Week #2 #EMconf Archive Is Now Available

Week number 2 of the 2015 #EMconf archive is now available for download here.  This Symplur transcript includes all #EMconf tweets, including links and images.  Over the last 7 days the Emergency Medicine training program conference/lecture series hashtag generated > 270,000 impressions via >380 tweets by 140 participants.

The most frequently mentioned EM programs in last week’s tweets and retweets were: Northwestern (@NorthwesternEM), Washington University in St. Louis (@WUSTL_EM), University of Maryland EM (@UMEmergencyMed), and Carolinas Medical Center (@CMCEM).  They must have had something good to say – be sure to give them a follow.

Leading participants this week were: @danieljafari, @mkleinmd, @docbond007, @wustl_EM, @stanfordemres, @em_stevemcguire, @pedemmorsels, @northwesternEM, @dukeemergency, @emswami.

Something to think about from Washington University in St. Louis (@WUSTL_EM):

Another one from Wash U that got a lot of attention:


And a couplet from @EMSwami on the HEART Score validation: 


Do you tweet from your weekly conference/lecture series?  Add #EMconf to your tweets and join the global conversation!

A continuous feed from #EMconf and other leading FOAM hashtags is always available at FOAMfeeds.



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Words Matter

Image words matterIn healthcare, we do love a label, and we rush to find one as soon as we possibly can. No sooner as an elderly patient booked in to the reception desk than thoughts turn to whether or not she’s an ‘appropriate’ attendance. For Mrs Smith, an 87- year old grandmother of four who worked as a nurse here for decades, that’s hardly an issue. She’s poorly and, whatever the context, has, by arriving at your unit, declared a need for help. And that’s absolutely appropriate.

Picking up her notes you reflect on what the role of ‘primary care’ could, should or might be in her management. But that’s a difficult judgment because you don’t really know what ‘primary care’ really means. Is it a GP? A district nurse? A therapist? Or is it just anything which doesn’t involve a hospital? It must be different to ‘general practice’ because that is a separate label. It doesn’t matter to Mrs Smith – nor should it. But we make it matter to ourselves. She has only been in the building for twenty minutes and already she is an ‘inappropriate primary care attendance’.

Assessment reveals a respiratory tract infection and in all probability things can be managed without the need for an admission. But someone somewhere has already taken some blood samples on Mrs Smith. And our ‘inappropriate primary care attendance’ is now also ‘waiting for bloods’. Nobody quite knows why this is so, but the blood tests have been taken so we may as well await their return. Mrs Smith is 87 and her blood indices will not have been ‘normal’ since 1995. But that isn’t really noticed.

There is no surprise to discover that her U&E results are not deemed satisfactory. Although she in herself is keen to go home, it’s Friday, and because the ‘out of hours’ service isn’t yet operational, yet the GP surgery has no appointments to offer, it seems best just to run this case past the medical team. They’re busy, of course, and so Mrs Smith is now not only an ‘inappropriate primary care attendance’ who ‘awaited bloods’, she’s now a ‘breach’ because of capacity challenges.

In fact, such is the delay to be seen that Mrs Smith, who still really wants to go home before it gets dark, is now almost a ’12 hour trolley wait’. She is comfortable enough; space is available to care for her in a rapidly-cleaned cubicle. And, by and by, a bed is identified on an ‘outlier’ ward for her. If only there was an ‘outlier doctor’ free to see her. But there isn’t. The next day is a Saturday and nobody thinks that Mrs Smith will manage unless she has a commode and a carer to put her to bed. She herself thinks she’ll be fine. But what she doesn’t know is that she’d steadily becoming a ‘bed blocker’ because no carer can be had until Monday.

Come Monday, Mrs Smith goes home. She came seeking help because she thought that was the right thing to do. Her chest infection is getting better, but there is much more to it than that. Without even trying, this elderly lady, who worked here all those years ago, has been ‘inappropriate’, a product of failed ‘primary care’, has ‘waited for bloods’, been a ‘breach’, a ’12 hour trolley wait’, an ‘outlier’, and a ‘bed blocker’.

