A novel approach to community CPR and AED outreach focused on underserved learner communities.

Creating a sustainable community cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) program that reaches underserved communities poses a challenge for the emergency medical services (EMS) community. Attendance, funding, and resources have all been linked to struggles surrounding community CPR/AED programs. Through our experience in conducting CPR/AED trainings in underserved regions of eastern North Carolina, we propose a method of effectively utilizing existing organizations and institutions of learning to expand and maintain a sustainable community CPR/AED program. Furthermore, we demonstrate 10 cornerstones in developing relationships within the community to increase attendance and participation in diverse communities.

Diagnosis and Management of Oncologic Emergencies.

Oncologic emergencies may be seen in any emergency department and will become more frequent as our population ages and more patients receive chemotherapy. Life-saving interventions are available for certain oncologic emergencies if the diagnosis is made in a timely fashion. In this article we will cover neutropenic fever, tumor lysis syndrome, hypercalcemia of malignancy, and hyperviscosity syndrome. After reading this article the reader should be much more confident in the diagnosis, evaluation, and management of these oncologic emergencies.

Infectious Disease Emergencies in Oncology Patients.

Oncology patients are a unique patient population in the emergency department (ED). Malignancy and associated surgical, chemotherapeutic, or radiation therapies put them at an increased risk for infection. The most ominous development is neutropenic fever, which happens often and may not present with signs or symptoms other than fever. A broad differential diagnosis is essential when considering infectious disease pathology in both neutropenic and non-neutropenic oncology patients in the ED.

Iodinated Contrast Administration Resulting in Cardiogenic Shock in Patient with Uncontrolled Graves Disease.

BACKGROUND: Thyroid storm (also known as thyroid or thyrotoxic crisis) is part of the spectrum of thyrotoxicosis and represents the extreme end of that spectrum. The condition is quite rare, yet mortality rates are high and may approach 10-30%. CASE REPORT: A 34-year-old-man who had a history of Graves disease presented in atrial fibrillation with rapid ventricular response and mild congestive heart failure. During the course of his Emergency Department (ED) stay he deteriorated into cardiogenic shock. Roughly 10 h transpired between his presentation and the development of cardiogenic shock. He had received an intravenous contrast load of iohexol shortly after initial presentation, and the associated iodine bolus, we suspect, contributed to his abrupt deterioration into cardiogenic shock. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Thyroid storm is infrequently seen in the ED, and there is potential for management errors that can lead to a detrimental patient outcome.

Evaluation of fever in the emergency department.

BACKGROUND: Fever is one of the most common complaints in the emergency department (ED) and is more complex than generally appreciated. The broad differential diagnosis of fever includes numerous infectious and non-infectious etiologies. An essential skill in emergency medicine is recognizing the pitfalls in fever evaluation. OBJECTIVE OF REVIEW: This review provides an overview of the complaint of fever in the ED to assist the emergency physician with a structured approach to evaluation. DISCUSSION: Fever can be due to infectious or non-infectious etiology and results from the body's natural response to a pyrogen. Adjunctive testing including C-reactive protein, erythrocyte sedimentation rate, and procalcitonin has been evaluated in the literature, but these tests do not have the needed sensitivity and specificity to definitively rule in a bacterial cause of fever. Blood cultures should be obtained in septic shock or if the results will change clinical management. Fever may not be always present in true infection, especially in elderly and immunocompromised patients. Oral temperatures suffer from poor sensitivity to diagnose fever, and core temperatures should be utilized if concern for fever is present. Consideration of non-infectious causes of elevated temperature is needed based on the clinical situation. CONCLUSION: Any fever evaluation must rigorously maintain a broad differential to avoid pitfalls that can have patient care consequences. Fever is complex and due to a variety of etiologies. An understanding of the pathophysiology, causes, and assessment is important for emergency physicians.

Is Telemetry Monitoring Useful in Patients Admitted With Suspected Acute Coronary Syndrome?

Patients with a chief complaint of chest pain are frequently monitored by telemetry for evaluation of acute coronary syndrome (ACS). However, there is insufficient evidence to support this practice in younger patients without coronary artery disease (CAD). The objective is to assess outcomes of patients younger than 50 years of age and monitored by telemetry. Consecutive medical records of patients admitted for chest pain between January 1, 2009, and June 30, 2010, were reviewed. Patients were excluded who had a CAD history, an abnormal initial troponin, or an abnormal initial electrocardiogram. The remaining patients' charts were evaluated for adverse events such as death, dysrhythmias, ST-elevation myocardial infarction, or upgrade to a higher level of care. Ultimately, 814 patients were selected for study. No study participants suffered a significant adverse event. When being evaluated for ACS, patients younger than 50 without a history of CAD may not benefit from telemetry monitoring.

Source Identification and Source Control.

Identifying sources of infection and establishing source control is an essential component of the workup and treatment of sepsis. Investigation with history, physical examination, laboratory tests, and imaging can in identifying sources of infection. All organ systems have the potential to develop sources of infection. However, there are inherent difficulties presented by some that require additional diligence, namely, urinalysis, chest radiographs, and intraabdominal infections. Interventions include administration of antibiotics and may require surgical or other specialist intervention. This is highlighted by the Surviving Sepsis Campaign with specific recommendations for time to antibiotics and expeditious time to surgical source control.

Influenza in the Emergency Department: Vaccination, Diagnosis, and Treatment: Clinical Practice Paper Approved by American Academy of Emergency Medicine Clinical Guidelines Committee.

