May 2021 Monthly Review

Academic Emergency Medicine

Conclusion: “Many risk stratification scores are not validated or not sufficiently accurate for clinical use. The CSRS is an accurate validated prediction score for ED patients with unexplained syncope. Its impact on clinical decision making, admission rates, cost, or outcomes of care is not known.”

Of the 542 included patients, 46 (10%) required transfer to ICU within 24 hours of admission. The final composite model, adjusted for age and admission location, included history of heart failure and initial oxygen saturation of <93% plus either white blood cell count > 6.4 or glomerular filtration rate < 46. The odds ratio (OR) for decompensation within 24 hours was 5.17 (95% confidence interval [CI] = 2.17 to 12.31) when all criteria were present. For patients without the above criteria, the OR for ICU transfer was 0.20 (95% CI = 0.09 to 0.45).

Take home: use the brief negotiation interview (BNI) to help motivate patients to start Suboxone.

American Journal of Emergency Medicine

No articles this month

Annals of Emergency Medicine

Harm reduction for ED patients with injection drug use includes free dispensation of Naloxone (learn more about how EDs can get free naloxone to dispense here), and syringe services programs (find the SSP closest to you here).

2.6% of patients intubated patients recall an awareness of paralysis, with a two-fold risk among patients paralyzed with rocuronium (have your sedative ready to hang immediately after intubation).

BMJ

Treatment of opioid use disorder in primary care

California Bridge

Here’s the most important takeaway of the “HHS Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder”: All prescribers with a valid state license and DEA can register for an X wavier without mandatory training. It’s now a simple process. Get your X waiver TODAY!

Circulation

No articles this month

EMCRIT

IBCC – Approach to the poisoned patient

Emergency Medicine Journal

No articles this month

EMRAP

Pharmacology Rounds: Electrolyte Repletion

PO Potassium Bicarbonate more palatable than KCl, dose is 50meq PO
Oral Magnesium Oxide 400-800mg tablet
Mag IV 4-8g if Mag<1, 2-4g if mag 1-1.4, 1-2g if Mag 1.5-1.9.
Calcium: 2g CaGluconate over 1 hour if sick.
Phosphate: typically replete if Phos<1, give Potassium Phos if K is low, give Sodium Phos if serum potassium is high, can give 15, 30 or 45 mmol depending on how low phosphate level is, typically 15 mmol/hr

Ask permission to share bad news: “I am afraid I have serious news. Would it be ok if I share?”
Align: “We need to work together quickly to make the best decisions for her care”.
Baseline function: “To decide which treatments might help her the most, I need to know more about her, what type of activities was she doing before her illness.”
“How much more would she be willing to go through for the possibility of more time?”
Summarize

Good tone and respirations: hand baby to mom
Poor tone: warm baby, stimulate, suction if signs of obstruction
Place on monitor
If HR<100 start BVM
If HR<60, intubate, cpr, epi dose .03-.05 mg/kg
Compressions: 3 compressions to 1 breath, 120 total/min, 90 compressions, 30 breaths
Preferred venous access is a 5f umbilical vein line, inserted in the little mouth of the umbilical stump face (umbilical arteries are the eyes, vein is the mouth). insert the 5f line 4-5cm until blood returns.
IO also an option but has a higher failure rate than in older kids.
Consider termination of CPR after 20 minutes with no detectable heart rate.

JAMA