Modern Resident - The newsletter of AAEM/RSA
June/July 2014
Volume 6: Issue 1  |  FacebookTwitterLinkedIn


Your 2014-2015 Leaders:

President
Meaghan Mercer, DO

Vice President
Victoria Weston, MD

Secretary-Treasurer
Edward Siegel, MD

Immediate Past President
Leana Wen, MD MSc

At-Large Board Members
Nicole Battaglioli, MD
Mary Calderone, MD
Michael Gottlieb, MD
Sean Kivlehan, MD
Amrita Lalvani, MD
Andrew Phillips, MD

Medical Student Council President
Michael Wilk

Publications Advisor - Ex-Officio Board Member
Joel Schofer, MD RDMS FAAEM

Copy Editor: Mary Calderone, MD
Managing Editor: Lauren Johnson, AAEM/RSA Staff

Modern Resident Contributors

Special thanks to this issue's contributors:
Karina Bartlett, MSIV; Kaitlyn Fries, MSIII; Katrina Gipson, MD MPH; Michael Gottlieb, MD; Ashley Grigsby, MSIV; Nate Haas, MSIV; Randy Kring, MSIV; Alexandra Murray, MSIII; Tatiana Ramage, MSIII; Lauren Sims, MSIII; Jennifer Stancati, MSIII; Joseph Yard, MSIII

Interested in writing?

Email submissions to: info@aaemrsa.org

Please submit articles by July 20th for the August/September edition.

Articles appearing in Modern Resident are intended for the individual use of AAEM members. Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM/RSA. Articles may not be duplicated or distributed without the explicit permission of AAEM/RSA. Permission is granted in some instances in the interest of public education. Requests for reprints should be directed to the AAEM/RSA, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202, Tel (800) 884-2236; Fax: (414) 276-3349, Email: info@aaemrsa.org.


What’s the Diagnosis?
Ashley Grigsby, DO
Arizona College of Osteopathic Medicine

A four-year-old female presents with her mother to the ED for new onset of rash on her left ear and neck for three days. Mom says she’s been acting more tired than usual, but eating and drinking normally. The rash is pruritic and painful and has spread from her ear down her neck over the course of three days. Mom does not recall any contact with new detergents or chemicals. Past medical history is only positive for asthma and atopic dermatitis, for which she takes albuterol inhaler as needed and triamcinolone 0.1% ointment.

Physical exam is positive for temperature of 38.4°C, monomorphic umbillicated vesicular eruption overlying eczematous skin, extending from left ear down left side of her neck. No purulent discharge noted. Cervical lymphadenopathy also present on exam.

Question:
What is the most likely diagnosis?

  1. Chicken pox
  2. Widespread impetigo
  3. Eczema herpeticum
  4. Molluscum contagiosum
  5. Acrodermatitis enteropathica

Answer:
C is correct. Eczema herpeticum (EH) is a potentially life-threatening viral infection, usually secondary to infection with herpes simplex virus (HSV) type 1 or 2, that is superimposed over already damaged skin.1 It is most commonly seen in the setting of atopic dermatitis (AD) and occurs in 3-6% of patients with AD.2 The highest incidence of the disease occurs in children under three years of age.2 EH begins with clusters of monomorphic umbillicated vesicles overlying areas of AD, but can spread to normal skin over a seven to 10 day period.1 The head, neck and trunk are the most commonly affected areas.2 In addition to the vesicles, patients often present with generalized malaise, fever and lymphadenopathy.3

EH can lead to significant morbidity and mortality due to its complications. Bacterial superinfection is common, usually from Staphylococcus, Streptococcus or Pseudomonas species. Keratoconjunctivitis can also occur and an ophthalmologist should be consulted if any concern for eye involvement.2 HSV disseminated infection can also complicate EH and lead to multiple organ involvement, meningitis, and encephalitis.2 Mortality rates of EH have been reported as high as 50% in immunocompromised patients, although mortality rates are more likely between 1-9% in normal populations.1,2

Definitive diagnosis can be made with PCR for viral DNA of vesicular fluid; however, due to the high mortality, treatment should not be delayed while laboratory tests are pending.1,2 The mainstay of treatment is acyclovir, oral or intravenous (IV), depending on severity. Severe cases, or cases in immunocompromised patients, should be treated with IV acyclovir. However, less severe cases may be managed with oral acyclovir with adequate follow up.4 Since bacterial superinfection commonly complicates cases of EH, empiric antibiotic therapy is also indicated.2

Eczema herpeticum is a potentially life threatening infection and should be considered in patients with new vesicular rash in the setting of AD. Treatment with acyclovir should be started promptly.

