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July’s audio/podcast for Annals of EM is now posted here. Highlights:
-Early vs late rhythm analysis in OOHCA
-Ground based EMS transports and complications
-When do sepsis patients become septic? Usually NOT on arrival. Time to change the metric?
-Diethylene glycol outbreak
-Much, much more!
By Justin McNamee, DO; Nilesh Patel, DO; and Joseph Affortunato, DO
Department of Emergency Medicine
St. Joseph’s Regional Medical Center, Paterson, New Jersey
A 26-year-old woman presented to the emergency department, complaining of a 3-day history of lower abdominal pain and vaginal bleeding. She reported positive home pregnancy test results and that her last menstrual period was 17 weeks ago. On examination, the patient appeared comfortable and was afebrile, with a blood pressure of 131/67 mm Hg, pulse rate of 100 beats/min, and respiratory rate of 16 breaths/min.
Clinical Policy: Critical Issues in the Evaluation and Management
of Adult Patients Presenting to the Emergency Department With Seizures
By J. Stephen Huff, MD, FACEP
In the April 2014 issue of the Annals of Emergency Medicine, the American College of Emergency Physicians (ACEP) published a clinical policy focusing on seizures. This is a revision of a 2004 clinical policy with the same name.
This clinical policy can also be found on ACEP’s website www.acep.
This clinical policy takes an evidence-based approach to answering four frequently encountered questions with regards to decision making associated with seizures in the emergency department. Recommendations (Level A, B, or C) for patient management are provided based on the strength of evidence using the Clinical Policies Committee’s well-established methodology:
Level A recommendations represent patient management principles that reflect a high degree of clinical certainty; Level B recommendations represent patient management principles that reflect moderate clinical certainty; Level C recommendations represent other patient management strategies based on Class III studies, or in the absence of any adequate published literature, based on consensus of the members of the Clinical Policies Committee.
During development, this clinical policy was reviewed and expert review comments were received from emergency physicians, neurologists, and individual members of the American Epilepsy Society, the American Academy of Neurology, the Epilepsy Foundation of America, the National Association of Epilepsy Centers, and ACEP’s Quality and Performance Committee. The draft was also open to further comments through various ACEP communication pieces. All responses were used to further refine and enhance this policy; however, their responses did not imply endorsement of this clinical policy.
This revision of the clinical policy on critical issues in the evaluation and management of adult patients with seizures in the emergency department focused on selected critical questions. Key to this policy revision was employing updated nomenclature for classification of seizures. Seizures can be thought of as provoked or unprovoked. Provoked seizures are secondary to electrolyte disturbances, toxins, infections, central nervous system mass lesions, withdrawal syndromes, or other etiologies. These provoked seizures, also known as acute symptomatic seizures, by definition occur at the time of or within seven days of acute neurologic, systemic, metabolic, or toxic processes. Unprovoked seizures occur in the absence of acute precipitating factors. Seizures from such processes as stroke, brain injury, and other CNS insults that occurred more than seven days in the past are also classified as unprovoked seizures. Epilepsy is defined by recurrent unprovoked seizures.
The question of initiating treatment with antiepileptic drugs for the adult patient presenting to the ED following a first generalized seizure who has returned to baseline clinical status was one critical question. The short-term recurrence risk of this group of patients is unknown but thought to be low. After literature review and grading the evidence, level C recommendations were developed for subgroups of patients. Appropriate clinical assessment by emergency physicians of patients is important since presumptive assignment of the seizure as provoked or unprovoked drives the treatment recommendation. However, it is unclear if seizures can be precisely identified as provoked or unprovoked using information available during an emergency department evaluation. Additionally, patient safety should remain a paramount concern for the practicing physician. Though the evidence supports discharging an adult patient who has returned to baseline status following a first unprovoked seizure, supporting articles assumed a safe support system for the discharged patient. Consideration of social issues or other factors may prompt consideration for admission.
Another critical question addressed treatment of ED patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine. There are remarkably few randomized prospective studies on this problem and none that consider the causes of status epilepticus. Large prospective studies are in the planning stages. Until these studies are completed, recommendations for specific drugs must reflect current lower levels of evidence. Many different medications are recommended and no medication or class of medications is clearly superior.
