Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient.

RATIONALE: Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI). OBJECTIVES: To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI. DESIGN: A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process. METHODS: Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist. RESULTS: From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence. CONCLUSIONS: Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research.

Epinephrine autoinjector prescribing following anaphylaxis presentation to the emergency department.

Background: Guidelines recommend patients with anaphylaxis are prescribed epinephrine autoinjectors (EAI), carry the EAI with them, and are referred to an allergist. There also are barriers to EAI administration, such as acquiring the medication, having it available, recognizing when to use it, and administering it appropriately. Objective: The objective was to describe how often patients with anaphylaxis discharged from the emergency department (ED) receive an EAI prescription and allergist referral; also, to assess the frequency of EAI pick-up by the patient from the outpatient pharmacy, out-of-pocket cost, change in EAI device during dispensing, and if patient training on EAI use and allergist follow-up occurred. Patient-specific factors associated with the occurrence of these variables were investigated. Methods: This was a retrospective, observational study of adult and pediatric ED patients who presented with anaphylaxis between July and December 2020. Data were collected from medical records and telephone calls to outpatient pharmacies and included patient demographics; ED treatment; EAI prescribing, EAI pick-up from the outpatient pharmacy, and cost; device changes; EAI training; and allergist referral and follow-up. Data are presented descriptively, and bivariate analyses were used for comparisons between patient-specific factors and incidence of EAI prescribing, patient pick-up, and allergist referral. Results: A total of 102 patients were included; mean age ± standard deviation 34 ± 7 years, 52% were < 18 years of age; and 54% had a history of allergy and/or anaphylaxis. EAI prescribing occurred in 79% of the patients. Of these, 71% picked up the EAI from the outpatient pharmacy, the median cost to the patient was $5 (range, $0-$379), 18% had an EAI device change at dispensing, and 23% received EAI training. Allergist referral occurred in 22%, and 28% followed up with an allergist within 60 days. Presenting symptoms of mucosal edema and respiratory stridor were associated with the occurrence of EAI prescribing. Presenting symptoms of respiratory wheezing, hoarseness, throat itching, skin flushing and allergist referral from the ED were associated with the occurrence of EAI pick-up from the outpatient pharmacy. Conclusion: Overall, 79% of ED patients with anaphylaxis had an EAI prescribed and 22% had an allergist referral; 71% picked up the EAI from the outpatient pharmacy, EAI dispensing changes occurred, and training was infrequent. Collaboration between emergency medicine clinicians, allergists, and pharmacists is needed to streamline treatment and follow-up.

Small Bowel Volvulus as Delayed Presentation of Undiagnosed Crohn's Disease: A Case Report.

INTRODUCTION: Emergency department (ED) visits related to flare-ups of inflammatory bowel disease (IBD) are becoming more prevalent. There are many potentially dangerous complications and sequelae of uncontrolled IBD. CASE REPORT: We report a case of a middle-aged woman who presented with a few hours of severe abdominal pain, nausea, and vomiting. Given her hemodynamic instability, she was sent urgently for computed tomography, which showed an incomplete small bowel malrotation, mesenteric volvulus, and high-grade small bowel obstruction with evolving ischemia. The patient underwent exploratory laparotomy to resect most of her small intestines. Biopsies later revealed active Crohn's disease. CONCLUSION: Patients with flare-ups of IBD are common in the ED, but very few present with a midgut volvulus later in life. Our case is unique and adds to the literature due to the dramatic consequences of undiagnosed Crohn's disease in a patient with intermittent symptoms and extensive workup spanning over two decades.

Emergency Medicine Intern Education for Best Practices in Opioid Prescribing.

INTRODUCTION: Opioid exposure has been identified as a contributing factor to the opioid epidemic. Reducing patient exposure, by altering heavy opioid prescribing patterns but appropriately addressing patient pain, may represent one approach to combat this public health issue. Our goal was to create and implement an opioid education program for emergency medicine (EM) interns as a means of establishing foundational best practices for safer and more thoughtful prescribing. METHODS: This was a retrospective study at an academic, urban emergency department (ED) comparing ED and discharge opioid prescribing practices over a 12-week time period for two 14-intern EM classes (2016 and 2018) to evaluate an early opioid reduction education program. The education program included opioid prescribing guidelines for common ED disease states associated with moderate pain, clinician talking points, and electronic education modules, and was completed by EM interns in July/August 2018. Opioid prescription rates per shift were calculated and opioid prescribing best practices described. We used chi-squared analysis for comparisons between the 2016 and 2018 classes. RESULTS: Overall, ED and discharge opioid orders prescribed by EM interns were fewer in the 2018 class that received education compared with the 2016 class. ED opioid orders were reduced by 64% (800 vs 291 orders, rate per shift 1.8 vs 0.7 orders) and opioid discharge prescriptions by 75% (279 vs 70 prescriptions, rate per shift 0.7 vs 0.2 prescriptions). The rate of prescribing combination opioid products compared to opioids alone was decreased for ED orders (32% vs 16%, P < 0.01) and discharge prescriptions (91% vs 74%, P < 0.01) between the groups. Also, the median tablets per discharge prescription (14.5 vs 10) and total tablets prescribed (4305 vs 749) were reduced, P < 0.01. There were no differences in selection of opioid product or total morphine milligram equivalents prescribed when an opioid was used. CONCLUSION: An opioid reduction education program targeting EM interns was associated with a reduction in opioid prescribing in the ED and at discharge. This may be an effective way to influence early prescribing patterns and best practices of EM interns.

