Jack Perkins

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.

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 infants fever is a UTI.

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 bodys 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.

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.

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.

An Introduction to the Most Complex Disease in Emergency Medicine

Sepsis is one of the most complex and challenging diseases in medicine. Timely diagnosis and initiation of therapy are required in order to prevent unnecessary increases in patientmorbidity andmortality. Unfortunately, the clinical presentation of sepsis is often nonspecific andmay lead to delays in diagnosis and treatment. Since themajority of patients with sepsis initially present to the emergency department, it is imperative for the emergency provider (EP) to be knowledgeable regarding current concepts and controversies in sepsis management. Recent literature has improved our understanding of numerous critical aspects in sepsis management. In addition, the Centers for Medicare and Medicaid Services recently implemented a sepsis core measure (SEP-1) in the United States. SEP-1 contains several measures that are a matter of intense debate across the United States. Given these recent developments, we have dedicated this issue of Emergency Medicine Clinics of North America to a current evidence-based review of more than a dozen sepsis-related topics. The initial articles of this special issue are dedicated to a discussion of the new definitions of sepsis and septic shock, the new “usual care,” current recommendations on appropriate antimicrobial therapy, fluid administration, source control, vasoactive medications for septic shock, and endpoints of sepsis resuscitation. Additional articles are dedicated to the prehospital resuscitation of septic patients, pearls in pediatric sepsis resuscitation, sepsis in austere settings, biomarkers, and sepsis care in special patient populations. The final three articles in this issue discuss common pearls and pitfalls in emergency department sepsis care, antimicrobial stewardship, and SEP-1. EPs should have a detailed understanding of SEP-1, as every hospital in the United States will be accountable to meet these metrics. Unfortunately, it appears that significant monetary penalties may be assessed against those hospitals that fail to achieve adequate compliance.

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.