Jessica Mason

The Nitty-Gritty of Clinical Decision Rules

ANNALS CASE How are clinical decision rules (CDRs) applied (and maybe misapplied) in emergency medicine? This question arose after we read the article by Babl et al. Here, they compared clinician gestalt with 3 decision rules for head injury in children. Surprisingly, CDR use would not have increased sensitivity and may have led to increased use of imaging! Aren’t CDRs supposed to aid judgment and reduce unnecessary testing? We had hoped yes, but unfortunately, they sometimes lead us astray. CDRs, otherwise known as prediction rules or prediction models, combine multiple patient historical and examination variables, test results, and other disease characteristics to estimate the probability of either a diagnosis or a prognosis. The term “rule” is a misnomer in that CDRs are not inflexible or absolute, but should function more to supplement clinical judgment. Hence, many providers prefer the term “clinical decision tools.” (To avoid a superfluous acronym, we will stick with CDRs.)

Can Neutropenic Fever Ever Be Low Risk

Editor’s Note: Annals has partnered with EM:RAP, enabling our readers without subscriptions to EM:RAP 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 Hippo Education, EM:RAP, or its authors.

Does the Intranasal Route Pass the Sniff Test

ANNALS CASE Medication Route Options Physicians and scientists have developed creative and varied routes of medication administration to patients. Some of the many options include intravenous, intramuscular, intrathecal, intraosseous, per os, subcutaneous, intravaginal, and per rectum routes. The intravenous route is further divided into peripheral and central and use, depending on the clinical situation. For example, line infiltration of specific drugs can lead to necrosis; thus, these drugs should be given only through central access. Another intravenous access, the umbilical line, is available only at certain times, typically only within the first week of life. The latest up-and-comer is the intranasal route, which has increased application in many different clinical scenarios and is potentially underused in many emergency departments (EDs). But does it pass the sniff test? How do we choose the ideal route for each medication and each patient? There are so many factors to consider that we may not even consciously acknowledge the many decision points in choosing a route. Different routes vary in bioavailability and time of onset of drug effect. Some routes are more operator dependent and some take longer to obtain. Some routes cause more discomfort, are more invasive, or can put patients at risk for adverse events. Certain drugs can be administered to target specific body parts and limit systemic absorption and adverse effects, such as the intrathecal route or nebulized medications. In a pinch, the intraosseous route can be lifesaving for many

Risk Stratifying Febrile Infants: A Moving Target

It is no surprise that the winter months bring a host of pediatric patients with fever. In fact, 1 in 5 pediatric emergency department (ED) visits is for fever, and most involve little more than parental reassurance and good return precautions. With this volume, you would think that as emergency providers we would be able to simply and confidently risk stratify febrile infants younger than 90 days. Unfortunately, risk stratification continues to be a moving target. In this month’s issue of Annals of Emergency Medicine, the article by Powell et al on the epidemiology of bacteremia in febrile infants sheds some new light on the ever-changing picture of serious bacterial infections in this population.

Working Through the Paradox of Methotrexate Toxicity

INTRODUCTION: MTX[WTF Although it won’t be the most common “meth” toxicity that youmanage in your emergency department (ED),MTXrelated complaints are common, affecting 16% of patients who receive it for rheumatoid arthritis. Although single acute overdoses of MTX are well tolerated, long-term overdoses, or accidental misadventures because of dosing errors, are frequent. It is these exposures that commonly cause severe toxicity, as illustrated in the case above. MTX seems to fit perfectly the paradox of clinical medicine: every problem has a solution, but every solution comes with its own set of problems. More specifically, the same pharmacologic properties make MTX both very useful and also quite dangerous. It is beneficial in a broad variety of illnesses, and yet it can damage almost any organ in the body when things run afoul. To cloud things a bit more, MTX toxicity in one patient presentation may not at all resemble that in the next, and toxicity with long-term

Narcan or Nar-can’t: Tips and Tricks to Safely Reversing Opioid Toxicity

ANNALS CASE Your next patient is a 34-year-old man with a history of intravenous drugusewhowasbrought inby emergencymedical services. In the field, he had a respiratory rate of 5 breaths/min, decreased mental status, and pinpoint pupils, all of which significantly improved with out-of-hospital naloxone. He now has normal mental status and normal vital signs, and admits to intravenous fentanyl (or so he was told) use. After downing 3 hospital tuna salad sandwiches, he requests discharge. Sound familiar? Well, it should. Drug overdose is now the leading cause of injury death in the United States, with frequency tripling from 1999 to 2014. Illicit opioids contribute to the significant increase in opioid-associated deaths. The result: you have probably administered naloxone recently once, twice, or even dozens of times to reverse acute opioid overdoses. But what is the “standard” dose again? And how long do patients need to be observed? For somethingwe do frequently, the lack of evidence-based dosing and observation times is troubling. Lucky for us, the recent publication by Scheuermeyer et al examines the safety of an empiric emergency department (ED) protocol for the management of patients with presumed fentanyl intoxication. After primarily intravenous fentanyl use, the majority of patients were safely discharged after a 2-hour observation period.