References:

  1. Hasegawa K, et al. Visual Diagnosis in Emergency Medicine: Eczema Herpeticum. The Journal of Emergency Medicine. 2012:43 (5); 341-342.
  2. Luca N, et al. Eczema Herpeticum in Children: Clinical Features and Factors Predictive of Hospitalization, 161( 4 ): The Journal of Pediatrics. 2012: 161( 4 );671-675.
  3. Wollenberg A, et al. Predisposing factors and clinical features of eczema Herpeticum: A retrospective analysis of 100 cases. J Am Acad Dermatol. 2003: 49 (2); 198-205
  4. Studdiford JS, et al. Eczema Herpeticum: Making the diagnosis in the Emergency Department. The Journal of Emergency Medicine. 2011: 40(2); 167-169.

Clinical Pearl: "Light Bulb Sign" in Posterior Shoulder Dislocation
Nathan Haas, MD
University of Michigan

Posterior shoulder dislocations are relatively uncommon, comprising only 2-4% of all shoulder dislocations. Thus, posterior dislocations often go undiagnosed, and can lead to severe consequences for both the patient and emergency physician (EP). A high index of suspicion and a firm grasp of associated radiologic findings are key to making the diagnosis.

Posterior shoulder dislocations are classically associated with seizures, electrocution and severe trauma. As a group, the internal rotators of the humerus (teres major, pectoralis major and latissimus dorsi) are more powerful than the external rotators (infraspinatus, posterior deltoid and teres minor), leading to internal rotation during global muscle contraction from electrical activity (seizure, electrocution, electroconvulsive therapy, etc.). This internal rotation is what allows the humeral head to dislocate posteriorly from the glenoid fossa, and also produces the characteristic "light bulb sign" of the humeral head seen in posterior shoulder dislocations.

The AP view of the normal shoulder demonstrates the normal asymmetry of the humeral head in anatomic position. The larger portion is on the medial side, seated in the glenoid fossa. With internal rotation in the setting of a posterior dislocation, this larger portion rotates out of view producing the more round and symmetric "light bulb sign" of the humeral head in the second image. It is important to note that this pertains only to the AP view, and not the axillary or lateral view of the shoulder.

    

*Image 1: Normal AP view of shoulder
Source: Dr. M Daya; ebmedicine.net

Reprinted with permission from EB Medicine, publisher of Emergency Medicine Practice, from: Daya M, Nakamura Y. Shoulder girdle fractures and dislocations. Emergency Medicine Practice. 2007; 9(10):4, www.ebmedicine.net

*Image 2: Posterior dislocation, "light bulb sign"
Source: Dr. Alexandra Stanislavsky; radiopaedia.org

While the axillary or scapular Y views often help demonstrate posterior shoulder dislocations, the "light bulb sign" of the humeral head is often present on the AP view. Other signs include the rim sign (>6mm gap between the medial humeral head and anterior glenoid rim), the trough sign/reverse Hill-Sachs lesion (compression fracture of anteromedial humeral head), or fracture of the lesser tuberosity.

References:

  1. Shoulder Girdle Fractures And Dislocations. EB Medicine. Web. 20 May 2014. http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=120&seg_id=2471
  2. Stanislavsky A. Posterior Shoulder Dislocation. Radiopaedia. Web. 20 May 2014. http://radiopaedia.org/cases/posterior-shoulder-dislocation
  3. Tosif, S. Posterior Shoulder Dislocation. Life in the Fast Lane. Web. 20 May 2014. http://lifeinthefastlane.com/posterior-shoulder-dislocation/


Casting Off: A Medical Student’s Guide to EM Podcasts
Randy Kring, MSIV
Tufts University School of Medicine

During medical school, time is a precious commodity. As it can be difficult to decide between studying for an extra hour or recharging with some exercise, why not accomplish both simultaneously? Over the past year I’ve discovered a great way to supplement my morning run and my commute to the hospital with FOAMed, or Free Open Access Medical Education. The term FOAM, coined by Dr. Mike Cadogan and his colleagues responsible for the blog "Life in the Fast Lane," refers to the ever-expanding collection of blogs, podcasts, video lectures and other online resources produced by medical educators around the world and available for free online. Podcasts are one of the highlights of the FOAM movement, as their portable format makes them easy to enjoy in many settings. Download the "Podcasts" application to your smart phone in order to best access and store podcasts, and then start checking out some of the podcasts I have reviewed below:

EM Basic (www.embasic.org): This podcast is produced by Dr. Steve Carroll, who recently completed his emergency medicine residency. EM Basic provides a go-to resource for basic content, discussed at the level of medical students and interns. As Dr. Carroll describes on his website, "Each podcast starts exactly how a patient interaction in the ED starts — with a chief complaint. From there, we’ll go over the important points of the patient’s history and physical exam, the workup, and the basic treatment and disposition of each chief complaint … all in 30 minute easy-to-digest audio podcasts." In addition, each episode comes with a one- to two-page summary, perfectly formatted for printing out and stuffing in your white coat for easy reference.

