Michael K. Abraham

Levosimendan does not improve survival time in a rat model of verapamil toxicity

ObjectiveCalcium channel blocker (CCB) toxicity, in particular that induced by verapamil and diltiazem, presents clinical challenges with no true antidote. Levosimendan, a calcium sensitizer, improves cardiac contractility in patients with heart failure. We tested the hypothesis that calcium channel sensitization will prolong survival in a rat model of severe verapamil poisoning.MethodsThis was a blinded, randomized, controlled animal study. Wistar rats (mean weight, 371 ± 50 g) were used. Verapamil (2.5 mg/ml) was infused at a rate of 37.5 mg/kg per hour. Bolus doses of levosimendan (5 μg/mL) were given at 0 min (12 μg/kg) and 5 min (18 μg/kg); saline control was of equal volume. The rats were intubated and maintained under general anesthesia with isoflurane. Electrocardiographic activity and core temperature were monitored during the poisoning and treatment phases. Each rat underwent femoral vein cannulation and was then randomized, in blinded fashion, to receive either levosimendan or an equal volume of saline at 0 and 5 minutes. Death, defined as 1 minute of asystole, was used as the primary endpoint.ResultsRats treated with levosimendan died before the control group (7.37 ± 0.7 min [n = 7] vs. 16.4 ± 4.2 [n = 7] [p=.053]). All animals experienced bradycardia prior to asystole.DiscussionAlthough levosimendan has the ability to sensitize and enhance binding of troponin C to Ca2+, this study did not show an improvement in survival time in the setting of verapamil toxicity. This may be attributed to levosimendan’s inhibition of phosphodiesterase, which possibly exacerbated the CCB-induced hypotension.ConclusionIn this rat model, levosimendan as a solitary antidotal treatment for verapamil toxicity was not beneficial.

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.

Propofol for Procedural Sedation and Analgesia Reduced Dedicated Emergency Nursing Time While Maintaining Safety in a Community Emergency Department

INTRODUCTION Procedural sedation and analgesia is a core competency in emergency medicine. Propofol is replacing midazolam in many emergency departments. Barriers to performing procedural sedation include resource utilization. We hypothesized that emergency nursing time is shorter with propofol than midazolam, without increasing complications. METHODS Retrospective analysis of a procedural sedation registry for two community emergency departments with combined census of 100,000 patients/year. Demographics, procedure, and ASA physical classification status of adult patients receiving procedural sedation between 2007-2010 with midazolam or propofol were analyzed. Primary outcome was dedicated emergency nursing time. Secondary outcomes were procedural success, ED length of stay, and complication rate. Comparative statistics were performed with Mann-Whitney, Kruskal-Wallis, chi-square, or Fishers exact test. Linear regression was performed with log-transformed procedural sedation time to define predictors. RESULTS Of 328 procedural sedation and analgesia, 316 met inclusion criteria, of which 60 received midazolam and 256 propofol. Sex distribution varied between groups (midazolam 3% male; propofol 55% male; P = 0.04). Age, procedure, and ASA status were not significantly different. Propofol had shorter procedural sedation time (propofol 32.5 ± 24.2 minutes; midazolam 78.7 ± 51.5 minutes; P < 0.001) and higher rates of procedural success (propofol 98%; midazolam 92%; P = 0.02). There were no significant differences between complication rates (propofol 14%; midazolam 13%; P = 0.88) or emergency department length of stay (propofol 262.5 ± 132.8 minutes; midazolam 288.6 ± 130.6 minutes; P = 0.09). DISCUSSION Use of propofol resulted in shorter emergency nursing time and higher procedural success rate than midazolam with a comparable safety profile.

Status Epilepticus: What’s New?

The emergent evaluation and treatment of generalized convulsive status epilepticus presents challenges for emergency physicians. This disease is one of the few in which minutes can mean the difference between life and significant morbidity and mortality. It is imperative to use parallel processing and have multiple treatment options planned in advance, in case the current treatment is not successful. There is also benefit to exploring, or initiating, treatment algorithms to standardize the care for these critically ill patients.

Altered mental status and endocrine diseases.

Although the altered mental status is a common presentation in the emergency department, altered mental status caused by endocrine emergencies is rare. The altered patient could have an endocrine cause that can quickly improve with appropriate diagnosis and interventions. When dealing with limited information and an obtunded patient, it is important to have a broad differential diagnosis, pick up on the physical examination findings, and evaluate laboratory abnormalities that could suggest an underlying endocrine emergency. This article outlines the findings and provides a description of altered patients with endocrine emergencies to facilitate the diagnosis and treatment in the emergency department.

