended-interval dosing, but instead synergistic dosing targeting a peak of 3-4 mcg/ml.

Vancomycin— There is some variation in the IDSA’s endocarditis recommendations for trough targets depending on the pathogen:

  • For native valve Streptococcus spp., the trough goal is 10-15 mg/L
  • For native valve MRSA, the trough goal is 10-20 mg/L 
  • For prosthetic valve MRSA, the trough goal is 10-20 mg/L 
  • For PCN-resistant Enterococcus spp., the trough goal is 10-20 mg/L 

Again, as we are in the ED, we haven’t isolated a pathogen yet, so empirically we should be erring on the side of caution and tailor our dosing towards the higher trough targets of around 20 mg/L. Interestingly, the 2009 IDSA Vancomycin Guidelines(3) offer slightly different recommendations for goal vancomycin trough levels: 


Summary and recommendations: Based on the potential to improve penetration, increase the probability of optimal target serum vancomycin concentrations, and improve clinical outcomes for complicated infections such as bacteremia, endocarditis, osteomyelitis, meningitis, and hospital- acquired pneumonia caused by S. aureus, total trough serum vancomycin concentrations of 15–20 mg/L are recommended.

As you can see, higher trough ranges of 15-20 mg/L

have been previously recommended by the IDSA so it’s unclear why those recommendations are different than what’s stated in the endocarditis guidelines (10-15 mg/L and 10-20 mg/L). Either way, as you are empirically covering these patients for endocarditis and a bacteremia, it is best to go with the higher/more aggressive dosing targets (i.e., a trough goal of 15-20 mg/L). To achieve steady-state as quickly as possible, a loading dose can be utilized to help saturate the volume of distribution. In our practice we generally use a 25 mg/kg loading dose, capping doses at 2500 mg. Other institutions may have their own limits on the weight-based or maximum single dose, or employ a divided-load protocol. Either way, we recommend being aggressive and encourage giving as large a dose as permitted with the aim of reaching steady-state as soon as possible. 


Take Home Points

  • Definitive endocarditis treatment is based on the patient’s valve status (native vs prosthetic) as well as the causative pathogen(s) identified via blood cultures 
  • For our patients in the Emergency Department, most treatment is empirical and should be directed against the most likely pathogens for each patient 
  • Empiric endocarditis therapy using vancomycin should target a trough of 15-20 mg/L 
  • Ensure blood cultures are obtained prior to initiation of antibiotics 
  • Empiric treatment recommendations: 

Valve Status
Empiric Regimen
Empiric Regimen if Severe PCN Allergy*
Native valve
Cefepime 2 g IV
Vancomycin 25 mg/kg IV**
Aztreonam 2 g IV
Vancomcyin 25 mg/kg IV**
Prosthetic valve
Cefepime 2 g IV
Vancomycin 25 mg/kg IV**
Gentamicin 1 mg/kg IV
Rifampin 300 mg IV/PO
Aztreonam 2 g IV
Vancomcyin 25 mg/kg IV**
Gentamicin 1 mg/kg IV
Rifampin 300 mg IV/PO

*If non-severe PCN allergy, consider challenging with cefepime

**Or maximum allowable loading dose per institutional guidelines

Scott Dietrich, PharmD

@PCC_PharmD
Emergency Medicine Clinical Pharmacist
University of Colorado Health, North Region

Tony Mixon, PharmD, BCPS

@MixonMarkA
Emergency Medicine/Infectious Disease Clinical Pharmacist
University of Colorado Health, North Region

Edited by Craig Cocchio, PharmD, BCPS (@iEMPharmD) and Nadia Awad, PharmD BCPS (@Nadia_EMPharmD)

References

  1. Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications. Circulation. 2016;134:1435-1486 
  2. Korzeniowski O, Sande MA. Combination antimicrobial therapy for Staphylococcus aureus endocarditis in patients addicted to parenteral drugs and in nonaddicts: a prospective study. Ann Intern Med 1982; 97: 496–503. 
  3. Rybak, Lomaestro BM, Rotschafer JC, et al. Therapeutic monitoring of vancomycin in adults summary of consensus recommendations from the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Pharmacotherapy. 2009;29(11):1275-1279 

RCEM Learning FOAMed Workshop: Departmental websites

For more details on the workshop go to RCEM Learning

This came up on the day as something people were quite interested in. Common interests were

  • Induction programs
  • Storing and collating the departmental teaching activities
  • Storing and organising guidelines
  • Promotion of your ED and improving recruitment

As we saw on the day setting up a website is fairly straightforward. We highlighted the pros and cons of a woprdpress.com versus a self hosted site and most seemed to lean towards the self hosted for all the added functionality available

A number of people raised concerns about representing a hospital department outside the official sanction  of the trust. This is very legitimate and I would encourage you to speak with your communications team and even IT folk. The best example i’ve seen of a department website is the one from Edinburgh Royal Infirmary. They promote the department and haven’t shied away from engaging patients and helping them with their journey through the ED. A site like this will only improve the reputation of the trust.

Assuming you’ve got permission (or asked for forgiveness…) let’s look at a few things you could do

Induction Programs

This is relatively low hanging fruit in my opinion. We have so many juniors rotating so frequently that need to have some kind of ED specific induction so that they’re up to speed with for example the ED approach to chest pain (as opposed to the medical team’s approach to chest pain.) Traditionally this involves giving the same lecture every 4-6 months to a new group of juniors.