ERCast (www.blog.ercast.org): "Welcome to ERCast. We cut through all the BS and get to the nitty gritty of nuts and bolts emergency medicine." This intro, followed by a brief clip of heavy metal music, captures the spirit of ERCast. Produced by Dr. Rob Orman in Oregon, ERCast feels like a talk show and covers a wide variety of topics. While the content occasionally ventures beyond my current level of training, I’ve found that listening to the articulate (and often quite humorous) guests on ERCast has taught me how to think like an emergency physician. Two outstanding episodes include "The Birth of Emergency Medicine," a fantastic primer on the history of our specialty, and "The Rant Off 2013", a hilarious yet informative collection of call-ins from ED docs frustrated about various issues they’ve seen in practice.

EMCrit (www.emcrit.org): Produced by Dr. Scott Weingart, an ED intensivist in New York City, EMCrit covers "the best evidence-based care from the fields of critical care, resuscitation, and trauma and translates it for bedside use in the ED." Most EMCrit episodes are advanced for medical student listeners given the complexity of critical care topics. There are, however, several podcasts interspersed that give practical advice helpful to students and physicians of all levels. "Making Things Happen," for instance, is an excellent primer on effective leadership in the ED. "The Path to Insanity," a segment relating one EP’s approach to staying up to date with the EM literature, is also broadly applicable.

EM:RAP (www.emrap.org): EM Reviews and Perspectives (EM:RAP) is a "monthly podcast with in-depth and up-to-date reviews of emergency medicine" produced by Dr. Mel Herbert and Dr. Stuart Swadron. Each month, EM:RAP releases a new four-hour episode, accompanied by an extensive written summary and several pages of board review questions and answers related to the topics discussed. Although advanced, EM:RAP is expertly organized and engaging, with clear summaries at the end of each chapter that significantly aid in retaining information. EM:RAP requires a $55 yearly subscription for students and residents, but you can obtain free access through your AAEM/RSA membership!

AAEM Podcasts (www.aaem.org/publications/podcasts): In 2013, AAEM started three podcast series, each of which focuses on a different area of interest to emergency physicians: critical care, medical-legal issues and operations management. In these podcasts, experts in the field discuss a wide range of topics, from the Surviving Sepsis Campaign to the impact of the Affordable Care Act on emergency medicine. Podcasts range from lecture-style to conversational. These podcasts are a great option for learning about important issues in emergency medicine.

There are several other podcasts that you can check out, including PEM ED (www.pemed.org), Ultrasound Podcast (www.ultrasoundpodcast.com), Smart EM (www.smartem.org), and The Skeptics’ Guide to Emergency Medicine (www.thesgem.com). While podcasts certainly can’t replace core content in textbooks or a close reading of the EM literature, they can fuel your enthusiasm for EM, give you access to the experts’ opinions on current issues and provide clinically relevant pearls.


Providing Patients with an Emergency Department Roadmap
Katrina Gipson, MD MPH
University Hospitals, Case Medical Center Emergency Medicine Residency Program

The practice of medicine involves many players requiring a complex set of rules and bureaucracy. Navigating this bureaucracy is often difficult and patients require a voice. The American Academy of Emergency Medicine Resident and Student Association (AAEM/RSA) seeks not only to advocate on behalf of professionals who practice emergency medicine, but on behalf of those who receive our services as well. In many ways, health care is a service like many others with providers and consumers. An educated consumer can better take advantage of provided services. With this in mind, the Patient Advocacy Subcommittee of the AAEM/RSA Advocacy Committee sought to create a set of brochures, a roadmap if you will, informing the public of how to best navigate a visit to the emergency department (ED).

Why didn’t I receive a clear diagnosis? Should I continue to take my antibiotics even though my symptoms have resolved? What resources are available for those with mental health disorders following an ED visit? Our patient populations commonly face questions like these. The Patient Advocacy Subcommittee has compiled many of the resources addressing these questions into one accessible location on the AAEM website: www.aaemrsa.org/resources/patient-and-discharge-resources. Here, readers will find printable brochures in both color and black and white versions to supplement patient education upon discharge from the ED. The subcommittee is continually expanding this list of resources to include other topics. The subcommittee hopes this growing list of resources serves as an adjunct to our respective hospitals’ preexisting electronic medical record systems and discharge instruction resources.

The implications of these resources are widespread. For instance, patients who are better informed on how to take their medication may be less prone to unnecessary return ED visits and hospital admissions.1 Furthermore, patients who have realistic expectations for their ED visits may be more satisfied with its eventual outcome. Also, as busy emergency physicians, time constraints may make it difficult to clearly convey all of the necessary information during a single encounter.2 The Patient Advocacy Subcommittee’s brochures may serve as a method of reinforcing important information.