BACKGROUND: Influenza is an acute respiratory virus that results in significant worldwide morbidity and mortality each year. As emergency physicians, we are often the first to encounter patients with seasonal influenza. It is therefore critical that we draw on the most recent and relevant research when we make clinical decisions regarding the diagnosis, treatment, and prophylaxis of this disease. METHODS: A MEDLINE literature search from August 2009 to August 2015 was performed using the keywords influenza vaccination efficacy AND systematic, influenza AND rapid antigen testing, and Oseltamivir AND systematic, while limiting the search to human studies written in the English language. General review articles and case reports were omitted. Each of the selected articles then underwent a structured review. RESULTS: We identified 163 articles through our literature search, of which 68 were found to be relevant to our clinical questions. These studies then underwent a rigorous review from which recommendations were given. CONCLUSIONS: Influenza vaccine efficacy continues to range between 40% and 80%. Vaccination has the potential to decrease disease severity and is recommended for individuals older than 6 months of age. If resources permit, vaccination can be offered to patients presenting to the emergency department. Rapid antigen detection for influenza is a simple bedside test with high specificity, but generally low sensitivity. If a patient presents with a syndrome consistent with influenza and has negative rapid antigen detection, they should either receive a confirmatory reverse transcriptase polymerase chain reaction or be treated as if they have influenza. Treatment with neuraminidase inhibitors can decrease the duration of influenza and is recommended in hospitalized patients, or in those with high risk of complications.

American Academy of Emergency Medicine Position Statement: Safety of Droperidol Use in the Emergency Department.

BACKGROUND: Droperidol (Inapsine®, Glaxosmithkline, Brent, UK) is a butyrophenone used in emergency medicine practice for a variety of uses. QT prolongation is a well-known adverse effect of this class of medications. Of importance to note, QT prolongation is noted with multiple medication classes, and droperidol increases QT interval in a dose-dependent fashion among susceptible individuals. The primary goal of this literature search was to determine the reported safety issues of droperidol in emergency department management of patients. METHODS: A MEDLINE literature search was conducted from January 1995 to January 2014 and limited to human studies written in English for articles with keywords of droperidol/Inapsine. Guideline statements and nonsystematic reviews were excluded. Studies identified then underwent a structured review from which results could be evaluated. RESULTS: There were 542 papers on droperidol screened, and 35 appropriate articles were rigorously reviewed in detail and recommendations given. CONCLUSION: Droperidol is an effective and safe medication in the treatment of nausea, headache, and agitation. The literature search did not support mandating an electrocardiogram or telemetry monitoring for doses < 2.5 mg given either intramuscularly or intravenously. Intramuscular doses of up to 10 mg of droperidol seem to be as safe and as effective as other medications used for sedation of agitated patients.

Telemetry bed usage for patients with low-risk chest pain: review of the literature for the clinician.

BACKGROUND: Telemetry monitoring in patients with low-risk chest pain is highly utilized, despite the lack of quality data to support its use. STUDY OBJECTIVES: To review the medical literature on the utility of telemetry monitoring in patients with low-risk chest pain and to offer evidence-based recommendations to emergency physicians. METHODS: A PubMed literature search was performed and limited to human studies written in English language articles with keywords of "telemetry" and "chest pain." Studies identified then underwent a structured review from which results could be evaluated. RESULTS: There were 114 paper abstracts on telemetry monitoring screened; 30 articles were considered relevant. Twelve appropriate articles were rigorously reviewed and recommendations given. CONCLUSIONS: Insufficient data exist to support telemetry use in low-risk chest pain patients. Telemetry monitoring is unlikely to benefit low-risk chest pain patients with a normal/nondiagnostic electrocardiogram, a normal first set of cardiac enzymes, and none of the following: hypotension, rales above the bases, or pain worse than baseline angina.

Is culture-positive urinary tract infection in febrile children accurately identified by urine dipstick or microanalysis?

BACKGROUND: Fever from a urinary tract source remains the predominant etiology of serious bacterial infection in children ages 0-36 months. Urine culture is the gold standard for diagnosing a urinary tract infection (UTI); however, urine dipstick (UDip) and urine microanalysis (UA) are typically used real time by Emergency Physicians to diagnose and treat UTIs, as cultures can take days to grow and be available. The purpose of this article is to evaluate the literature on the accuracy and utility of the UDip and UA in this pediatric population. METHODS: A structured review of the medical literature to determine the accuracy of UDip and UA for the diagnosis of UTI in children before the result of the urine culture. RESULTS: Upon comprehensive review and after applying predefined inclusion criteria, a total of 13 articles met inclusion criteria, addressed the clinical question, and were reviewed in detail. CONCLUSIONS: The literature search did not conclusively identify any component of either the UDip or the UA, which would allow a practitioner to conclude definitively that the source of an infant's fever is a UTI.

Skin and soft tissue infections.

The spectrum of skin and soft tissue infections seen by the primary care physician can be as benign as folliculitis to as life-threatening as NF. Cellulitis remains the most common skin and soft tissue infection seen in primary care. The ever present danger of ca-MRSA, however, has changed the way primary care physicians approach the common problem of cellulitis. The presence of risk factors for colonization with ca-MRSA and a history or examination finding of skin abscess should raise the suspicion of ca-MRSA, and antibiotic therapy should include TMP-SMZ, clindamycin, doxycycline, or minocycline. Skin abscess may occur independently of cellulitis, and often may safely be incised and drained in the primary care setting as long as timely follow-up is assured to assess for wound healing. Available evidence suggests that abscess formation without accompanying cellulitis does not require oral antibiotic therapy. Finally, although NF is rare as an outpatient clinical presentation, it is a diagnosis that the primary care physician should be familiar with. Failure to consider the diagnosis and refer may lead to significant morbidity and even mortality.