Sexually Transmitted Infection Review for the Acute Care Pharmacist.

PURPOSE: Review selected sexually transmitted infections (STIs) and treatment recommendations for pharmacists and providers practicing in the acute care setting. SUMMARY: In 2015, the Centers for Disease Control and Prevention (CDC) published an updated guideline on the treatment of STIs with an emphasis on prevention and new diagnostic strategies to combat the growing problem of STIs in the United States. Despite this guidance, the incidence of infection has continued to grow. In October 2016, an in-depth analysis reported that 20 million new infections occur annually in the United States. With this growing burden of disease, it is pertinent that health-care providers optimize their treatment strategies to improve upon the management of STIs. Focusing on identification of asymptomatic- and symptomatic-infected persons, treatment, education, effective follow-up, and counseling for patients and sexual partners, emergency medicine pharmacists and providers can help minimize the negative long-term health consequences of STIs. CONCLUSION: In the emergency department setting, clinical pharmacists and providers can play a crucial role in preventing and treating STIs and should continue to expand and keep current their knowledge of this topic.

MRSA nares swab is a more accurate predictor of MRSA wound infection compared with clinical risk factors in emergency department patients with skin and soft tissue infections.

OBJECTIVES: Skin and soft tissue infections (SSTI) caused by methicillin-resistant Staphylococcus aureus (MRSA) are prevalent in the emergency department (ED). We determined whether MRSA nasal carriage better identifies patients with MRSA wound infection than clinical risk factors or emergency medicine (EM) provider's choice of discharge prescriptions. METHODS: Adult patients presenting to a large academic medical centre ED in the USA with SSTI between May 2010 and November 2011 were screened. Research assistants administered a questionnaire regarding MRSA risk factors, and MRSA nares swab PCR testing, wound culture results and information on antibiotics prescribed at discharge were collected. Measures of classification accuracy for nares swab, individual risk factors and physician's prescription for MRSA coverage were compared with gold standard wound culture. RESULTS: During the study period, 116 patients with SSTI had both wound cultures and nares swabs for MRSA. S. aureus was isolated in 59.5%, most often MRSA (75.4%). Thirty patients (25.9%) had a positive MRSA nares swab and culture for a sensitivity of 57.7% and specificity of 92.2%. Positive predictive value (PPV) for MRSA nares swab was 85.7% and positive likelihood ratio was 7.4, while negative predictive value was 72.8% and negative likelihood ratio 0.5. None of the individual risk factors nor EM provider's prescription for MRSA coverage had a PPV or positive likelihood ratio higher than nares swabs. CONCLUSIONS: MRSA nares swab is a more accurate predictor of MRSA wound infection compared with clinical risk factors or EM provider's choice of antibiotics. MRSA nares swab may be a useful tool in the ED.

Effectiveness of glucagon in relieving esophageal foreign body impaction: a multicenter study.

PURPOSE: Glucagon is thought to decrease lower esophageal sphincter tone and is used as an alternative to invasive endoscopy for esophageal foreign body impaction (EFBI). The purpose of this study was to evaluate efficacy and safety of glucagon and identify characteristics associated with success. METHODS: A multicenter, retrospective study of patients receiving glucagon for EFBI at 2 academic emergency departments was conducted between 2006 and 2010. A control group of patients that did not receive glucagon was evaluated. Data collection included demographics, type of foreign body, glucagon dose, resolution of impaction, incidence of vomiting, additional medication, and endoscopy required. Descriptive and univariate analysis was performed as appropriate. RESULTS: A total of 133 doses of glucagon were administered in 127 patients. Glucagon-related resolution of EFBI occurred in 18 patients (14.2%) and vomiting in 16 patients (12.6%). No statistical differences between successful and unsuccessful groups were seen with the exception of concomitant medication administration (benzodiazepine or nitroglycerin) being associated with less glucagon success, 33.3% vs 59.6%, respectively (P = .04). Eighty-four percent of patients in the unsuccessful group underwent endoscopy. Comparing those that received glucagon (n = 127) and the control group (n = 29), there was no significant difference in resolution of EFBI, 14.2% vs 10.3%, respectively (P = .586). CONCLUSIONS: Glucagon-related resolution occurred in 14.2% of patients and was not significantly different compared with those that did not receive glucagon (10.3%). Concomitant medication administration was associated with lower success. Overall, glucagon had a low success rate, was related to adverse effects, and does not offer advantages for treatment.