Health care encounters are becoming increasingly difficult for patients to navigate as diagnoses become more obscure and treatments more complex. Emergency physicians (EPs) can aid patients in maximizing the benefits of emergency care by providing helpful resources at discharge. The Patient Advocacy Subcommittee hopes that the growing list of patient education brochures contributes to the arsenal that strengthens the quality of the care EPs deliver and its outcomes. If you have ideas for future brochure topics and/or patient education ideas, the committee would love to hear from you! Please contact info@aaemrsa.org.

Current Brochures
Resources for Antibiotic Use
Why Don’t I Have a Clear Diagnosis?
Medication Safety: Tips for Parents & Seniors
Resources for Mental Health: How to Find the Help You Need
Guide to Pain Medication: What You Need to Know
Resources for Alcohol Abuse and Alcoholism
Being Safe at Home – Domestic Violence

References:

  1. Engel KG. Knowledge Deficits at ED Discharge. Physician’s Weekly. April 2013. Available at: http://www.physiciansweekly.com/ed-discharge-knowledge-deficits/. Accessed: March 24, 2014.
  2. Engel KG, Buckley BA, McCarthy DM, et al. Communication amidst chaos: challenges to patient communication in the emergency department. J Clin Outcomes Manag. 2010;17:4. - See more at: http://www.physiciansweekly.com/ed-discharge-knowledge-deficits/#sthash.mDDUbiLU.dpuf

Pharmacological Management of Agitation in the ED
Joseph Yard, MSIII
Chicago Medical School, Rosalind Franklin University of Medicine and Science

Agitated patients are often found in emergency departments (EDs) across the country. Many of these patients will need pharmacologic assistance for their safety and proper medical care as well as for the safety of the ED staff. However, prior to rapid tranquilization of a patient, verbal de-escalation should be attempted. Successful verbal de-escalation resolves a potentially violent situation without the risks of medications, avoids damaging the therapeutic relationship with the patient and actually increases the efficacy of the ED.1,2 Typically, three classes of medications are used with the goal of calming the patient to assist with patient assessment: first-generation antipsychotics, second-generation antipsychotics and benzodiazepines.2

The most common first-generation antipsychotic used to treat ED agitation is haloperidol.2 Haloperidol can lengthen QT intervals and cause extrapyramidal symptoms (EPS). However, the risk of EPS is significantly reduced if it is administered with the benzodiazepine lorazepam.2 Typical dosing for haloperidol is 5mg IM or IV. Haloperidol remains the drug of choice for agitation related to acute alcohol intoxication.3,2 Note that both first- and second-generation antipsychotics have a black box warning for use in patients with dementia-related psychosis.3

Second-generation (atypical) antipsychotics tend to have lower EPS side effect profiles than those of the first-generation antipsychotics, and are subjectively preferred by patients.2 They have not been researched to the same extent as haloperidol in the treatment of acute agitation, but are preferred when the agitation appears to be due to psychiatric illness.2,3 The most commonly used atypicals are olanzapine and ziprasidone, both of which come in oral and IM preparations.2 Typical dosing for olanzapine is 10mg IM and ziprasidone is 20mg IM.3 Acute dystonias resulting from antipsychotics should be addressed by using benztropine or diphenhydramine to alleviate the symptoms.3

Benzodiazepines are also useful in addressing the agitated patient. Lorazepam is the most commonly used medication for this purpose within this class. It is preferred for agitated patients undergoing withdrawal and those whose agitation is of unknown etiology. Respiratory depression is a serious side effect, especially when mixed with a CNS depressant such as alcohol.3,2 Typical dosing for lorazepam is 2mg IV or IM.3

A more complete discussion of the management of agitation in the ED, including psychopharmacology, can be found in the Project BETA (Best Practices in Evaluation and Treatment of Agitation) articles published in volume 13, issue 1 of the Western Journal of Emergency Medicine.

References:

  1. Holloman GH Jr, Zeller SL. Overview of Project BETA: best practices in evaluation and treatment of agitation. West J Emerg Med. 2011;13:1–2
  2. Wilson MP, Pepper D, Currier GW, et al. The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West J Emerg Med 2011;13:27–35.
  3. Martel ML, Biros MH. Psychotropic Medications and Rapid Tranquilization. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. New York: McGraw-Hill, 2011. 1952-955. Print.


