Jan Shoenberger

ROCURONIUM VS. SUCCINYLCHOLINE IN THE EMERGENCY DEPARTMENT: A CRITICAL APPRAISAL

BACKGROUND Two methods of paralysis are available for rapid sequence intubation (RSI) in the emergency department (ED): depolarizing agents such as succinylcholine, and non-depolarizing drugs such as rocuronium. Rocuronium is a useful alternative when succinylcholine is contraindicated. Contraindications to succinylcholine include allergy, history of malignant hyperthermia, denervation syndromes, and patients who are 24-48 h post burn or crush injury. Non-depolarizing drugs have the advantage of causing less pain due to post-paralysis myalgias. CLINICAL QUESTION Can rocuronium replace succinylcholine as the paralytic of choice for RSI in the ED? EVIDENCE REVIEW Four relevant studies were selected from an evidence search and a structured review performed. RESULTS For the outcomes of clinically acceptable intubation conditions and time to onset, the two agents were not statistically significantly different. Succinylcholine seems to produce conditions that have higher satisfaction scores. CONCLUSION Succinylcholine remains the drug of choice for ED RSI unless there is a contraindication to its usage.

Death Notification in the Emergency Department: Survivors and Physicians

When patients die in the emergency department (ED), emergency physicians (EP) must disclose the bad news to family members. The death is often unexpected and the act of notification can be difficult. Many EPs have not been trained in the skill of communicating death to family members. This article reviews the available literature regarding ED death notification training and proposes future directions for educational interventions to improve physician communication in ED death disclosure.

Nebulized Tranexamic Acid as a Noninvasive Therapy for Cancer-Related Hemoptysis.

BACKGROUND Many patients with cancer involving the respiratory system suffer from the frequent recurrence of significant, submassive hemoptysis, which may result in invasive procedures, hospital stays, and a reduction in quality of life. Currently, there are no widely accepted noninvasive therapeutic options. Few case studies have looked at the benefit of tranexamic acid (TXA) as a noninvasive therapy in the treatment of hemoptysis. METHODS A patient with an invasive airway malignancy presented to the emergency department with substantial hemoptysis. A nebulized TXA solution was used as a noninvasive therapy to control the hemorrhage. RESULTS The patients hemoptysis resolved fifteen minutes after the nebulized TXA therapy was initiated. There were no known adverse events. CONCLUSION Nebulized TXA seems to be a safe, effective, and noninvasive method for controlling, or at least temporizing, hemoptysis in select patients. Nebulized TXA may be useful as a palliative therapy for chronic hemoptysis and as a tool in the acute stabilization of hemoptysis.

Development of Hospice and Palliative Medicine Knowledge and Skills for Emergency Medicine Residents: Using the Accreditation Council for Graduate Medical Education Milestone Framework

Emergency medicine (EM) physicians commonly care for patients with serious life‐limiting illness. Hospice and palliative medicine (HPM) is a subspecialty pathway of EM. Although a subspecialty level of practice requires additional training, primary‐level skills of HPM such as effective communication and symptom management are part of routine clinical care and expected of EM residents. However, unlike EM residency curricula in disciplines like trauma and ultrasound, there is no nationally defined HPM curriculum for EM resident training. An expert consensus group was convened with the aim of defining content areas and competencies for HPM primary‐level practice in the ED setting. Our overall objective was to develop HPM milestones within a competency framework that is relevant to the practice of EM.

Does the Flipped Classroom Improve Learning in Graduate Medical Education

BACKGROUND The flipped classroom model for didactic education has recently gained popularity in medical education; however, there is a paucity of performance data showing its effectiveness for knowledge gain in graduate medical education. OBJECTIVE We assessed whether a flipped classroom module improves knowledge gain compared with a standard lecture. METHODS We conducted a randomized crossover study in 3 emergency medicine residency programs. Participants were randomized to receive a 50-minute lecture from an expert educator on one subject and a flipped classroom module on the other. The flipped classroom included a 20-minute at-home video and 30 minutes of in-class case discussion. The 2 subjects addressed were headache and acute low back pain. A pretest, immediate posttest, and 90-day retention test were given for each subject. RESULTS Of 82 eligible residents, 73 completed both modules. For the low back pain module, mean test scores were not significantly different between the lecture and flipped classroom formats. For the headache module, there were significant differences in performance for a given test date between the flipped classroom and the lecture format. However, differences between groups were less than 1 of 10 examination items, making it difficult to assign educational importance to the differences. CONCLUSIONS In this crossover study comparing a single flipped classroom module with a standard lecture, we found mixed statistical results for performance measured by multiple-choice questions. As the differences were small, the flipped classroom and lecture were essentially equivalent.

A Missed Case of Occult Bilateral Temporomandibular Dislocation Mistaken for Dystonia

A 24-year-old male with a history of psychiatric disorder and no prior significant temporomandibular joint (TMJ) pathology presented to the emergency department for “lockjaw.” Plain film X-rays of the mandible were read as unremarkable by an attending radiologist, leading to the initial diagnosis of medication-induced dystonic reaction. Following unsuccessful medical treatment a maxillofacial computed tomography (CT) was ordered. CT confirmed bilateral dislocation, illustrating the importance of clinical judgment, and limitations of certain radiographic images. The authors believe this case to be the first reported case in the medical literature of bilateral anterior TMJ dislocation with a false negative X-ray.

Twiddle Me This! A Look at Twiddler’s Syndrome

Editor’s note: Annals has partnered with EM:RAP, enabling our readers without subscriptions to the EM:RAP service to enjoy their commentary on Annals publications. This article did not undergo peer review and may not reflect the view and opinions of the editorial board of Annals of Emergency Medicine. There are no financial relationships or other consideration between Annals and EM:RAP or its authors.