Tiny Tips: Modified Centor Score for Streptococcal Pharyngitis

Upper Respiratory Infection symptoms like cough or sore throat are still some of the top reasons for Canadian emergency department visits, and will likely be even higher in the upcoming months and in Urgent Care Centres.1 The most common organisms responsible for uncomplicated acute pharyngitis are viral agents at 50-80% and Streptococcal agents, specifically Group A Beta-Hemolytic Strep, at 5-36%.2 It is clinically significant to differentiate between these two pathogens as patients with the latter ...

The post Tiny Tips: Modified Centor Score for Streptococcal Pharyngitis appeared first on CanadiEM and was written by Richard Tang.

Vaginal Bleeding

A quick and simple algorithm to address the presentation of vaginal bleeding in the ED.

A quick and simple algorithm to address the presentation of vaginal bleeding in the ED.

Vaginal Bleeding Algorithm

Vaginal Bleeding Algorithm

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Vaginal Bleeding Algorithm (PDF)

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EM Updates: Rule Out Ectopic in the Emergency Department

The Ultrasound Podcast: Pregnancy Ultrasound Part 1

The Ultrasound Podcast: Pregnancy Ultrasound Part 2

EM Basic: Non-Pregnant Vaginal Bleeding

EM Basic: First-Trimester Vaginal Bleeding

EM in 5: Vaginal Bleeding in 1st TM Pregnancy

Tibbles CD: Selected Gynecologic Disorders in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 100: p 1355-1365.

Houry DE, Salhi BA. Acute Complications of Pregnancy in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 178: p 2282-2302.


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BTS/SIGN Asthma Guidelines Part 2 – Children

[Direct Download Podcast MP3]

For the second part of the Asthma Guideline Podcast Chris Connolly and Becky Maxwell focus on its application in Paediatric Emergency Departments. Nikki Abela has already done a great blog on this for RCEM which is worth a read (and it provides more detail than these show notes).

Just like for adults, the Guideline gives a long list of clinical parameters to ascertain whether the child in front of you falls into the mild, moderate, severe or life threatening category. These are important to know for exams but in reality on the shop floor we tend to use a checklist or protocol to remind ourselves of them! It is worth noting that the features of life threatening asthma are similar in children and adults – cyanosis, silent chest etc.

Important things to remember when treating the asthmatic child:

  • Beta agonists: If less than 2 years old and they don’t get better with bronchodilators delivered appropriately in hospital – rethink the diagnosis – this is what Edward Snelson often talks about with beta agonists in the under 1. It’s not ‘that beta agonists don’t work, it’s that the diagnosis is wrong’.
  • What’s your approach to an asthmatic child? If the child falls into the moderate category  or above start with 10 puffs x3, 20 mins apart and review the kids 5 mins between them and then at 20 mins afterwards.
  • The Guideline recommends if the  patient is hypoxic (<92%) use nebulisers. Add ipratropium 250mcg every 20mins for the first 2 hours if refractory to beta agonists.
  • Consider adding 150 mg magnesium sulphate to each nebulised salbutamol and ipratropium in the first hour in children with a short duration of acute severe asthma symptoms presenting with an SpO2 <92%. This was something that was news to us, evidence for this advice comes from the MAGNETIC Trial – which did not show a improvement in the asthma severity score when nebuliser magnesium was added but did demonstrate a clinical response in those children with SpO2  <92%.
  • Consider adding IV Magnesium in these children 40mg/Kg (but remember it may take a while to work so start drawing up the next drug……..)
  • Second line is IV salbutamol – bolus dose – 15mcg/kg over 10mins followed by a continuous infusion. In our opinion this is the point we would consider getting our critical care colleagues down to the ED!

When/how to discharge the asthmatic child:

Discharge those who have been observed and are now requiring  2-4 hourly inhalers. Make sure you have follow up in 48 hours and provide a written asthma plan ( we are much better at this in children than in adults!)

There are  two big ‘social’ treatments we should explore in the ED are the smoking cessation and obesity. Chris Connolly is happy with addressing smoking cessation but really struggles with telling parents their children are overweight. The thing is; as awful as this is, it has to be part of our job, we aren’t doing our job properly unless we discuss the issue – perhaps bringing parent away from child to have a discussion in private is more sensitive than discussing weight issues in front of the child.

In summary:

  • For us nothing major has changed in terms of treatment interventions or diagnostic categories other than adding nebulised Magnesium in children whose SpO2 < 92%
  • It is really all about doing the simple stuff well, the importance of appropriate follow up and written plan and the importance of addressing smoking and obesity cannot be underestimated
  • Chris Connolly to date is still working on his social awkwardness…..

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EM is a Failed Paradigm PRO: Scott Weingart CON: Simon Carley

Weingart Carley - EM is a failed paradigm

Scott Weingart presents his views on emergency medicine being a failed paradigm, where Simon Carley presents the opposing view. Carley states: “He’s wrong of course. For a starter, millions of people can’t be wrong. Sure, it’s not the same as when we started, but such dynamism and adaptation is something to be celebrated not vilified. Emergency Medicine will never die. […]

The post EM is a Failed Paradigm PRO: Scott Weingart CON: Simon Carley appeared first on Intensive Care Network.