48 hours ago, she was just a retired old lady who felt unwell.

The vital elements of care are lost in translation as we rush to describe models premised upon meaningless labels. We don’t even know what they mean. Words matter. We must do better.

Should you supply a salty solution for bronchiolitis symptoms?

Continuing onward with the next in the top ten articles presented at the recent AAP NCE in San Diego is a study of the use of hypertonic saline (HTS) in bronchiolitis. I’ll stray a bit form the usual format in that this paper was presented in a point counterpoint fashion. I’ve also posted on this topic previously as a part of my Bronchiolitis! series (yes, the exclamation point is intentional).

Nebulized hypertonic saline for bronchiolitis: a randomized clinical trial

Wu S, Baker C, Lang ME, Schrager SM, Liley FF, Papa C, Mira V, Balkian A, Mason WH. JAMA Pediatrics, 2014

Links PubMed JAMA Pediatrics

Nebulized hypertonic saline for bronchiolitis in the emergency department: a randomized clinical trial

Florin TA, Shaw KN, Kittick M, Yakscoe S, Zorc JJ. JAMA Pediatrics, 2014

Links PubMed JAMA Pediatrics

The bottom line

Hypertonic saline might help reduce the risk of admission in bronchiolitis, but then again it might not.

What they did

Wu and colleagues performed a RCT over 3 consecutive bronchiolitis seasons and recruited a convenience sample of patients <24 months old with bronchiolitis. from March 1, 2008, through April 30, 2011. 211 patients were randomized to HTS and 197 to saline. They received each treatment up to 3 times. All patients were premedicated with albuterol. The main outcome was hospital admission. Additional outcomes included length of stay for admitted patients, and Respiratory Distress Assessment Instrument score.

  • The authors reported that the HTS group had lower odds of admission. HTS was 28.9% compared with 42.6% in the NS group (aOR=0.49 [95% CI, 0.28-0.86])
  • There was no significant difference in the respiratory distress score in either group
  • Length of stay was marginally shorter for HTS but not significant

Meanwhile Florin et al performed a RCT comparing HTS versus normal saline. 62 patients between 2 and 24 months of age (31 in each arm) with their first episode of bronchiolitis were randomized to placebo or HTS, with the primary outcome being respiratory distress at 1 hour after administration. The included patients were enrolled after they had been suctioned and received albuterol and were determined to still have respiratory distress. They also assessed  vital signs, oxygen saturation, hospitalization, physician clinical impression, parental assessment, and adverse events.

  • They noted that 1 hour after treatment the HTS improved less versus placebo (HTS, −1 [interquartile range, −5 to 1] vs saline placebo, −5 [interquartile range, −6 to −2]; P = .01)
  • They saw no significant differences in heart rate, oxygen saturation, hospitalization rate, or other outcomes
  • This study was limited by small numbers and a single trial of HTS
  • It is also uncertain as to what effect (if any) the albuterol had on these patients

What you can do

The post Should you supply a salty solution for bronchiolitis symptoms? appeared first on PEM Blog.

Should parents to be accompanying their children?

Hola a tod@s, my dear friends.

Your opinion is important, and we need to listen you.

Only one thing is necessary: you want to share it. Anyone can comment, you don't have to be a health care professional.

From the Pediatric ICU of the Hospital 12 de Octubre, a group of healthcare professionals including auxiliar (Rafaela Pozo and Laura Palomino), nurses (Raquel Vinagre, Sonia Gil and Raquel Arenas) and pediatricians (Sylvia Belda, Luisa Barón and Marta Olmedilla), ask us for help.

Should parents or family members be accompanying their children during the procedures we perform them?.

The admission to the PICU is always a traumatic event for children and families and we are very concerned about trying to improve the care of the children and their families to minimize the emotional impact.

