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Kudos to Dan for his thoughtful analysis of three papers highlighting aspects of agitation management in the emergency department.

Take-home points from Journal Club this week:

* 5mg of midazolam (versed) was significantly faster at causing sedation in violently agitated patients at a large academic ED, compared to 5mg of haldol and 2mg of lorazepam (ativan). Patients getting midazolam also had significantly faster times to recover from sedation, also the least incidence of sedation failure.

* Droperidol has an FDA black box warning for QT prolongation leading to torsades de pointes and death. While the association between droperidol use and QT prolongation is clear, the risk of sudden cardiac death as caused by droperidol is much less clear. Many centers still use droperidol to good effect; an ECG after administration and prior to discharge is strongly recommended (and, if possible, prior to use).

* In treating behavioral emergencies, the accepted and endorsed practice in this country is to confront the violent or uncooperative patient with a ‘show of force’ to obtain consent, and if that fails, forcible medication ensues. Covert administration of meds, while maybe expedient or supported by the patient’s family, threatens the therapeutic alliance and exposes the institution to liability and the practitioner to claims of criminal battery. There exists an opportunity for further study and policymaking, both within our institution and beyond.

An in-depth discuss of the three papers awaits you, below.

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Thanks to Dr. Leung for her expertly-presented M&M case this morning.
Teaching points from the case:
* Patients with upper GI bleed are at high risk to vomit and aspirate before and during intubation. An NG tube may decrease the likelihood of aspiration and is not contraindicated in variceal bleeding.
* When intubating a patient with upper GI bleed, extra precautions should be taken to avoid regurgitation and subsequent aspiration. Consider intubating with the head of bed at 30 to 45 degrees.
* Bag-valve-mask ventilation is ideally avoided in these cases, as insufflating the stomach is particularly dangerous. Maximize your chance of success on the first pass of laryngoscopy by optimizing preparation and technique, using an experienced operator initially. Additionally, an airway management adjunctive device (such as the glidescope) may be valuable to use initially.
* Despite the value of avoiding BVM, if laryngoscopy is not generating an adequate view, abandon that attempt early so that BVM may be performed gently and slowly, ideally with oral and nasal airways in place, to minimize insufflation of the stomach. Bagging via LMA is an even better approach.
* Use a bougie immediately if only part of the vocal cords are seen or if there is trouble passing the tube through the cords.<
* Aspiration of gastric contents is a chemical and not an infectious pneumonitits; antibiotics are not indicated initially.

Thanks to Henry Curtis for an excellently prepared M&M today. Read on for some important learning tips from today’s discussion.
* In cases where the history is limited and the diagnosis is not clear, the patient must be completely disrobed and examined head to toe.
* In elderly, debilitated, or terminally ill patients, engage the patient or proxy in a discussion of goals of care. Treatment or even diagnosis of dangerous conditions may not be compatible with the patient’s or family’s wishes, but often their priorities will not be offered spontaneously and must be elicited.
* Proxies are often reluctant to take responsibility for “reducing” goals of care as they perceive this decision as contributing to the death of their loved one. When appropriate, voice your opinion supporting this type of decision. Example phrases that may be used include “If it were my mother, I would not want further testing and treatment, my priority would be keeping her comfortable,” and “It is completely appropriate to choose to let nature take its course.”
* Proxies often feel as though the decision is their own and lose sight of their role, which is to represent the wishes of the patient. “What do you think your mom would want in this situation if she were able to tell us?”
* As CT scanners evolve and their resolution improves, the benefit of contrast diminishes. A growing body of literature suggests that contrast, especially oral contrast, does not aid in the interpretation of abdominal CT scans. As emergency departments bear the burden of administering oral contrast, emergency medicine may be the stimulus for change for relevant radiology protocols

Thanks to Dr. Close for her wonderful M+M presentation yesterday. The following M+M tips are adapted from Dr. Strayer’s followup email:

We recently saw a patient with active malignancy present with typical symptoms of hypercalcemia. Though the GEMM was resulted shortly after presentation and demonstrated a very high ionized calcium (more than twice the upper limit of normal and qualifies as hypercalcemic crisis), the diagnosis was not made for some time.

Consider the following diagnoses in patients with malignancies who present with unexplained symptoms.

1. Malignant pericardial effusion. Have a low threshold to perform point-of-care ultrasound to evaluate for an effusion.

2. Spinal cord compression. Back pain, lower extremity weakness, urinary retention, fecal incontinence.

3. Hypercalemia. Lethargy, confusion, generalized weakness.

4. Tumor lysis syndrome. Hematologic malignancy s/p chemotherapy with renal failure and electrolyte disturbances.

5. Neutropenic fever. Definition is a single temperature ? 101 (38.3) or fever of 100.4 (38.0) lasting longer than 1 hour in patient with ANC < 500. ANC = WBC * (%PMNs + %bands).