There’s no reason that this can’t be done as an online educational module to be completed in the first week of their rotation.

As a little aside please be sure and arrange appropriate remuneration for this. If you’re asking them to do 6 hours work then this needs facilitated in the rota NOT as something to do in their free time.

I set up a very basic induction series in a couple of hospitals I’ve worked and I’ll run you through the technical side of these. Be aware that the success of this still depends on someone ensuring that the docs complete the module which hasn’t always happened in the institutions I’ve been in.

Of note St Emlyns have been doing this for years and at a much higher level. All I’m doing here is documenting my very simple and fumbling efforts.

In this department site we had an SHO induction.

We created a number of modules for our doctors to complete.

In this example the educational material was a 15 minute video produced by SEMEP, these are freely available online and are set at about the right level for a new junior doctor coming to your ED. It would probably be better to record your own local material but there are lots of great resources already out there.

After watching the video they are expected to answer a few short questions on an embedded google form. This is one of the key steps – not because the questions are a particularly good way to assess learning but they do ensure that the doctor has actually watched the material. For those with a requirement to have a documented induction then this process ensures a paper trail that it actually happened. I am well aware that this does not make it effective education.

You can set as many questions as they like. I used 5. As mentioned the questions are mainly there to show the trainee as watched the material.

Once submitted the google form will populate a google spreadsheet.

There are some limitations with this as a lot of trusts will block video sites and any google apps so that your trainees won’t be able to complete the form or even see the video sometimes. It would also be nice to be able to automatically generate a certificate of completion once all the induction modules are complete.

This can be reviewed by the educational supervisor to ensure trainees have completed te module. Using google scripts you can set up more advanced functions like automatically generated emails when a trainee completes a module. This may have improved in the past few years since i set this up but i found it quite cumbersome at the time.

There are better ways to do this using Learning Management Systems. This is apparently a massive topic in itself and there are lots available. A local colleague put me on to Namaste and Watu quizzes

This is a lot more structured and allows you to assign and monitor an individual’s learning in much more detail.

It’s a plugin in wordpress and while a little cumbersome, it’s free and fairly easy to use.

I used the same videos from SEMEP but for the questions I used the Watu Quizzes plug in. This allows you to design all the questions within wordpress and it got round the firewall issue we had with google forms.

As you can see the end result is very similar to our initial example.

The nice thing is Namaste can be setup to email a pdf certificate of completion at the end of all the modules.

I think this is a better way to do it overall but it is a bit more cumbersome in the set up.

Again, as we discussed – this does not make your education any better in any way, it can help with dissemination and administration of your education but if your education was a bit crap to start with then it’ll still be crap with a website.

Storing and collating the departmental teaching activities

We all know that it’s very difficult to get everyone together for teaching at the same time. So the idea of collating and storing all your regular activity in one place is a great idea. There are various ways to do this.

  • Upload the power points
    • I think this is a particularly poor way to do things as @ffolliet is keen to remind us the slides are the least useful part of the presentation
  • Upload a recording/screencast of the presentation
    • This isn’t bad but requires either a pre or post recording of the presentation so the presenter has to give it twice
    • Or you record the screencast live which requires a reasonable degree of technical knowledge, equipment and coordination
  • You do a live recording of everything
    • This is great, see Maryland CC project as a great example of this
    • However it’s the most time, knowledge and equipment intensive.

There are lots of opportunities to use a flipped classroom model to provide good educational resources. But once again a website does not magically make this happen. If you have no one committed to engaging trainees and providing high quality education then a website will not fix this.

However if your department’s education is the bomb then you definitely should be sharing it and a website is a great way to do that.

Storing and organising guidelines

Hospital guidelines are often strewn throughout the hospital intranet and frequently difficult to find. It seems like a great idea to collate all these in one place.

However as soon as you download that pdf and upload it to your own ED bespoke site the document is no longer controlled and might be out of date and you would have no idea. There are lots of information governance issues here so I would strongly suggest engage someone else before taking hospital wide guidelines outside of the intranet

In one place I worked we had access to an ED specific guideline repository on the intranet where i could link to all the relevant hospital guidelines on the intranet. That way if that file was updated the link would either die or it would link to the new file.

In another hospital we had our own paper based ED handbook. This was ED specific and included advice about what to do with specific conditions out of hours. The ED itself took responsibility for the contents of that book. I simply digitised it on the ED website so that it was easier to find, update and link to external resources. It was also now searchable. It stays behind a password that changes every 6 months.

Promotion of your ED and improving recruitment

This can work quite well, but once again only if you actually have something decent to offer. If you offer great training opportunities then yes a website will help publicise that, but if you just want more middle grades for service provision then don’t expect much.

In one place I worked they created a number of fellow jobs with significant non clinical time (ultrasound and education for example). These were available on the ED website (but also on my own which gets significant traffic and is likely to be the deciding factor in this case…) and we had a number of staff who were investigating working in EM in Ireland and ended up applying for jobs.

Linda Dykes in Bangor has done a lot of similar work as have the EM3 team.

So a site can be useful to promote and recruit but it is not magical – you need actual substance behind it and it is not a panacea.