Medical Student Ambassadors in the Big Apple
Lauren Sims, MSIII
Tatiana Ramage, MSIII
University of California Irvine School of Medicine

This past February, a group of medical students from across the United States and abroad came together to serve as medical student ambassadors at the 20th Annual Scientific Assembly in New York, NY. This was the first time AAEM included medical students in the program, allowing us to contribute to the conference by facilitating workshops and gathering program feedback.

Although we were assigned to assist with specific presentations as medical student ambassadors, we were also given time to attend the Medical Student Track and other presentations of particular interest to us. Having a defined role at the conference allowed us to be a part of the AAEM community and to learn firsthand about the mission of the organization. In addition, having the flexibility to sculpt the day’s itinerary to meet our interests enabled us to take full advantage of the conference events.

We had the opportunity to learn a breadth of clinical knowledge, including the latest research that may not yet have reached the classrooms. A personal favorite track was titled, "Your Six Minute 40 Second Session Begins in 3-2-1… Just the Facts!" where there were over a dozen six minute mini-presentations spotlighting the clinical pearls of topics ranging from "Steroids in COPD" to "Shoulder Dislocation Tips and Tricks." The presentations brought our second-year medical school curriculum to life by highlighting the clinical aspects of our lectures.

Another favorite aspect of the five-day conference was the opportunity to network with fellow students and physician-leaders in the field of emergency medicine (EM). We ran into old friends and met new friends during the Medical Student Track. Several of us chatted about our various student programs, opportunities for collaboration between schools, and then later grabbed a bite to eat together in the Big Apple. The emergency physicians (EPs) we encountered listened intently to our inquiries and responded to our questions. Several physicians approached us and expressed that they were both impressed and appreciative of our efforts.

We would strongly encourage any student interested in EM to get involved with EM organizations, such as AAEM. Serving as medical student ambassadors allowed us to learn from successful EPs, to observe the clinical application of our medical student curriculum and to connect with other medical students. We found the opportunity both rewarding and unparalleled by any classroom experience.

For more information about the medical student ambassador program at Scientific Assembly, please visit http://www.aaemrsa.org/medical-student-ambassadors or email us at info@aaemrsa.org.



Image of the Month
Jennifer Stancati, MSIII
Loyola University Chicago Stritch School of Medicine

A 49-year-old man with a past medical history of hypertension, hyperlipidemia and type two diabetes is brought into the emergency department (ED) by his wife for confusion, difficulty speaking and agitation. The patient had just been discharged from acute rehabilitation one week ago after a lengthy hospital stay related to complications from ascending cholangitis. This morning, the patient’s wife noticed that he was having difficulty speaking, could not sit still and was becoming increasingly agitated. About five hours after the onset of symptoms, she brought him to the ED. The physical exam is severely limited by his inability to cooperate. He will only answer some questions, often with mumbling and unintelligible speech. He will not follow commands. There is no facial asymmetry, pupils are equal, ocular motility is full and there is no nystagmus. He is moving all extremities symmetrically.

Vitals: BP 147/71, Pulse 91, Temp 36.7°C, Resp 26, SpO2 100%
Medications: acetaminophen, amlodipine, aspirin, clonidine, diphenhydramine, gabapentin, hydralazine, insulin, lisinopril, metoclopramide, metoprolol, ondansetron.
Imaging: A complete metabolic panel was unremarkable. A CT head showed no acute abnormalities. A head MRI was done. Findings on FLAIR are shown below:

Question:
What is your next step in management?

  1. Discontinue metoclopramide
  2. tPA
  3. IV mannitol
  4. Acyclovir
  5. Lorazepam

Answer:
D is Correct. Acyclovir. The patient’s clinical presentation and MRI findings are consistent with herpes simplex encephalitis (HSE). HSE is an infection involving the frontal and temporal lobes of the brain. In adults, HSE is most commonly due to herpes simplex virus type 1 (HSV-1) infection, which is present in up to 90% of the population, occurs early in life and is asymptomatic. Even though HSV-1 infection is so prevalent, very few people are diagnosed with HSE. The exact pathophysiology of HSE is not well understood but the virus is known to exist in the dorsal root ganglia and has the ability to transport in a retrograde fashion to the brain.

The signs and symptoms of HSE include: fever, headache, lethargy, irritability, confusion, focal deficits, aphasia, seizures, behavioral changes, and memory impairment. The presentation of HSE is quite variable, making timely diagnosis difficult. MRI and CSF PCR are important diagnostic tests to do in any patient where there is a clinical suspicion of HSE. HSE is often mistaken for stroke, epilepsy, delirium and psychiatric disorders.

Delayed treatment is associated with significantly worse outcomes, often resulting in neuropsychological impairment and amnesia. If untreated, mortality is close to 70%, and 97% of patients do not return to normal function. Given these devastating consequences, treatment with acyclovir should be started immediately, before CSF analysis confirms HSE. With treatment, mortality is reduced to 19%.