6.  SVC syndrome. Dyspnea, hoarseness, cough, facial and upper extremity swelling with distended neck and chest wall veins, facial edema and plethora.

7. Intracranial metastases. Seizure, altered mentation, neurologic symptoms or signs.

8. Hyperviscosity syndrome. Multiple myeloma / Waldenstrom’s / Leukemia blast crisis / Polycythemia patient with visual changes, mental status changes or neurologic symptoms, bleeding diathesis, or CHF.

Dr. Zane’s wonderful lecture is now online, for those of you who missed it or want a refresher on surge capacity in disaster settings.

Thanks also to Dr. Constantine for his wonderful M+M presentation yesterday. The following M+M tips are adapted from Dr. Strayer’s followup email:

Key teaching points from this case of infective endocarditis:

* Do not convey undue diagnostic certainty to patients. In patients without definitive evidence of a specific diagnosis, consider that their symptoms, instead of reflecting a benign disease, could be the early symptoms of a more serious disease that hasn’t declared itself yet, and advise accordingly.

* Be careful about assigning specific diagnoses when lack of definitive evidence of these diagnoses exists. Gastritis, gastroenteritis, reflux, dyspepsia, heartburn, constipation, costochondritis, migraine, influenza, muscle spasm, sprain, strain, and anxiety are examples of diagnoses that should be assigned cautiously.  Symptom-based diagnoses such as chest pain, abdominal pain, headache, cough, and knee pain, while less satisfying to patients, usually better reflect the degree of diagnostic certainty we are able to generate in an emergency visit.

* Unless a patient is discharged without a period of observation or diagnostic studies, the chart should include a follow-up note, documenting the evolution of care and justifying discharge.

* Abnormal vital signs should either be normalized, explained, or a plan for addressing them included in the chart.

* Infective endocarditis may present with a variety of signs and symptoms. Consider the diagnosis in patients who have risk factors (intravenous drug use, abnormal heart valves) or suggestive findings (prolonged course of fevers and malaise, new murmur).

Thanks to all who spoke this past Wednesday — Jim, Kit, Shawn, Shefali, Seth, Dr. Paul, Dr. Weingart, and Dr. Kalb.

Jim has graciously agreed to let me load his first “Screen Sim” program online — you can download the whole zipped folder onto your computer here (see me if you need help). I just tried it and am thrilled to have my own little window with Jim speaking to me about stroke. Hopefully more simulators are on the way.

Also, thanks to Chris Strother for pointing me to some screen-simulators hosted at trauma.org. They’re called Moulages, a word that’s amazingly appropriate.

If you enjoyed the debate on dobutamine in sepsis, between our own Dr. Weingart and the MICU’s Dr. Kalb, you can relive the magic by downloading the audio (mp3 format).

Alternatively, Shawn has transcribed the key points, below (and thrown in some of his own thoughts, at the end):

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Thanks to Mieka, Liz, Dr. Beattie, Dr. Weingart, and our Grand Rounds speaker, Dr. Sharma, for presenting early this Wednesday morning. Seems like a lot of us were up late for a Tuesday night, but those that made the early morning trek to the Hurst were well rewarded.

Mieka’s case report and talk on Sgarbossa’s criteria for AMI in LBBB provided a great overview of this controversial topic. The criteria are below, and I’m reprinting the findings from an EM meta-analysis in last month’s Annals (Tabas et al, Volume 52, Issue 4, October 2008, Pages 329-336,  PMID: 18342992):

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Thanks to Grand Rounds speaker Dr. Gail D’Onofrio — her talk on rapid and effective alcohol use assessment and counseling for ED patients is online (many of this year’s Grand Rounds lectures are collected under the ‘conference’ tab).

Also thanks to Evelyn, whose Senior Lecture on US-guided regional anesthesia generated interest. Some of her links for futher information, anatomic diagrams, and sono screencaptures  are below:

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Conference was a little different this week.  Thanks to all who visited — Sinai EM grad Dr. Roland Merchant of Brown, Professor Paul Klotman, Sinai’s Chair of Medicine, and Dr. Calfee from ID. Also thanks to our own speakers and panelists –Drs. Goodman, Nassisi, Jagoda, Strother and Shoenstein.

Some points I thought bear repeating, or that I want to expand upon:

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