Designation of a seizure as provoked or unprovoked at some level is arbitrary and may change with the clinical course or as additional studies are performed. Emergency physicians play a critical role in determining whether a seizure is provoked or unprovoked. If there is an underlying medical condition, identification and treatment of that process is the primary consideration. It is hoped that future studies will focus on seizure recurrence of patients presenting to the ED with seizures, and study outcomes over days or another time frame relevant to emergency medicine.
Critical Questions and Recommendations
Question 1: In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the ED to prevent additional seizures?
Level C recommendations.
(1) Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first provoked seizure. Precipitating medical conditions should be identified and treated.
(2) Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first unprovoked seizure without evidence of brain disease or injury.
(3) Emergency physicians may initiate antiepileptic medication* in the ED, or defer in coordination with other providers, for patients who experienced a first unprovoked seizure with a remote history of brain disease or injury.
* Antiepileptic medication in this document refers to medications prescribed for seizure prevention.
Question 2: In patients with a first unprovoked seizure who have returned to their baseline clinical status in the ED, should the patient be admitted to the hospital to prevent adverse events
Level C recommendations. Emergency physicians need not admit patients with a first unprovoked seizure who have returned to their clinical baseline in the ED.
Question 3: In patients with a known seizure disorder in which resuming their antiepileptic medication in the ED is deemed appropriate, does the route of administration impact recurrence of seizures?
Level C recommendations. When resuming antiepileptic medication in the ED is deemed appropriate, the emergency physician may administer IV or oral medication at their discretion.
Question 4: In ED patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine, which agent or agents should be administered next to terminate seizures?
Level A recommendations. Emergency physicians should administer an additional antiepileptic medication in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Level B recommendations. Emergency physicians may administer intravenous phenytoin, fosphenytoin, or valproate in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Level C recommendations. Emergency physicians may administer intravenous levetiracetam, propofol, or barbiturates in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Dr. Huff is Professor of Emergency Medicine and Neurology, University of Virginia, Charlottesville, Virginia
Nearly half of emergency physicians responding to a poll are already seeing a rise in emergency visits since January 1 when expanded coverage under the Affordable Care Act (ACA) began to take effect. In an online poll conducted by the American College of Emergency Physicians (ACEP), 86 percent expect emergency visits to increase over the next three years. More than three-fourths (77 percent) say their ERs are not adequately prepared for significant increases.
“Emergency visits will increase in large part because more people will have health insurance and therefore will be seeking medical care,” said Alex Rosenau, DO, FACEP, president of ACEP. “But America has severe primary care physician shortages, and many physicians do not accept Medicaid patients, because Medicaid pays so low. When people can’t get appointments with physicians, they will seek care in emergency departments. In addition, the population is aging, and older people are more likely to have chronic medical conditions that require emergency care.”
The data suggest that states that expanded Medicaid are more likely to see increases in the volume of Medicaid emergency patients. Dr. Rosenau said that policymakers need to make sure there are adequate resources to care for growing numbers of emergency patients.
What other jobs allow you to stay up all night long, party with crazy people, and get paid for it?
That’s what I like to say every New Year’s Eve. New Year’s Eve is my favorite shift, and it’s because of the people.
They are what keep me going in this career: the people, the crazy people, and I don’t mean just the patients.
Docs, nurses and techs all have to be a little bit loony to enjoy this job as well. It is the best job in the world! I come to work not knowing exactly what I will be doing, and even while working we never know what’s going to happen next.
Time-bombs are lurking in the humdrum of the daily routine. Our job is to identify them and defuse them. This keeps us on our toes, and this keeps me intrigued. When I can solve a medical puzzle, I am intellectually rewarded. When I can help someone I am gratified. When I can make a child smile I am happy. I can’t figure everything out or everybody out but I can sure have fun trying! This is why I continue my career of emergency medicine.
Why did I make it my career in the first place?
It looked exciting, isn’t that why we all chose it?