Discontinuation of metoclopramide (A) would be indicated if the suspected diagnosis was akathisia. Given the MRI findings, HSE is more likely. Administration of tPA (B) is indicated in acute ischemic stroke, however brain imaging did not show any acute changes consistent with stroke and the patient presented at a time out of the window for administration of tPA. IV mannitol (C) would be given to decrease intracranial pressure, however there were no signs of increased intracranial pressure on physical exam or imaging. It would be important to monitor for signs of increased intracranial pressure because HSE can cause brain edema leading to uncal herniation. Lorazepam (E) would be indicated to treat seizure activity. This patient’s presentation was not consistent with seizures, although it is important to monitor the patient for signs of seizure activity, as this is one manifestation of HSE.

References:

  1. Steiner I, Benniger F. Update on herpes virus infections of the nervous system. Curr Neurol Neurosci Rep. 2013; 13: 414-420.
  2. Sabah M, Mulcahy J, Zeman A. Herpes simplex encephalitis. BMJ. 2012; 344.
  3. Baringer JR. Herpes simplex infections of the nervous system. Neurol Clin. 2008; 26: 657-674.
  4. Whitley RJ. Herpes simplex encephalitis: adolescents and adults. Antiviral Research. 2006: 71; 141-148.

ED Patient Flow and Patient Care
Karina Bartlett, MSIV
University of Texas Health Science Center at San Antonio

In a recent article published in Academic Emergency Medicine, a group of physicians studied the effect of the implementation of a midtrack area in the emergency department (ED).1 Previous studies have shown that fast-track areas staffed by midlevel providers and utilized to improve efficiency of care for patients with low-acuity complaints have decreased left-without-being-seen (LWBS) rates as well as overall length-of-stay (LOS) for low-acuity patients (ESI 4 or 5).2 However, this can increase the LWBS and LOS for medium-acuity (ESI 3) patients.3 A midtrack area is similar in concept to a fast-track area, but is dedicated to patients with medium-acuity complaints.

The goal of this study was to determine if implementing a midtrack area could decrease the LWBS rate and LOS for patients with medium-acuity complaints. The ED staff used three rooms from a previously instituted fast-track area (staffed by mid-level providers) and three hallway beds for their midtrack area, staffed by an attending physician moved from the main ED. The physician determined, after triage, which patients were placed into rooms for an initial evaluation. Attendings were instructed to choose patients who were uncomplicated with a high likelihood of being discharged home. Once patients were evaluated, they were moved to either the hallway beds or returned to the waiting room while their workup was completed. This midtrack area operated on weekdays from 1pm to 9pm, a time frame that was determined to represent peak hours for medium-acuity patients.

Ultimately, the study showed that both LWBS rates and LOS decreased after the implementation of the midtrack area. This occurred despite an increase in patient volume and high-volume days. Not only did it affect medium-acuity patients, with LWBS decreasing from 9.5% to 5.3%, but also high- and low-acuity patients. Additionally, LOS times decreased in the medium-acuity group by 36 minutes. Both of these were statistically significant. Also of note, there was no decrease or increase in LOS times in the low-acuity group, despite the room reallocation. There was an increase in LOS for high-acuity patients by 24 minutes. The authors hypothesized that attending reassignment from the main ED to the midtrack area could account for this finding.

This decrease in LWBS and LOS, both important markers for ED patient care and ED crowding, shows that targeting an intervention to a large cohort of medium-acuity patients can be effective. With continually increasing patient volumes, effective interventions to decrease patient LWBS and LOS times are necessary. Continuing research evaluating different interventions will be needed, but this study shows one potentially promising solution for improving ED flow.

References:

  1. Soremekun OA, Shofer FS, Grasso D, Mills AM, Moore J, Datner EM. The Effect of an Emergency Department Dedicated Midtrack Area on Patient Flow. Acad Emerg Med. 2014;21(4):434-439.
  2. Ginde AA, Espinola JA, Sullivan AF, Blum FC, Camargo CA. Use of midlevel providers in US EDs, 1993 to 2005: implications for the workforce. Am J Emerg Med. 2010;28(1):90-4.
  3. Sanchez M, Smally AJ, Grant RJ, Jacobs LM. Effects of a fast-track area on emergency department performance. J Emerg Med. 2006;31(1):117-20.

Toxicology Board Review Question
Michael Gottlieb, MD
Cook County Hospital

Which of the following is true in regards to acetaminophen toxicity?

  1. The Rumack-Matthew Normogram may be used for both acute and chronic ingestions.
  2. The Acetaminophen (APAP) level should ideally be checked within one to four hours of ingestion.
  3. The Rumack-Matthew Normogram applies for ingestions up to 48 hours post-ingestion.
  4. N-Acetylcysteine (NAC) should be started within eight hours of ingestion if an APAP level cannot be obtained.
  5. Activated charcoal should be used for all sustained-release ingestions.