Implementation of a Team-based Physician Staffing Model at an Academic Emergency Department

Introduction There is scant literature regarding the optimal resident physician staffing model of academic emergency departments (ED) that maximizes learning opportunities. A department of emergency medicine at a large inner-city academic hospital initiated a team-based staffing model. Its pre-interventional staffing model consisted of residents and attending physicians being separately assigned patients, resulting in residents working with two different faculty providers in the same shift. This study aimed to determine if the post-interventional team-based system, in which residents were paired with a single attending on each shift, would result in improved residents’ learning and clinical experiences as manifested by resident evaluations and the number of patients seen. Methods This retrospective before-and-after study at an academic ED with an annual volume of 52,000 patients examined the mean differences in five-point Likert-scale evaluations completed by residents assessing their ED rotation experiences in both the original and team-based staffing models. The residents were queried on their perceptions of feeling part of the team, decision-making autonomy, clinical experience, amount of supervision, quality of teaching, and overall rotational experience. We also analyzed the number of patients seen per hour by residents. Paired sample t-tests were performed. Residents who were in the program in the year preceding and proceeding the intervention were eligible for inclusion. Results 34 of 38 eligible residents were included (4 excluded for lack of evaluations in either the pre- or post-intervention period). There was a statistically significant improvement in resident perception of the quality and amount of teaching, 4.03 to 4.27 (mean difference=0.24, p=0.03). There were non-statistically significant trends toward improved mean scores for all other queries. Residents also saw more patients following the initiation of the team-based model, 1.24 to 1.56 patients per hour (mean difference=0.32, p=0.0005). Conclusion Adopting a team-based physician staffing model is associated with improved resident perceptions of quality and amount of teaching. Residents also experience a greater number of patient evaluations in a team-based model.

Academic Primer Series: Key Papers About Competency-Based Medical Education

Introduction Competency-based medical education (CBME) presents a paradigm shift in medical training. This outcome-based education movement has triggered substantive changes across the globe. Since this transition is only beginning, many faculty members may not have experience with CBME nor a solid foundation in the grounding literature. We identify and summarize key papers to help faculty members learn more about CBME. Methods Based on the online discussions of the 2016–2017 ALiEM Faculty Incubator program, a series of papers on the topic of CBME was developed. Augmenting this list with suggestions by a guest expert and by an open call on Twitter for other important papers, we were able to generate a list of 21 papers in total. Subsequently, we used a modified Delphi study methodology to narrow the list to key papers that describe the importance and significance for educators interested in learning about CBME. To determine the most impactful papers, the mixed junior and senior faculty authorship group used three-round voting methodology based upon the Delphi method. Results Summaries of the five most highly rated papers on the topic of CBME, as determined by this modified Delphi approach, are presented in this paper. Major themes include a definition of core CBME themes, CBME principles to consider in the design of curricula, a history of the development of the CBME movement, and a rationale for changes to accreditation with CBME. The application of the study findings to junior faculty and faculty developers is discussed. Conclusion We present five key papers on CBME that junior faculty members and faculty experts identified as essential to faculty development. These papers are a mix of foundational and explanatory papers that may provide a basis from which junior faculty members may build upon as they help to implement CBME programs.

Emphysematous pyelonephritis in a renal allograft

Emphysematous pyelonephritis (EPN) is a necrotizing infection characterized by the presence of gas in the renal parenchyma, collecting system, and surrounding structures. It is a rare, life-threatening disease, which poses a diagnostic challenge due to its rarity and nonspecific presentation. EPN can affect both native and allograft kidneys and is often treated surgically. In this report, we describe a patient with EPN in a renal allograft, who was treated conservatively with intravenous (IV) antibiotics without percutaneous drainage or nephrectomy.

The neurology literature 2016

Emergency neurology is a complex and rapidly changing field. Its evolution can be attributed in part to increased imaging options, debates about optimal treatment, and simply the growth of emergency medicine as a specialty. Every year, a number of articles published in emergency medicine or other specialty journals should become familiar to the emergency physician. This review summarizes neurology articles published in 2016, which the authors consider crucial to the practice of emergency medicine. The articles are categorized according to disease process, with the understanding that there can be significant overlap among articles.

Neurologic Emergencies—Making the Diagnosis and Treating the Life Threats

When Dr Amal Mattu asked us to consider organizing and editing this issue of Emergency Medicine Clinics of North America, we both had to say yes. This is, in part, due to our respect for him, but also to our interest in and commitment to improving the care of our patients who present to the emergency department with acute neurologic problems. This group of patients is not an insignificant number, and most estimates suggest that between 5% and 8% of all patients seen in an emergency department have neurologic issues. If you need confirmation, simply think about your last shift and consider howmany patients had back pain or headache or dizziness or altered mentation. Most of these patients have fairly trivial and often self-limited problems. However, as with emergency medicine in general, there are the needles in the haystack. Several decades ago, when one of us started practicing emergency medicine, the range of diagnostic imaging was quite limited and the menu of various therapeutic options for patients with neurologic problems even more so. Computed Tomography (CT) scan was available, but often only during daytime hours. MRI was still on the drawing board. TPA was a couple of decades away. The notion that treating patients with transient ischemic attack (TIA) within the first couple of days could reduce the outcome of stroke did not exist. Phenobarbital was a common treatment for patients with status epilepticus, and the probability of getting an EEG in the emergency department was essentially zero. My younger counterpart wasn’t so lucky. For quite some time, a spirit of therapeutic nihilism existed for patients with neurologic emergencies. Neurologic emergencies incite fear into emergency physicians as they can be more complicated than many of the other critical issues that confront emergency physicians every day. But the range of diagnostic modalities and the various treatments that are now available for these patients have markedly expanded