By: Seth R. Gemme, MD
The ACEP Clinical Policies Committee regularly reviews guidelines published by other organizations and professional societies. Periodically, new guidelines are identified on topics with particular relevance to the clinical practice of emergency medicine. This article highlights recommendations for the education, recognition, and management of concussions, published by the American Academy of Neurology in June, 2013.
Concussions have become a popular topic of concern in the media and with the public over the last several years as many amateur and professional athletes have had career ending head injuries. According to the Centers for Disease Control and Prevention, concussion visits to the emergency department have increased, likely as a result of the increased awareness. Thus there is a need for a better understanding of the neurocognitive pathology and risks associated with a concussion.
In June of 2013, the American Academy of Neurology (AAN) published a guideline focusing on the risk factors of concussion, clinical features associated with worse outcome, and management. They graded the literature since 1955 using a modified version of the GRADE working group process and made recommendations using a modified Delphi process.
Various risk factors were investigated. There was not enough evidence that age made a difference in risk of concussion. With regards to gender, men make up the majority of concussions, likely due to more men playing contact sports, with the greatest risk in American football and Australian rugby. Females were found to be at higher risk if participating in soccer or basketball versus other sports. There is no evidence that mouth guards protect athletes from concussion in any sport. In American football, there is no evidence regarding superiority of one type of football helmet in preventing concussion. Other factors associated with greater risk include a BMI of greater than 27 or training for less than three hours per week. In addition, it is likely that there is an increased risk for repeat concussion within 10 days of the initial concussion.
Clinical features associated with severe or prolonged early postconcussion impairments include a history of prior concussion, early post-traumatic headache, fatigue or fogginess at the time of diagnosis, early amnesia, altered mental status or disorientation, or younger age. Increasing concussion exposure is a risk factor for chronic neurobehavioral impairment in a broad range of professional contact sports but evidence is insufficient in amateur sports of whether or not prior concussion exposure increases chronic cognitive impairment.
The AAN recommends that school-based professionals, athletes, and parents be educated by a designated licensed health care provider (LHCP) about concussions in general and associated risks. A LHCP is one who has acquired skills and knowledge relevant to the evaluation and management of sport concussions and is practicing within his or her scope of practice. This can be either a sideline or clinical LHCP. AAN also recommends that assessment tools be used by the sideline LHCP and those results be made available to the clinical LHCP. One sideline tool discussed is the Standardized Assessment of Concussion which can be administered in 6-minutes and assesses orientation, immediate memory, concentration and delayed recall. Other sideline tools discussed include the Post-Concussion Symptom Scale and the Graded Symptom Checklist which also may be administered in a short time interval and identify concussion.
Two important grade B recommendations are that team personnel should immediately remove any athlete from play with a suspected concussion and that the athlete not be allowed to return until evaluated by the LHCP. It is also recommended that no player should return to play until a LHCP has deemed the concussion to be resolved after being off all medications. A graded process for return of play is recommended with consideration given for formal neurocognitive testing. This makes it essential that patients with a concussion who are discharged from the ED follow up with a LHCP in the outpatient setting.
Per this guideline, in the diagnosis of a concussion, head CT scan is not indicated unless other more serious complications are possible. Factors they deemed as risks in their recommendation include loss of consciousness, post-traumatic amnesia, persistence of a GCS<15, focal neurologic deficit, clinical skull fracture, or clinical deterioration. The guideline does not go into any more detail with regards to imaging.
As an athlete gets older and enters more competitive sports, there is a high level of pressure to get back to play. With continued awareness programs and through this guideline, physicians, parents, coaches, and athletes may be able to reduce risk of recurrent concussions and help prevent long-term neurobehavioral impairment.
Summary of evidence-based guideline update: Evaluation and management of concussion in sports. Neurology. June 11, 2013;80(24):2250-2257.
Dr. Gemme is a resident in emergency medicine at Alpert Medical School of Brown University, and is the 2013-2014 EMRA Representative to the ACEP Clinical Policies Committee.
By Francis L. Counselman, M.D., CPE, FACEP
In the August 2013 issue of ACEP News, the various pathways available to current and future emergency medicine residency graduates to achieve Critical Care Medicine (CCM) certification through fellowship training were reviewed. In this issue, the options available to ABEM diplomates who completed a Critical Care Medicine fellowship prior to the establishment of the current pathways will be discussed.