Agitation Crisis Control.

ANNALS CASE The often frustrating and occasionally dangerous challenge of acute agitation in the emergency department (ED) seems to be increasing in frequency and severity. Acutely agitated patients are not only experiencing distress themselves but also creating a threat to the safety of themselves, staff, and even their fellow patients; hence, the vital need for safe and prompt treatment. In this month’s Annals, Miner et al look at the prevalence of agitation at an urban ED. Spoiler alert: it is common! Decisions to restrain or sedate agitated patients can vary by provider and patient. Let’s take a closer look at the options and what you might choose in some scenarios.

The Long and Winding Triage Road

ANNALS CASE The Dark Ages Imagine a poor, conscripted foot soldier, fighting for Napoleon’s army circa the late 1700s. During a gruesome battle, he shatters his femur. He cannot walk and consequently is left in the battlefield. Despite having injuries that are treatable, even by 18th-century standards, he has been abandoned, helpless on the field. If lucky, he might receive medical help the following day.but only if his army won.and only after a long wait because triage back then was determined by military rank, family wealth, and ability to quickly return to battle. At the turn of the 18th century, Napoleon’s military surgeon, Dominique Jean Larrey, implemented a battlefield triage system based on severity of injury and urgency needed for medical care, regardless of rank or allegiance. Examples of emergency injuries requiring immediate intervention included hemorrhage, cardiac tamponade, sucking chest wounds, and hemothorax. An urgent injury, such as a gravely injured limb, could wait a few hours for treatment, in this case debridement and amputation. Soldiers with nonurgent injuries were minimally wounded and could go by horse themselves to the nearest hospital. These 3 tenets of triage (emergency, urgent, and nonurgent) persisted in acute care settings both on and off the battlefield for the next 200 years.

Out With the Old, In With the Flu

ANNALS CASE It’s another winter overnight shift and the waiting room track board looks like a cough syrup commercial: sore throat, flulike illness, cough, cough, fever, viral illness, body aches, and, yep, another flulike illness. Your first patient is a pregnant 35-year-old with 2 days of fever, vomiting, and body aches. In the next room is a 75-year-old man who complains of fever and cough for the past day. Do these 2 have influenza (flu)? Should we treat them for the flu? What about the tachypneic, febrile nursing home patient you just saw whose infectious evaluation is negative for a source? Should that patient get a flu test? Emergency clinicians may not view flu testing to be especially useful for clinical management, as demonstrated by the fraction of emergency department (ED) patients (5% to 21%) who receive rapid flu testing when presenting with an acute respiratory illness during influenza season. The antigen-based point-of-care testing traditionally used in clinics and EDs has such poor sensitivity that a negative test result is of little clinical utility. Hence, patients with a high clinical suspicion of flu or who are at high risk should be presumed to have the flu even after a negative rapid flu test result! Definitive testing by batched polymerase chain reaction has seemingly been reserved for identifying the start of the flu season. This may be a helpful step to mentally prepare for the onslaught of incoming patients in the following weeks, but it takes multiple days to provide a result, too long to be clinically useful. However, after reading the article by Frazee et al in this month’s Annals of

Asymptomatic and Under Pressure

ANNALS CASE Asymptomatic hypertension (HTN) may not be the “problem” that inspired us to pursue careers in emergency medicine. Frankly, any asymptomatic chronic complaint probably doesn’t elicit a positive or energetic response from us emergency physicians. Yet it is an unfortunately common emergency department (ED) presentation. Although it may be easy to dismiss these patients, they are often extremely concerned (or were told by other professionals to be concerned) about their elevated blood pressure. Our evaluation of and—more important, empathetic and compassionate care for—the concerned patient in front of us is key. In this month’s Annals, Atzema et al describe the characteristics of patients who visit the ED after checking their blood pressure at home or at the pharmacy.