Anaphylaxis: Emergency Department Treatment.

Anaphylaxis is a potentially life-threatening, multisystem allergic reaction that can cause airway, breathing, or circulatory compromise. Intramuscular epinephrine is the immediate treatment of all patients. Intravenous epinephrine should be used in patients in shock, either as a bolus or infusion, along with fluid resuscitation. Airway obstruction must be recognized, and early intubation may be necessary. For shock that is refractory to epinephrine, additional vasopressors may be needed. Disposition depends on patient presentation and response to treatment. Mandatory observation periods are not necessary, because biphasic reactions are difficult to predict and may occur outside of typical observation periods.

Implementation of a pilot novel objective peer comparison evaluation system in an emergency medicine residency program.

Objectives: Emergency medicine (EM) residents are currently evaluated via The Milestones, which have been shown to be imperfect and subjective. There is also a need for residents to achieve competency in patient safety and quality improvement processes, which can be accomplished through provision of peer comparison metrics. This pilot study aimed to evaluate the implementation of an objective peer comparison system for metrics that quantified aspects of quality and safety, efficiency and throughput, and utilization. Methods: This pilot study took place at an academic, tertiary care center with a 3-year residency and 14 residents per postgraduate year (PGY) class. Metrics were compared within each PGY class using Wilcoxon signed-rank and rank-order analyses. Results: Significant changes were seen in the majority of the metrics for all PGY classes. PGY3s accounted for the significant change in EKG and X-ray reads, while PGY1s and PGY2s accounted for the significant change in disposition to final note share. Physician evaluation to disposition decision was the only metric that did not reach significance in any class. Conclusions: These preliminary data suggest that providing objective metrics is possible. Peer comparison metrics could provide an effective objective addition to the milestone evaluation system currently in use.

Anaphylaxis: Emergency Department Treatment.

Anaphylaxis is a potentially life-threatening, multisystem allergic reaction that can cause airway, breathing, or circulatory compromise. Intramuscular epinephrine is the immediate treatment of all patients. Intravenous epinephrine should be used in patients in shock, either as a bolus or infusion, along with fluid resuscitation. Airway obstruction must be recognized, and early intubation may be necessary. For shock that is refractory to epinephrine, additional vasopressors may be needed. Disposition depends on patient presentation and response to treatment. Mandatory observation periods are not necessary, because biphasic reactions are difficult to predict and may occur outside of typical observation periods.

Haloperidol Use in the Emergency Department for Gastrointestinal Symptoms: Nausea, Vomiting, and Abdominal Pain.

INTRODUCTION: Haloperidol (HL) has successfully been used for nausea and abdominal pain in emergency departments (EDs). This study examines outcomes and predictive factors for clinical improvement of patients presenting to an ED with gastrointestinal (GI) symptoms (nausea, vomiting, and abdominal pain) who received HL. METHODS: Review of patients' records who presented to our ED between August 2016 and March 2019 with GI symptoms and received HL. International Classification of Diseases, Tenth Revision codes were used to identify patients. RESULTS: In all, 281 patients (410 encounters) presented to the ED with GI symptoms and received HL for their symptoms: 66% were women, 32% had diabetes, 68% used marijuana, and 27% used chronic opioids. Patients received HL 1.1 ± 0.3 times with dose 2.5 ± 3.0 mg, mostly intravenously (84.6%). Total ED length of stay was 7.5 ± 3.9 hours (3.2 ± 2.1 hours before HL and 4.4 ± 3.4 hours after). Approximately 4.4% of patients developed side effects to HL, including 2 patients with dystonia which improved with medication before discharge. Most patients (56.6%) were discharged home while 43.2% were admitted to hospital mostly because of refractory nausea or vomiting (70.1%). Receiving HL as the only medication in the ED led to lower hospital admission (odds ratio = 0.25, P < 0.05). Diabetes, cannabinoid use, anxiety, male sex, and longer ED stay were associated with increased hospital admissions. DISCUSSION: Most patients treated in our ED with HL for GI symptoms, particularly nausea, vomiting, and/or abdominal pain, were successfully treated and discharged home. HL use seemed relatively safe and, when used as the only medication, led to less frequent hospital admissions.

Consensus Guidelines for Digital Scholarship in Academic Promotion.