First, there is no “practice only” pathway for Critical Care Medicine. All CCM certification requires successful completion of ACGME-accredited CCM fellowship training, and practice of Critical Care Medicine. Secondly, there is no “grandfather” pathway available through the American Board of Surgery (ABS) for Surgical Critical Care. This decision by ABS was made for internal policy consistency, and there are no exceptions. Finally, like all “grandfather” pathways, there is a time-limited window during which one can apply for certification. Please make yourself aware of these dates.
American Board of Internal
Medicine (ABIM) Critical Care Medicine
For Internal Medicine-Critical Care Medicine (IM-CCM), the “grandfather” pathway requires both the completion of a 24-month CCM fellowship and the practice of Critical Care Medicine. This pathway is scheduled to close on June 30, 2016. For the 24-month CCM fellowship to count, it must meet one of the following criteria: a) an ACGME-accredited IM-CCM fellowship completed prior to September 21, 2011; b) an unaccredited IM-CCM fellowship that subsequently became ACGME-accredited on or before December 31, 1992; or c) an ACGME-accredited fellowship in another critical care specialty (i.e., Surgical CCM, Anesthesiology CCM).
The second component, the practice portion, is a little more complicated. The EM applicant must have met the practice criteria as of the date on which the application is submitted to ABEM. For at least three years, not necessarily contiguous, of the five years prior to submitting the application (including the 12 months immediately prior to submission), the applicant must have met one of the following criteria: a) 40% of post-training clinical practice time in the practice of CCM; or b) 25% of total post-training professional time in the practice of CCM.
Finally, for those ABEM diplomates who completed an ACGME-accredited IM-CCM fellowship in the recent past (i.e., between September 21, 2008, and September 20, 2011) criteria can be met if, during 60% of the time between completing fellowship training and applying for certification, the applicant completed one of the following: a) 40% of post-training clinical practice in the practice of CCM or; b) 25% of total post-training professional time in the practice of CCM. For example, if an applicant completed fellowship training on June 30, 2011, and applied for certification on July 1, 2013, 60% of the time (i.e., 24 months) would be 14.4 months. So, during that 14.4-month period between completion of fellowship training and application submission, the applicant must meet either the 40% or 25% criterion, as described above.
Physicians whose total practice exceeds 40 hours per week may use 40 hours as the denominator for the “40%” or “25%” calculations for either of the above scenarios.
American Board of Anesthesiology (ABA)
Critical Care Medicine (ACCM)
ABEM diplomates seeking certification through the “grandfather” pathway must have completed both an ACGME-accredited ACCM fellowship program (one or two years in length) and the CCM practice component by the time of application submission, and no later than June 30, 2018; this is the final date of the last application period within the grandfather pathway. The ACCM fellowship training must have been started prior to July 1, 2013. In order for the fellowship program to count, it must have been ACGME-accredited at the time of the applicant’s training; it does not count if the fellowship subsequently became accredited.
For the practice component, during the two years immediately preceding the application submission, the applicant must have completed one of the following: a) 40% of post-training clinical practice time in the practice of CCM, or; b) 25% of total post-training professional time in the practice of CCM. For either calculation, if total practice time exceeds 40 hours per week, 40 hours may be used as the denominator for the “40%” or “25%” calculation.
For both the IM-CCM and ACCM eligibility criteria, the “practice of CCM” is strictly defined. An acceptable practice must occur in a designated critical care unit. Caring for critically ill patients in the ED does not count toward the practice component. For more detail on what constitutes the practice of CCM, please visit the ABEM website at www.abem.org
For all CCM subspecialty pathways, the ABEM diplomate must: meet the requirements of the ABEM Maintenance of Certifications (MOC) program at the time of application and throughout the certification process; be in compliance with the ABEM Policy on Medical Licensure; and provide information about someone who can independently verify the physician’s clinical competence in CCM, successful completion of ACGME-accredited CCM fellowship training, and the physician’s practice of CCM. No opportunities for CCM certification existed just two years ago for emergency physicians, but we now have three pathways going forward, including two grandfather pathways. It is a very exciting time for emergency physicians interested in Critical Care Medicine. The opportunities that now exist are the direct result of the hard work, persistence, and energy of many of our colleagues. To all involved, “Thank you!”
