Benjamin W. Hatten

Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department

This clinical policy from the American College of Emergency Physicians is the revision of a 2005 clinical policy evaluating critical questions related to procedural sedation in the emergency department.1 A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) In patients undergoing procedural sedation and analgesia in the emergency department,does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration? (2) In patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events? (3) In patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications? (4) Inpatients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil and remifentanil be safely administered? A literature search was performed, the evidence was graded, and recommendations were given based on the strength of the available data in the medical literature.

Bleeding Scrotal Arteriovenous Malformation

BACKGROUND Arteriovenous malformation (AVM) of the scrotum has, to our knowledge, been reported fewer than 10 times in the medical literature. It may be of congenital or post-traumatic etiology and has been reported to present with spontaneous bleeding. CASE REPORT A case of a spontaneously bleeding scrotal AVM that developed after remote trauma is presented. The differential diagnosis of a scrotal vascular lesion includes varicocele, hemangioma, lymphangioma, and AVM. Although ultrasound and magnetic resonance imaging play an important role in the evaluation, angiography is essential to fully delineate the feeder vessels, vascular takeoffs, and draining veins. CONCLUSION Scrotal AVMs are rare vascular scrotal lesions that may present with scrotal enlargement and a bruit. Definitive therapy should be planned in concert with Interventional Radiology and surgical consultants.

Clinical Policy: Critical Issues in the Evaluation of Adult Patients With Suspected Transient Ischemic Attack in the Emergency Department

This clinical policy from the American College of Emergency Physicians addresses key issues for adults presenting to the emergency department with suspected transient ischemic attack. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients with suspected transient ischemic attack, are there clinical decision rules that can identify patients at very low short-term risk for stroke who can be safely discharged from the emergency department? (2) In adult patients with suspected transient ischemic attack, what imaging can be safely delayed from the initial emergency department workup? (3) In adult patients with suspected transient ischemic attack, is carotid ultrasonography as accurate as neck computed tomography angiography or magnetic resonance angiography in identifying severe carotid stenosis? (4) In adult patients with suspected transient ischemic attack, can a rapid emergency department-based diagnostic protocol safely identify patients at short-term risk for stroke? Evidence was graded and recommendations were made based on the strength of the available data.

Establishing an Emergency Medicine Education Research Network

This project was developed from the research network track at the 2012 Academic Emergency Medicine consensus conference on education research in emergency medicine (EM). Using a combination of consensus techniques, the modified Delphi method, and qualitative research methods, the authors describe multiple aspects of developing, implementing, managing, and growing an EM education research network. A total of 175 conference attendees and 24 small-group participants contributed to discussions regarding an education research network; participants were experts in research networks, education, and education research. This article summarizes relevant conference discussions and expert opinion for recommendations on the structure of an education research network, basic operational framework, site selection, leadership, subcommittees, guidelines for authorship, logistics, and measuring success while growing and maintaining the network.

Critical care toxicology

Critical care toxicology : , Critical care toxicology : , کتابخانه دیجیتالی دانشگاه علوم پزشکی و خدمات درمانی شهید بهشتی

Envenomation by the great lakes bush viper (Atheris nitschei)

Abstract Introduction. We present a case of envenomation by a Great Lakes Bush Viper, Atheris nitschei. Atheris species are a group of snakes that are indigenous to the forested areas of Central Africa. Prior reports of envenomation by Great Lakes Bush Vipers were not found in a Medline search. However, reports of other Atheris species envenomations describe coagulopathy and acute renal failure. Case details. A 30-year-old male was bitten by a Great Lakes Bush Viper on his left hand. His left upper extremity was edematous with ecchymoses in the left axilla. There was bleeding from the bite site and from the patients oral mucosa. Initial laboratory studies demonstrated significant derangement of hematologic parameters including anemia, thrombocytopenia, coagulopathy, and hypofibrinoginemia. There is no antivenom for this species. The patient was treated with blood products. Mucosal bleeding ceased within 12 h of admission. Discussion. Atheris nitschei is an African snake with no available antivenom. In this case, the patient developed coagulopathy with hemolytic anemia, thrombocytopenia, and low fibrinogen. Renal function remained unaffected. Despite the lack of specific antivenom or the use of plasmapheresis, our patient was successfully treated with transfusion of multiple blood products.

Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non–ST-Elevation Acute Coronary Syndromes

&NA; This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of patients with suspected non–ST‐elevation acute coronary syndromes. A writing subcommittee conducted a systematic review of the literature to derive evidence‐based recommendations to answer the following clinical questions: (1) In adult patients without evidence of ST‐elevation acute coronary syndrome, can initial risk stratification be used to predict a low rate of 30‐day major adverse cardiac events? (2) In adult patients with suspected acute non–ST‐elevation acute coronary syndrome, can troponin testing within 3 hours of emergency department presentation be used to predict a low rate of 30‐day major adverse cardiac events? (3) In adult patients with suspected non–ST‐elevation acute coronary syndrome in whom acute myocardial infarction has been excluded, does further diagnostic testing (eg, provocative, stress test, computed tomography angiography) for acute coronary syndrome prior to discharge reduce 30‐day major adverse cardiac events? (4) Should adult patients with acute non–ST‐elevation myocardial infarction receive immediate antiplatelet therapy in addition to aspirin to reduce 30‐day major adverse cardiac events? Evidence was graded and recommendations were made based on the strength of the available data.

Clinical Policy: Emergency Department Management of Patients Needing Reperfusion Therapy for Acute ST-Segment Elevation Myocardial Infarction

Ischemic heart disease is the leading cause of death in the world. More than half a million patients present to emergency departments across the United States each year with ST-segment elevation myocardial infarctions. Timely reperfusion is critical to saving myocardium at risk. Multiple studies have been conducted that demonstrate that improved care processes are linked to improved survival in patients having an acute myocardial infarction. This clinical policy from the American College of Emergency Physicians addresses key issues in reperfusion for patients with acute ST-segment elevation myocardial infarction. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients having an ST-segment elevation myocardial infarction, are there patients for whom treatment with fibrinolytic therapy decreases the incidence of major adverse cardiac events when percutaneous coronary intervention is delayed? (2) In adult patients having an ST-segment elevation myocardial infarction, does transfer to a percutaneous coronary intervention center decrease the incidence of major adverse cardiac events? (3) In adult patients undergoing reperfusion therapy, should opioids be avoided to prevent adverse outcomes? Evidence was graded and recommendations were made based on the strength of the available data.

Correction: Correction to ‘Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department’ [Annals of Emergency Medicine 63 (2014) 247-258.e18]

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

Correction: Correction to ‘Clinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department’ [Annals of Emergency Medicine 66 (2015) 322-333.e31]

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.