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Objectives: Epinephrine can be a life-saving treatment for patients with anaphylaxis. Potential cardiovascular side effects of epinephrine may contribute to clinician hesitancy to use it. However, the frequency of cardiotoxicity resulting from epinephrine treatment for anaphylaxis is not well described. We sought to describe the frequency of cardiotoxicity following intramuscular (IM) administration of epinephrine in adult emergency department (ED) patients with anaphylaxis. Methods: We conducted a retrospective observational study at a single, quaternary care academic ED in Tennessee. We identified consecutive ED visits with the diagnosis of anaphylaxis from 2017 to 2021 who received at least one intramuscular (IM) dose of epinephrine in the ED. Analysis was primarily descriptive. The primary outcome was cardiotoxicity, the occurrence of any of the following after epinephrine administration: ischemic electrocardiogram changes, systolic blood pressure >200 mmHg, or cardiac arrest ≤4 h; elevated troponin ≤12 h; or percutaneous coronary intervention or depressed ejection fraction ≤72 h. Results: Among 338 included patients, 16 (4.7%; 95%CI: 2.8-7.6%) experienced cardiotoxicity. Cardiotoxic events included eight (2.4%) ischemic electrocardiogram changes, six (1.8%) episodes of elevated troponin, five (1.5%) atrial arrhythmias, one (0.3%) ventricular arrythmia, and one (0.3%) depressed ejection fraction. Patients with cardiotoxicity were significantly older, had more comorbidities, and were more likely to have received multiple doses of epinephrine or an epinephrine infusion compared with a single IM dose of epinephrine. Conclusions: Among 338 consecutive adult ED patients who received IM epinephrine for anaphylaxis during a recent 4-year period, cardiotoxic side effects were observed in approximately 5% of patients.
RESUMEN
INTRODUCTION: It is important for physicians to learn how to provide culturally sensitive care. Cultural humility is defined as a lifelong process with a goal of fixing power imbalances and creating institutional accountability through learning about another's culture as well as performing self-exploration about one's own beliefs, identities, and biases. One way to teach cultural humility in medicine is simulation. However, there are no peer-reviewed published studies that examine whether the skin tone or gender of the high-fidelity simulation manikins (HFSM) used by emergency medicine (EM) residency programs reflects the US population nor whether high-fidelity simulation is used to teach cultural humility. We aimed to address that gap in the literature. Our primary objective was to evaluate what proportion of EM residency programs use HFS to teach cultural humility. Our secondary objective was to evaluate whether the skin tone and gender breakdown of the EM residency program HFSM is representative of the US population. METHODS: We conducted a simple random sample of 80 EM residency programs to characterize HFSM and cultural humility training. Selected programs were emailed a questionnaire. Key outcomes included HFSM skin tone and gender and whether cultural humility was taught via HFSM. We calculated point and interval estimates for the proportion of dark-, medium-, and light-toned skin and the proportion of female and male manikins. Confidence intervals were employed to test the null hypothesis that dark/medium/light skin tone was 20/20/60 and that the female/male ratio was 50/50. Both ratios were extrapolated from the US Census data. RESULTS: Our response rate was 74% (59/80). Fifty-five of 59 EM residency programs that had manikins (0.93, 95% confidence interval [CI] 0.88-0.99) reported data on a total of 348 manikins. Thirty-nine of the 55 programs with manikins reported using HFS to teach cultural humility (0.71, 95% CI 0.60-0.82). Proportions of light-, medium-, and dark-toned manikins were 0.52 (0.43-0.62), 0.38 (0.29-0.47), and 0.10 (0.07-0.14), respectively. Proportions of male and female HFSM were 0.69 (0.64-0.76) and 0.31 (0.24-0.36), respectively. The null hypotheses that skin tone follows a 60/20/20 split and gender follows a 50/50 split were rejected, as not all confidence intervals contained these hypothesized values. CONCLUSION: While most EM residency programs surveyed use high-fidelity simulation to teach cultural humility, the manikins do not reflect either the skin tone or gender of the US population.