Dr. Counselman is Chairman of the Department of Emergency Medicine at Eastern Virginia Medical School, and President-elect of ABEM.
Here’s a link to the first article in this two-part series
When something interesting happens in the ED, you tell friends about it.
When a clinical study or great article comes out, you discuss it with other emergency physicians. Why not tell this work-related stuff to 33,000 people who know you best? Say it right here on The Central Line blog. The Central Line is ACEP’s official blog, and to get your blog posted, send your thoughts to this email address.
Once you become a regular, we’ll offer up the keys to the store and let you post directly. Get started!
By Jon Mark Hirshon, MD, MPH, PhD, FACEP
Report Card Task Force Chair
With the release of the 2014 ACEP Report Card on Emergency Medicine, the nation learns how well each state supports emergency medicine and your emergency department.
The nation received an overall grade of D+.
ACEP has produced Report Cards in 2006 and 2009 to evaluate the overall emergency care environment both nationally and on a state by state basis. This is not a report on the emergency care delivered in any specific hospital or by any individual physician, but rather an evaluation of how well the country supports emergency care.
The 2014 Report Card is based on 136 objective measures in five areas:
- Access to Emergency Care (30%)
- Quality & Patient Safety (20%)
- Medical Liability (20%)
- Public Health & Injury Prevention (15%)
- Disaster Preparedness (15%)
It reflects the most recent data available from high-quality sources such as the Centers for Disease Control and Prevention, the National Highway Traffic Safety Administration, the Centers for Medicare & Medicaid Services, and the American Medical Association. Additionally, two surveys were sent to state health officials to gather data for which no reliable, comparable state-by-state sources were available. These data elements were then combined to create the components of the Report Card.
Since 2006, ACEP chapters have used the Report Cards to help with the establishment of new emergency medicine residency programs, support the funding of a statewide trauma system, to help with the enactment of liability protection for federally mandated EMTALA related care, and to increase awareness of emergency medicine issues among state and national lawmakers. We plan to use the 2014 Report Card to educate policymakers and the public about the pivotal role of emergency medicine, help change the conversation from preventing “expensive” emergency visits to protecting access to emergency care, and use communications tools to achieve the national and state recommendations of the Report Card in order to improve the emergency care environment.
To access the most current state by state information, including state and national grades, and to be able to compare the 2014 Report Card with the previous Report Card, please visit: http://www.emreportcard.org/
-Jon Mark Hirshon, MD, MPH, PhD, FACEP
Report Card Task Force Chair
Dr. Hirshon is Board Certified in both Emergency Medicine and Preventive Medicine and has authored approximately 75 articles and chapters on various topics, including the development of public health surveillance systems in emergency departments and placing emergency care on the global health agenda. He has a doctorate in epidemiology and is a federally funded researcher and teacher with specific interest in improving access to acute care and in developing emergency departments as sites for surveillance and hypothesis driven research in public health.
Dr. Jeremy Brown is the director of the newly created Office of Emergency Care Research (OECR) at the National Institutes of Health (NIH). He trained as an emergency physician in Boston, and prior to joining the NIH he worked in the Department of Emergency Medicine at the George Washington University (GW) in Washington, DC. While at GW, he founded the emergency department (ED) HIV screening program and was the recipient of 3 NIH grants that focused on a new therapy for renal colic. He continues to teach at GW on the practice of clinical research, as well as teaching a course on science and religion. He is the author of more than 30 peer-reviewed articles and 3 books, including 2 textbooks of emergency medicine, all published by Oxford University Press. Annals News & Perspective editor Truman J. “TJ” Milling Jr., MD, interviewed Dr. Brown in his Bethesda, MD, office, on the importance of the OECR and how he plans to use his new position to coordinate and grow emergency research within the NIH. His comments have been edited for clarity.
Read the Q and A here