Answer:
D is Correct. The Rumack-Matthew Normogram is a graph of "possible" and "probable" hepatic toxicity for ingestions ranging from four to 24 hours before measurement. It has been validated in multiple patient populations and is not valid for chronic ingestions or ingestions outside of the above time range. The APAP level should be checked between four and 24 hours post-ingestion (consistent with the range of the normogram), ideally within four to eight hours of ingestion. Levels checked within four hours of ingestion are unreliable and will need to be rechecked at the four-hour mark. Studies have shown that NAC is most effective when given within eight hours of ingestion. If an APAP level will not be available at that time, NAC should be empirically started and can be stopped if the APAP level returns below the treatment threshold. Finally, activated charcoal may be used for acute ingestions within one hour (if the patient is not vomiting and can protect their airway), but should not be used beyond this time period.

References:

  1. Rumack BH, Matthew H. Acetaminophen poisoning and toxicity. Pediatrics. 1975 Jun;55(6):871-6.
  2. Prescott LF, Illingworth RN, Critchley JA, et al. Intravenous N-acetylcysteine: the treatment of choice for paracetamol poisoning. BMJ. 1979 Nov 3;2(6198):1097-100.
  3. Yeates PJ, Thomas SH. Effectiveness of delayed activated charcoal administration in simulated paracetamol (acetaminophen) overdose. Br J Clin Pharmacol. 2000 Jan;49(1):11-4.

Announcement to Residents

Are you interested in toxicology and emergency medicine? Do you want an opportunity to explore toxicology for free? The American College of Medical Toxicology (ACMT) and the Society for Academic Emergency Medicine (SAEM) Foundation offer travel scholarships for residents to attend the annual scientific meeting of the ACMT for free!

To apply, submit your current CV, letter documenting verification of employment, letter of support from your program director and a letter of nomination by the application deadline. Applicants may apply for both the ACMT and the SAEM Foundation award; however, the selected applicants can only receive one award.

View the ACMT Michael P. Spadafora Medical Toxicology Travel Award – deadline 07/15/2014

View the SAEM Foundation Michael P. Spadafora Toxicology Scholarship – deadline 08/01/2014

Dr. Michael P. Spadafora was an academic emergency physician and medical toxicologist who was a member of ACMT and SAEM and was dedicated to resident education. After his death in October 1999, memorial donations were directed to SAEM and ACMT for the establishment of a scholarship fund to encourage emergency medicine residents to pursue medical toxicology fellowship training.


Guillain-Barré Syndrome and its Relationship to the Flu Shot
Alexandra Murray, MSIII
Ohio University Heritage College of Osteopathic Medicine

Guillain-Barré syndrome (GBS) encompasses a group of acute immune-related polyneuropathies that causes acute areflexic paralyzing illness.1 The proposed mechanism for GBS is that a preceding infection (usually an upper respiratory infection or gastrointestinal infection) stimulates an immune response that creates molecular mimicry.1-4 The immune system consequently targets myelin or the axon of peripheral nerves which results in an acute polyneuropathy.1-4

The first link between GBS and the influenza vaccine was noted during the 1976 swine flu pandemic. In response to the fear that there was a novel swine-origin influenza A (H1N1) virus, the United States implemented a program that vaccinated over 49 million people between October and December 1976.2-4 By December 1976, it was noted that there was an eight times increased risk of contracting GBS in the first nine weeks following vaccination. The vaccination program was subsequently suspended and a vaccine safety and surveillance effort for future influenza seasons was initiated.2-4

Analyses of influenza seasons following 1976 have not shown any significant link between the influenza vaccine and the risk of contracting GBS. 2-4 The highest reported association between GBS and the influenza vaccine was one additional GBS case per million vaccinations administered. 2-4 With the recent 2009 influenza pandemic, there has been increased focus on the safety of widely administering influenza vaccinations. A retrospective analysis from the end of the 2009-2010 peak influenza months has shown that there was a lower cumulative GBS risk in those vaccinated with the pH1N1 vaccine, compared to those who were unvaccinated. 4 These results suggest that the influenza vaccine may provide a protective effect against GBS.4

Based on current research, there has been no significant association between GBS and the influenza vaccine since the 1976 influenza pandemic.2-4 Further research is needed to examine the anecdotal relationship of preceding viral infections leading to GBS as well as the possible protective role the influenza vaccine may have against GBS. A formal competing-risk analysis that simultaneously balances the risks and benefits of both influenza vaccines and infection is also needed.2 Patients considering immunization should be fully informed of the risks and benefits from immunization, as well as the relative risk of GBS from both influenza vaccines and influenza illness.2-4