Our unit is a 24 hours open unit and we are beginning to raise awareness of the need of children to be accompanied by their parents.

In this context we ask your collaboration to know your opinion about family presence in different procedures and moments. It is a small survey and it will only take less than 5 minutes to fill out this form (available in English). 

They are searching opinions from over the World!

Your opinion will help us in trying to adapt our care to the real needs.
Thank you very much for your cooperation.

From The IC-HU Project, let´s help them to collect the highest number of responses for these necessary questions. Knowing where we are we can know where we want to go.

Congratulations mates!

Happy Tuesday,

Must-Know EM Pharmacotherapy Articles of 2014

canstockphoto23105821There is so much literature to sift through each year, it becomes nearly impossible to stay abreast of it. Here is a quick summary of the 6 must-know Emergency Medicine pharmacotherapy articles from 2014, in my humble opinion.



1. High-Dose Droperidol and Risk of QT Prolongation2. Dexmedetomidine As Adjunct Therapy for EtOH Withdrawal - RCT3. A Simpler Dosing Regimen for Digoxin-Specific Antibody Fragments4. Treatment for Calcium-Channel Blocker Overdose: A Systematic Review5. Bactrim + ACE-Inhibitor (or ARB) + Older Adult = Increased Sudden Death6. Is That IV Antibiotic Before ED Discharge Really Necessary?
46 patients treated with high-dose droperidol (10-40 mg) were studied prospectively with continuous holter recording.

What they did

Patients initially received 10 mg droperidol as part of a standardized sedation protocol (for aggression). An additional 10 mg dose was given after 15 min if required and further doses at the clinical toxicologist’s discretion.

Continuous 12-lead holter recordings were obtained for 2-24 hours. QTc > 500 msec was defined as abnormal (with heart rate correction – QTcF).

What they found

Only 4 patients had abnormal QT measurements, three given 10 mg and one 20 mg. All 4 had other reasons for QT prolongation. No patient given > 30 mg had a prolonged QT. There were no dysrhythmias.

What it means

There was little evidence supporting droperidol being the cause and QT prolongation was more likely due to pre-existing conditions or other drugs.

Calver L, et al. High dose droperidol and QT prolongation: analysis of continuous 12-lead recordings. Br J Clin Pharmacol 2014;77(5):880-6. [PMID 24168079]

Originally posted Jan 4, 2014 as University of Maryland (UMEM, @UMEmergencyMed) pearl.

Four small case series (one prospective, 3 retrospective) have concluded that dexmedetomidine (Precedex) may be a useful adjunct therapy to benzodiazepines for ethanol withdrawal in the ED or ICU. They are summarized in a previous ALiEM post.

A new randomized, double-blind trial evaluated 24 ICU patients with severe ethanol withdrawal.

Group 1: Lorazepam + placebo

Group 2: Lorazepam + dexmedetomidine (doses of 0.4 mcg/kg/hr and 1.2 mcg/kg/hr).

  • 24-hour lorazepam requirements were reduced from 56 mg to 8 mg in the dexmedetomidine group (p=0.037).
  • 7-day cumulative lorazepam requirements were similar.
  • Clinical Institute Withdrawal Assessment or Riker sedation-agitation scale scores were similar within 24 hours.
  • Bradycardia occurred more frequently in the dexmedetomidine group.

In my opinion, a major limitation of this study is that patients had more than 24 hours of treatment before randomization. Eleven of the 24 patients were already intubated when the trial started. The best place to use dexmedetomidine is probably in the early treatment course to help avoid intubation altogether. I’m not sure this very exclusive trial (24 patients included/209 excluded over 4 years) provides any answers for the patients who may benefit most from this therapy. A reduction in benzodiazepines is not even the correct outcome to measure. That may lead to the erroneous notion that we don’t need benzodiazepines (as has happened in some of the other studies). We should be looking at reduction in intubations and ICU length of stay.

