Safely Managing Acute Osteoarthritis in the Emergency Department: An Evidence-Based Review.

BACKGROUND: Joint pain caused by acute osteoarthritis (OA) is a common finding in the emergency department. Patients with OA often have debilitating pain that limits their function and ability to complete their activities of daily living. In addition, OA has been associated with a high percentage of arthritis-related hospital admissions and an increased risk of all-cause mortality. Safely managing OA symptoms in these patients can present many challenges to the emergency provider. OBJECTIVES: We review the risks and benefits of available treatment options for acute OA-related pain in the emergency department. In addition, evidence-based recommendations will be made for safely managing pain and disability associated with OA in patients with comorbidities, including cardiovascular disease, renal insufficiency, and risk factors for gastrointestinal bleeding. DISCUSSION: Commonly used treatments for OA include acetaminophen, oral nonsteroidal anti-inflammatory drugs, and opioids, each with varying degrees of efficacy and risk depending on the patient's underlying comorbidities. Effective alternative therapies, such as topical preparations, intra-articular corticosteroid injections, bracing, and rehabilitation are likely underused in this setting. CONCLUSIONS: Emergency providers should be aware of the risks and benefits of all treatment options available for acute OA pain, including oral medications, topical preparations, corticosteroid injections, bracing, and physical therapy.

Clinical effects and antivenom use for snake bite victims treated at three US hospitals in Afghanistan.

OBJECTIVE: Annually, more than 100,000 US and international military and civilian personnel work in Afghanistan within terrain harboring venomous snakes. Current literature insufficiently supports Afghan antivenom treatment and stocking guidelines. We report the clinical course and treatments for snakebite victims presenting to US military hospitals in Afghanistan. METHODS: All snakebite victims presenting to 3 US military emergency departments between July 2010 and August 2011 in northern and southern Afghanistan were examined via chart review. Case information included patient demographics, snake description, bite details and complications, laboratory results, antivenom use and adverse effects, procedures performed, and hospital course. RESULTS: Of 17 cases, median patient age was 20 years (interquartile range [IQR], 12-30), 16 were male, and 82% were Afghans. All bites were to an extremity, and median time to care was 2.8 hours (IQR, 2-5.8). On arrival, 8 had tachycardia and none had hypotension or hypoxia. A viper was implicated in 5 cases. Ten cases received at least 1 dose of polyvalent antivenom, most commonly for coagulopathy, without adverse effects. Six received additional antivenom, 6 had an international normalized ratio (INR) > 10, and none developed delayed coagulopathy. Three received blood transfusions. Hospital stay ranged from 1 to 4 days. None required vasopressors, fasciotomy, or other surgery, and none died. All had resolution of marked coagulopathies and improved swelling and pain on discharge. CONCLUSIONS: We report the largest series of snake envenomations treated by US physicians in Afghanistan. Antivenom was tolerated well with improvement of coagulopathy and symptoms. All patients survived with minimal advanced interventions other than blood transfusion.

Is point-of-care ultrasound accurate and useful in the hands of military medical technicians? A review of the literature.

Over the past decade, point-of-care ultrasound (US) use by nonphysician providers has grown substantially. The purpose of this article is to (1) summarize the literature evaluating military medics' facility at US, (2) more clearly define the potential utility of military prehospital US technology, and (3) lay a pathway for future research of military prehospital US. The authors performed a keyword search using multiple search engines. Each author independently reviewed the search results and evaluated the literature for inclusion. Of 30 studies identified, five studies met inclusion criteria. The applications included evaluation of cardiac activity, pneumothorax evaluation, and fracture evaluation. Additionally, a descriptive study demonstrated distribution of US exam types during practical use by Army Special Forces Medical Sergeants. No studies evaluated retention of skills over prolonged periods. Multiple studies demonstrate the feasibility of training military medics in US. Even under austere conditions, the majority of studies conclude that medic can perform US with a high degree of accuracy. Lessons learned from these studies tend to support continued use of US in out-of-hospital settings and exploration of the optimal curriculum to introduce this skill.

Simulated Angioedema in a Fresh Frozen Cadaver: A Novel Teaching Model for Airway Training.

INTRODUCTION: As educators, we are charged with preparing emergency medicine residents for successfully intubating patients with even the most troublesome anatomy. This situation is encountered during the intubation of patients with angioedema. These patients are uncommon in the emergency department, and as a result, it is difficult to ensure that each resident is well trained in this intubation scenario before graduation. EDUCATIONAL OBJECTIVE: Our goal was to develop an angioedema teaching model to increase resident knowledge, confidence, and proficiency at intubating in this clinical setting. CURRICULAR DESIGN: Using a 22-gauge spinal needle and a 60-mL syringe, we were able to cause realistic distention of the lips, tongue, and pharynx when we injected approximately 300-mL of air bilaterally near the sublingual glands and into the tongue and lips. Before implementing the angioedema model into the curriculum, 5 board-certified attending emergency physicians evaluated the model for validation, and all agreed that it was high fidelity.Participants performed both direct and video laryngoscopy on the simulated angioedema cadaver. At the conclusion of their intubation experience, the participants completed a survey describing their impression of the angioedema model. IMPACT/EFFECTIVENESS: Participants included 29 emergency medicine residents, with participants from all year groups. In response to the statement, "The angioedema model was high fidelity," 12 residents strongly agreed, whereas the remaining respondents agreed. In response to the statement, "The angioedema model was a good training model for angioedema," 13 residents strongly agreed, whereas the remaining respondents agreed. When solicited for comments on the model, one participant wrote, "Awesome opportunity, I will be markedly less terrified when I get an angioedema/anaphylaxis case."We have developed an angioedema training model using air insufflation in a fresh frozen cadaver. Our participants uniformly expressed positive impressions of both the fidelity and training quality of this model.