William K. Mallon

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.

The AIDS patient with abdominal pain: a new challenge for the emergency physician

As the prevalence of HIV infection continues to increase, EPs will be called upon to evaluate increasing numbers of AIDS patients who have abdominal pain, some of whom will require emergent surgical intervention. In addition to the myriad causes of abdominal pain in the nonimmunocompromised patient, the differential diagnosis in the AIDS patient includes a wide variety of opportunistic infections and neoplasms (Table 5). Evaluation frequently requires extensive laboratory studies and cultures and advanced imaging (CT, ultrasound, and so forth). A low threshold for surgical and other subspecialty consultation should be in place because of the often subtle presentation of surgical emergencies in AIDS patients.

TRAUMA IN PREGNANCY

Over the past 60 years, trauma has become the leading cause of morbidity and mortality in the pregnant patient. The emotional and physiological challenges of treating two patients simultaneously adds to an already stressful situation. Resuscitation of the pregnant trauma patient is discussed from the prehospital setting to disposition. Also discussed are non-invasive monitoring tools, such as tocodynanomometry and ultrasonography.

Organ Procurement in an Urban Level I Emergency Department

STUDY OBJECTIVE To determine whether an intensive educational campaign of emergency department personnel on the organ donor and procurement process would result in both increased organ donor referrals and organs procured. METHODS A retrospective review of the performance of an urban teaching ED in identifying and referring potential organ donor candidates was performed. Subsequently an intensive educational campaign of all ED staff, in conjunction with the Regional Organ Procurement Agency of Southern California (ROPA), was initiated. Physicians and nurses were educated about the procurement process, and a ROPA representative was on call 24 hours a day to assist in this process. The need for aggressive resuscitation and vital sign maintenance in potential donors as a strategy to promote organ recovery was emphasized. Reeducation by ROPA occurred every 2 to 3 months. The identification and referral rates were then retrospectively reviewed to evaluate any improvement. RESULTS In 1994 the initial referral rate of potential organ donors from the ED was 30% (3 of 10) resulting in no organs procured. After the intervention the referral rate increased to 100% (25 of 25) in 1995 (P < .0001). The number of actual donors procured was 0 in 1994, 5 in 1995, and 9 in 1996. The increased ED referrals resulted in 14 and 32 organs procured in 1995 and 1996, respectively. CONCLUSION Emergency physicians are in a unique position as first caregivers to interact with both potential donors and their families. With intensive education of ED staff, proper identification and referral, as well as timely intervention by organ procurement representatives, the consent and donation rate of organs for transplantation can be increased and maintained.

Minimizing Gang Violence in the Emergency Department

Street gang members are frequently injured, and the violence of their subculture may follow them from the streets into the emergency department. We present four cases in which in-hospital gang violence occurred or was prevented. To decrease the risk of injury from gang-related violence within the hospital, we offer guidelines for patient care and health care provider safety. Emphasis is on education, awareness, and early hospital security involvement.

Nontraumatic intracranial internal carotid artery dissection: A case report

The case presented offers a demonstration of a rare yet devastating condition that may go unrecognized and incompletely worked up by the emergency physician. Internal carotid artery dissection is seen most often in previously healthy, young patients and thus all efforts toward diagnosing this condition and providing proper stabilization must be made. Unfortunately, little advancement in the therapeutic progress of this frequently fatal condition has been made over the past decades. To date, both medical management and surgical techniques have been utilized with variable success. This case should serve to remind physicians evaluating young patients with stroke symptoms or other neurological findings that a negative head CT scan may not be the last test necessary for the definitive diagnosis.

How Should Top-Five Lists Be Developed?: What Is the Next Step?