Mueller SW, et al. A randomized, double-blind, placebo-controlled, dose range study of dexmedetomidine as adjunctive therapy for alcohol withdrawal. Crit Care Med 2014;42(5):1131-9. [PMID 24351375]

Originally posted May 3, 2014 as UMEM pearl.

Digoxin-specific antibody fragments (Fab) are safe and indicated in all patients with life-threatening dysrhythmias and an elevated digoxin concentration. However, full neutralizing doses of digoxin-Fab are expensive and may not be required (not to mention cumbersome to calculate).

Based on pharmacokinetic modeling and published data, a new review suggests a simpler, more stream-lined dosing scheme as follows:

  • In imminent cardiac arrest, it may be justified to give a full neutralizing dose of digoxin-Fab.
  • In acute poisoning, a bolus of 80 mg (2 vials), repeat if necessary, titrated against clinical effect, is likely to achieve equivalent benefits with much lower total doses.
  • With chronic poisoning, it may be simplest to give 40 mg (1 vial) at a time and repeat after 60 min if there is no response.

Chan BS, et al. Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Clin Toxicol 2014;52:824-36. [PMID 25089630]

In a precursor to a forthcoming international guideline on the management of calcium channel blocker poisoning, a new systematic review has been published assessing the available evidence.

A few findings from the systematic review:

  • The majority of literature on calcium channel blocker overdose management is heterogenous, biased, and low-quality evidence.
  • Interventions with the strongest evidence are high-dose insulin and extracorporeal life support.
  • Interventions with less evidence, but still possibly beneficial, include calcium, dopamine, norepinephrine, 4-aminopyridine (where available), and lipid emulsion therapy.

Stay tuned for the international guideline coming out soon. One treatment recommendation from the new guideline, reported at the 8th European Congress on Emergency Medicine September 2014, is not to use glucagon.

St-Onge M, et al. Treatment for calcium channel blocker poisoning: a systematic review. Clin Toxicol 2014;52:926-44. [free full-text PDF]

Originally posted October 9, 2014 as UMEM pearl.

A new population-based case-control study in older adults has linked the administration of trimethoprim-sulfamethoxazole (Bactrim, TMP-SMX) to increased risk of sudden death in patients also receiving angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB).

Hyperkalemia is the suspected cause. Compared to amoxicillin, TMP-SMX was associated with an increased risk of sudden death (adjusted odds ratio 1.38, 95% confidence interval 1.09 to 1.76) within 7 days of exposure to the antibiotic.

Practice Change

In older patients receiving ACE-Is or ARBs, TMP-SMX is associated with an increased risk of sudden death. When appropriate, alternative antibiotics should be considered.

Fralick M, et al. Co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system: population-based study. BMJ 2014;349:g6196. [Free open access link]

Many of the oral antibiotics prescribed in the ED have good bioavailability. So, a one-time IV dose before discharge generally won’t provide much benefit.

In fact, a new prospective study found that a one-time IV antibiotic dose before ED discharge was associated with higher rates of antibiotic-associated diarrhea and Clostridium difficile infection. One-time doses of vancomycin for SSTI before ED discharge are also not recommended (see Academic Life in EM post by Zlatan Coralic).

Bottom Line

Though there are a few exceptions, if a patient has a working gut, an IV dose of antibiotics before ED discharge is generally not recommended and may cause increased adverse effects. An oral dose is just fine.

Haran JP, et al. Factors influencing the development of antibiotic associated diarrhea in ED discharged patients home: risk of administering IV antibiotics. Am J Emerg Med 2014;32(10):1195-9. [PMID 25149599]

Originally posted December 6, 2014 as UMEM pearl.

Image credit: (c) Can Stock Photo

Author information

Bryan D. Hayes, PharmD, FAACT

Bryan D. Hayes, PharmD, FAACT

ALiEM Associate Editor

Clinical Assistant Professor, University of Maryland (UM)

Clinical Pharmacy Specialist, EM and Toxicology

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