References:

  1. Nobuhiro Y, Hans-Peter H. Guillain–Barré Syndrome. New England Journal of Medicine. 2012 Jun; 366(24): 2294-2305.
  2. Kwong JC, et al. Risk of Guillain-Barré syndrome after seasonal influenza vaccination and influenza health-care encounters: a self-controlled study. Lancet Infect Dis. 2013 Sep; 13(9):769-76.
  3. Greene SK, et al. Guillain-Barré Syndrome, Influenza Vaccination, and Antecedent Respiratory and Gastrointestinal Infections: A Case-Centered Analysis in the Vaccine Safety Datalink, 2009-2011. PLoS One. 2013 Jun 26; 8(6):e67185. Print 2013.
  4. Vellozzi C, et al. Cumulative risk of Guillain-Barré syndrome among vaccinated and unvaccinated populations during the 2009 H1N1 influenza pandemic. Am J Public Health. 2014 Apr; 104(4):696-701.

Knee Pain: Mastering the Physical Exam Component
Kaitlin Fries, MSIII
Ohio University College of Osteopathic Medicine

Knee pain is a common complaint in emergency departments across the country. With the weather improving and more patients participating in outdoor activities, it is an excellent time to brush up on your knee examination skills. The first step of any good musculoskeletal exam is to inspect and palpate the injured area. Note any temperature changes, bruises, erythema or swelling.1 Palpate the knee for point tenderness along the extremity and assess the patient’s full range of motion.1 Finally, assess ligament stability through the maneuvers outlined below. For all elements of the exam, compare all findings with those of the uninjured leg, as there are always normal variations in anatomy.

Cruciate Ligaments
Anterior drawer test assesses for instability of the anterior cruciate ligament (ACL). The patient lies supine with their knee bent to 90 degrees and foot flat on the table. The physician places the thumbs on the tibial tuberosity and wraps his or her fingers around the patient’s calf. The physician then pulls the tibia forward with a force of about 15-20lbs.2 The test is considered positive when the tibia moves forward more than 3mm. The patient should relax their hamstrings in order to dramatically improve sensitivity of the test.1,2

Lachman test is another option for assessing the ACL. The patient lies supine with their knee bent to 30 degrees. The physician positions themselves lateral to the injured knee with one hand stabilizing the patient’s distal femur. The physician then holds the patient’s proximal tibia and applies a force underneath the calf in an attempt to move the tibia forward. If the physician is able to force the tibia anteriorly without hitting a hard end point the test is considered positive.

Posterior drawer test assesses for instability of the posterior cruciate ligament (PCL). This is set up in the same manner as the anterior drawer test. The patient lies supine with the knee bent to 90 degrees and foot flat on the table. Hand placement is the same as in the Lachman test, but the physician pushes posteriorly with the thumbs against the tibial tuberosity. A positive test is when posterior translation of the injured extremity occurs significantly more than in the uninjured extremity.

Collateral Ligaments
Valgus stress test assesses for instability of the medial collateral ligament. The patient lies supine with the leg resting on the table. The physician stands adjacent to the injured leg and grasps the ankle with a caudad hand to stabilize the extremity. The physician’s other hand is placed on the lateral side of the patient’s knee. The leg is flexed to 30 degrees and a 15-20lbs. force is applied medially on the knee with the hand.2 A positive test is when there is increased laxity in comparison to the unaffected side.

Varus stress test assesses for instability of the lateral collateral ligament (LCL). This test is performed exactly the same way as the Valgus test, only with a lateral force applied. A positive test occurs when significant laxity is noted. The lateral collateral ligament is very rarely torn in isolation and a positive test suggests that additional ligaments are likely affected. Therefore, be extremely careful when testing for the PCL and ACL.2

Meniscus
There are several tests to assess for meniscal injury, with McMurray’s test being among the most well known. McMurray’s test assesses for tears of both the medial and lateral menisci. The patient lies supine with one leg in a table-top position (knee and hip both flexed at 90 degrees). The physician supports the patient’s leg by holding the heel. The physician’s other hand rests on the knee joint line. The physician uses the hand on the heel to rotate the tibia internally while applying a lateral force at the joint line and slowly extending the leg. The same movement is then repeated with external rotation and a medial force. A positive test is any reproduction of pain symptoms or clicking at the joint line.

References:

  1. Calmbach WL, Hutchens M. Evaluation of Patients Presenting with Knee Pain: Part I. History, Physical, Examination, Radiographs, and Laboratory Test. American Family Physician. 2003 Sept 1;68(5): 907-912.
  2. Luke A. Knee Physical Examination. University of California, San Fransico Orthopaedic Trauma Institute: Sports Medicine.