Differences in noninvasive thermometer measurements in the adult emergency department.

PURPOSE: Detection of accurate temperature in the emergency department (ED) is integral for assessment, treatment, and disposition. The primary objective was to compare temperature measurements from noninvasive temperature devices in the adult ED. The secondary objective was to evaluate the discrepancy between febrile and afebrile patients. METHODS: This was a prospective observational study of adult patients presenting to the ED. Patients who required a temperature measurement based on standard of care were included. Data collection included oral and temporal artery (TA) temperature measurement taken consecutively. Data were evaluated using the paired Student's t test. RESULTS: A total of 100 patients were identified. Mean oral temperature was 37.51°C (SD ±1.25), and mean TA temperature was 37.03°C (SD ±0.94). The mean difference was 0.48°C (SD ±0.8), P < .0001. Overall, 49% of patients had a difference in temperature measurements greater than or equal to 0.5°C. There were 47 febrile patients, determined by a measurement greater than 38°C on oral or TA thermometer. The mean temperature difference in these patients was 0.87°C (SD ±0.85) compared with a mean temperature difference of 0.12°C (SD ±0.55) in the afebrile patients, P < .0001. A total of 57% of fevers recorded by the oral thermometer were not recorded by the TA thermometer. CONCLUSIONS: There was a statistically significant difference in measured temperatures between oral and TA thermometers and a clinically significant difference in 49% of patients. Febrile patients had a greater discrepancy and variability between noninvasive temperature measurements. Caution should be taken when evaluating temperature measurements with these noninvasive devices.

A case of tetanus infection in an adult with a protective tetanus antibody level.

Tetanus is a bacterial infection caused by Clostridium tetani and most commonly presents as trismus or other muscle spasms. Despite the development of the tetanus toxoid vaccine, tetanus infection has not been eradicated. Additionally, while there are hypothesized protective levels of tetanus antibody, tetanus infection may still occur in properly vaccinated individuals. We report the case of a 31-year-old male that presented to the emergency department (ED) with a 2-day history of neck and jaw pain. He reports puncturing his hand with a rusty nail 10 days prior. His reported vaccination history was that he received his last booster vaccination 13 years prior to presentation. In the ED, tetanus vaccine, tetanus immune globulin, and metronidazole were administered. His symptoms improved over the next 2 days and resolved at day 6. Despite his presentation of tetanus infection and rule out of other causes for his symptoms, his tetanus antibody level was reported at 8.4 U/mL, which is considered to be protective.A tetanus antibody level that is adequate for protective immunity should not preclude a patient from treatment of tetanus infection. This case demonstrates that a thorough history, physical exam, and rule out of other causes should guide treatment when there is concern for a tetanus infection.

Two cases of accidental injection of epinephrine into a digit treated with subcutaneous phentolamine injections.

Accidental injection into the digit from an epinephrine autoinjection device can cause discoloration, pain, and paresthesias. Although loss of digit is rare, treatment in the emergency department is commonly aimed at vasodilation of the affected tissue. We report two cases of accidental injection of epinephrine into the digits that were successfully treated with subcutaneous phentolamine injection with no adverse events.

Bacterial clearance and cytokine profiles in a murine model of postsurgical nosocomial pneumonia.

The development of a nosocomial pneumonia is facilitated by alterations in host innate pulmonary antibacterial defenses following surgical trauma, which can result in decreased pulmonary bacterial clearance and increased morbidity and mortality. In a murine model of postoperative nosocomial infection, surgical stress (laparotomy) decreased Escherichia coli clearance from the lungs of animals that underwent surgery. Consistent with previous studies, (i) pulmonary levels of tumor necrosis factor alpha at 6 h and of interleukin-1beta (IL-1beta), IL-6, and gamma interferon (IFN-gamma) at 24 h post-bacterial infection (PBI) were decreased in animals that underwent laparotomy 24 h prior to E. coli infection (LAP/E. coli) compared to animals that received E. coli only; (ii) KC and macrophage inhibitory protein 2 were elevated at 6 h PBI in LAP/E. coli animals compared to E. coli-only animals; however, at 24 h PBI, levels were higher in the E. coli-only group; (iii) at 24 h PBI, monocyte chemoattractant protein 1 was lower in the LAP/E. coli group compared to the E. coli-only group; (iv) IL-10 levels were unaffected at all time points evaluated; and (v) the total number of neutrophils present in the lungs of LAP/E. coli animals at 6 h PBI was decreased in comparison to that in E. coli-only animals, resulting in decreased bacterial clearance and increased mortality in LAP/E. coli animals by 24 h PBI. Similar changes in cytokine profiles, pulmonary bacterial clearance, and mortality were consistent with reported findings in patients following surgical trauma. This model, therefore, provides a clinically relevant system in which the molecular and cellular mechanisms that lead to the development of nosocomial pneumonia can be further explored.