Readers might wonder why the editors of JAMA Internal Medicine decided to publish “A Top-Five List for Emergency Medicine.” Some of our readers might practice emergency medicine (EM), and many provide “urgent” care. However, we decided to publish this article for another reason. We believe that “A Top-Five List for Emergency Medicine” from Schuur et al1 at Partners Healthcare demonstrates a solid methodological approach to developing a list of low-value tests, procedures, and treatments in response to the American Board of Internal Medicine Foundation’s Choosing Wisely campaign.Althoughmanyprofessional societies havepublished “top-five” lists,most havenot detailed the methods by which the list was created. In some cases, it is clear that the lists were developed without much input fromfrontlinepractitioners, usingaprocess thatwasnot transparent andwithout clear criteria for inclusionon the list. We hope the article by Schuur et al1 will stimulate other professional societies to adopt clear, transparentmethods for developingand revising top-five listswith substantial input from practicing clinicians. We would like to see a consensus develop around criteria for choosing items on top-five lists. To start this conversation, we suggest that there should be clear evidence that the tests and treatments on a top-five list cause potential harm or provide little benefit to patients, are frequentlymisused in clinical practice, aremeasureable, and are under the control of providers. At least 50 specialty societies have now developed topfive lists for Choosing Wisely, and about 10 more are expected to publish lists in the next fewmonths. This activity is gratifying, butwebelieve it is also time to consider next steps. An important next step is to develop ways to evaluate the effect of the top-five lists onhealth caredelivery andhealth care value. To collect data, it will be important to focus on highimpact activities that can be tracked using electronic databases. Although partnering with specialty societies has been successful, we also believe that another crucial next step is to include other health care providers in the Choosing Wisely campaign so that nurses and pharmacists, among others, are on the same page. The involvement of the American College of Emergency Physicians (ACEP) in theChoosingWiselycampaignbeganwith discussion and a passionate floor debate at the 2012 national ACEP Council meeting. Those in favor of joining the Choosing Wisely campaign believed that identifying 5 good costsaving ideaswouldbe easy and that itwouldbe anembarrassment if EM ended up conspicuously absent from the movement.Thoseagainstnotedthat theACEPalreadyhadconvenedaCost-effectivenessCareTaskForce toaddress thesame issue. This group also believed that other barriers to joining ChoosingWisely are unique to EM, including that emergency department patients are sicker on average thanpatients cared forby someother specialists, thatmalpractice ismoreof a concern, that EMphysiciansmust follow the EmergencyMedical Treatment and Active Labor Act that requires they treat and stabilize anyone with an emergency medical condition, and that reimbursement is alreadyunderattackby third-partypayers who regularly down-code and discount emergency patient care. Furthermore,manyof theexistingChoosingWisely campaign recommendations fromother specialties seemed to be aimedat theEMscopeof practice. Theoutcomeof a closely divided council floor vote that followed was that the ACEP Council recommended against joining the Choosing Wisely campaign. At that time, Dr Schuur and colleagues at Partners Healthcare decided to independently develop a top-five list for EM. After further reflection, the board of directors of ACEP reversed their initial stance and decided to join the Choosing Wisely campaign. They asked Dr Schuur to help lead this effort. They built on his work described in this issue as well as the work of the Cost-effectiveness Care Task Force to create the ACEP’s top-five list. The Task Force had already developed a survey of all ACEP members for “cost-saving measures,” and more than 200 individual suggestions were received. The results of this surveywere grouped intodomains, and an expert panel used amodified Delphi technique to prioritize the recommendations following methods similar to those used by Dr Schuur and colleagues at Partners Healthcare.Multiple roundsofvoting followedto identifyhighly rated strategies that offered cost reductions and benefit to patients and were highly actionable by practicing EM physicians. The development process had a high level of specialty awareness (a floor debate at thenationalmeeting and specialty-wide survey data) and transparency. The final step included a literature review to establish a solid evidence base that specifically sought to include available cost data. Scientific support was assembled by a subcommittee of the Cost-effectiveness Care Task Force for each of the EM proposals for the Choosing Wisely campaign. The strategies that received majority support of the expert subgroup were then forwarded to the ACEP board of directors, who selected the top 5 for submission to the American Board of Internal Medicine Foundation (http://www.choosingwisely Related article page 509 Opinion

Emergency department initiation of cardiopulmonary bypass: a case report and review of the literature.

BACKGROUND Out-of-hospital cardiac arrest carries a dismal prognosis. Percutaneous extracorporeal membrane oxygenation (ECMO) has been used with success for in-hospital arrests, and some literature suggests improvement in long-term survival for out-of-hospital arrests as well. OBJECTIVES This case highlights the use of ECMO in the emergency department. CASE REPORT We report a case in which emergency physician-initiated ECMO was used as a bridge to definitive care in an out-of- hospital cardiac arrest in the United States. CONCLUSIONS ECMO is a novel adjunct for patients in cardiac arrest in whom the usual advanced life support techniques have failed.

Identification of subcutaneous myiasis using bedside emergency physician performed ultrasound.

BACKGROUND Subcutaneous myiasis, a maggot infiltration of human tissue, is common in tropical countries. However, physicians in the United States may be unlikely to consider this etiology of dermatologic abnormalities even when a travel history suggests the diagnosis should be included in the differential. CASE REPORT We report the case of a patient who returned from Sierra Leone with an infestation of a maggot of Cordylobia anthropophaga (tumbu fly) that was diagnosed and appropriately treated based on ultrasound findings. CONCLUSION As international travel increases, clinicians should maintain a high level of suspicion for tumbu fly infestation in returned travelers from endemic areas. The increasing use of ultrasound in the Emergency Department for evaluation of skin and soft tissue infections may aid the physician in making the diagnosis of subcutaneous myiasis.

Tattoos and Piercings: A Review for the Emergency Physician

Tattoos and piercings are increasingly part of everyday life for large sections of the population, and more emergency physicians are seeing these body modifications (BM) adorn their patients. In this review we elucidate the most common forms of these BMs, we describe how they may affect both the physical and psychological health of the patient undergoing treatment, and also try to educate around any potential pitfalls in treating associated complications.