INTRODUCTION: As scholarship moves into the digital sphere, applicant and promotion and tenure (P&T) committee members lack formal guidance on evaluating the impact of digital scholarly work. The P&T process requires the appraisal of individual scholarly impact in comparison to scholars across institutions and disciplines. As dissemination methods evolve in the digital era, we must adapt traditional P&T processes to include emerging forms of digital scholarship. METHODS: We conducted a blended, expert consensus procedure using a nominal group process to create a consensus document at the Council of Emergency Medicine Residency Directors Academic Assembly on April 1, 2019. RESULTS: We discussed consensus guidelines for evaluation and promotion of digital scholarship with the intent to develop specific, evidence-supported recommendations to P&T committees and applicants. These recommendations included the following: demonstrate scholarship criteria; provide external evidence of impact; and include digital peer-review roles. As traditional scholarship continues to evolve within the digital realm, academic medicine should adapt how that scholarship is evaluated. P&T committees in academic medicine are at the epicenter for supporting this changing paradigm in scholarship. CONCLUSION: P&T committees can critically appraise the quality and impact of digital scholarship using specific, validated tools. Applicants for appointment and promotion should highlight and prepare their digital scholarship to specifically address quality, impact, breadth, and relevance. It is our goal to provide specific, timely guidance for both stakeholders to recognize the value of digital scholarship in advancing our field.

Barriers to Utilizing Social Media Platforms in Emergency Medicine Residency Programs.

Background Residency programs seek to incorporate various social media (SoMe) platforms into their educational curricula, yet little is known regarding the potential roadblocks towards implementation. Our objective was to assess the current utilization of SoMe platforms and identify common barriers to implementation by emergency medicine (EM) residency programs. Methods Members of the Council of Emergency Medicine Residency Directors (CORD) Information Technology (IT) Committee developed an anonymous survey distributed to representatives from EM residency programs using the "CORD Community" internet forum. Descriptive statistics including percentages for numerical data as well as Fisher's exact test for categorical data were used to report results. Results We received 116 individual responses from faculty, fellows, and residents of EM residency programs. The most common institutional, departmental, technological and knowledge barriers identified were restricted access to blogs (12.9%), insufficient protected time (17.2%), insufficient IT support to host the platform (16.4%), and a lack of knowledge among faculty of how to utilize blogs (23.3%) respectively. Ten respondents (8.6%) reported that their programs had not attempted to utilize any SoMe platforms. Community-based programs and smaller programs (<24 residents) were significantly more likely to identify barriers to SoMo use among this cohort. Conclusion Utilization of SoMe platforms for resident education by EM residency programs is increasingly common, but significant obstacles exist on many levels that prevent programs from leveraging these innovations for knowledge translation. This is particularly common for community-based and small residency programs. Awareness of these common barriers will allow institutions and programs to better anticipate and design solutions to overcome these obstacles.

The Treatment of Acute Pain in the Emergency Department: A White Paper Position Statement Prepared for the American Academy of Emergency Medicine.

BACKGROUND: Pain is one of the most common reasons patients present to the emergency department (ED). Emergency physicians should be aware of the numerous opioid and nonopioid alternatives available for the treatment of pain. OBJECTIVES: To provide expert consensus guidelines for the safe and effective treatment of acute pain in the ED. METHODS: Multiple independent literature searches using PubMed were performed regarding treatment of acute pain. A multidisciplinary panel of experts in Pharmacology and Emergency Medicine reviewed and discussed the literature to develop consensus guidelines. RECOMMENDATIONS: The guidelines provide resources for the safe use of opioids in the ED as well as pharmacological and nonpharmacological alternatives to opioid analgesia. Care should be tailored to the patient based on their specific acute painful condition and underlying risk factors and comorbidities. CONCLUSIONS: Analgesia in the ED should be provided in the most safe and judicious manner, with the goals of relieving acute pain while decreasing the risk of complications and opioid dependence.

Alternative treatments of pneumothorax.

BACKGROUND: Pneumothorax has traditionally been treated in the Emergency Department by tube thoracostomy. However, this is an invasive procedure with high risk of complication and prolonged hospitalization. DISCUSSION: In select settings, there are alternative forms of management of pneumothorax that carry lower risks and may reduce hospital stay. This article reviews the settings in which less invasive treatment, including observation alone, may be indicated. This article also reviews the techniques for simple aspiration and small-bore catheter insertion (by either Seldinger or catheter-over-wire technique) with Heimlich valve, as well as the indications, contraindications, and potential risks and benefits of each. CONCLUSIONS: The practices of observation, simple aspiration, and small-bore catheter insertion with Heimlich valve for selected patients may decrease complications, time, and costs by avoiding invasive procedures and hospital admissions.