EREM: Pitfalls and Perils of Emergency Department Discharge Instructions

In the emergency department (ED), failure to comply with discharge instructions has been associated with an increased rate of adverse outcomes for patients. ^1,2 There is tremendous variability in the information that is provided to patients in discharge paperwork. In some EDs, a simple handwritten discharge note is given to the patient, while in others, extensive, diagnosis specific pre-created instructions are provided to patients at time of discharge. To improve patient outcomes and reduce their medicolegal risk, providers must recognize pitfalls associated with discharge instructions and include two key elements as a part of all discharge paperwork.

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By Matthew DeLaney, MD|2016-11-11T19:37:15-08:00Jul 6, 2015|Expert Peer Reviewed (Clinical), Medicolegal|

Blast From the Past: Occult Sepsis, Lactic Acid, and Mortality

Severe sepsis and septic shock affect millions of patients worldwide and have high rates of morbidity and mortality as well as high resource utilization. The way we manage sepsis has changed quite a bit since the Rivers et al randomized controlled trial of early goal-directed therapy (EGDT) ¹ , which had an absolute decrease in mortality from 46% with “usual care” to 31% with EGDT. What we now know is that a proactive approach to septic patients will result in lower mortality rates and better outcomes (i.e. early identification, early intravenous fluids, and early antibiotics). Patients with sepsis are still missed despite the fact that we understand the benefits to morbidity and mortality with early recognition. In this blast from the past study from 2007, Howell et al ² answered the important question of does elevated lactic acid simply reflect a patient’s hemodynamic status or can it independently predict 28 day in-hospital mortality after controlling for other potential confounders in patients with sepsis. (more…)

By Salim Rezaie, MD|2016-11-11T19:37:14-08:00Jun 29, 2015|Critical Care/ Resus, Expert Peer Reviewed (Clinical), Infectious Disease|

Salicylate Toxicity PV card v2: Lessons in post-publication review

I was recently the author of a PV card for management of Salicylate Toxicity, which had some discrepancy with expert opinion. The point of contention was in regards to measurement of urine pH vs serum pH for alkalinization. In preparing the first version of the card, I began with notes from a recent toxicology rotation, and expanded by examining textbooks and review articles. Although there was mention of serum pH measurement, numerous sources emphasized urine alkalinization as the primary endpoint for the treatment of aspirin toxicity. Therefore I choose to include this on the size-limited PV card.

Despite review by numerous peers and colleagues, not long after publication we were met with concern from prominent toxicologists regarding an oversight in mentioning serum alkalinization. Utilizing the strengths of our blog and social media we were immediately able to initiate a discussion with experts on the topic.

Expert Peer Review Comments

Dr. Lewis Nelson of NYU was able to clarify that by prioritizing serum alkalinization, we will avoid the cerebral toxicity that is the primary etiology of mortality. Serum alkalinization should also facilitate urine alkalinization as well as allow time to arrange for hemodialysis. Dr. Bram Dolcourt from Detroit expanded that serum alkalinization and normokalemia alone do not guarantee an optimal urine pH and suggest measurement of both urine and serum. From Twitter, Dr. David Juurlink from Toronto also recommended measurement of both, stating his forthcoming publication will expand on the topic. Our own ALiEM clinical pharmacist Dr. Bryan Hayes also assisted with expert insight as I was revising the PV card.

My Reflections

As the ALiEM-CORD virtual fellow, I have had the challenging task of collaborating with experts in my field, while still very much in a learner role myself. I was fortunate enough to have been featured on a site that has a robust commenting system and pride in peer review, even if it is post-publication. There is certainly content on the web that may be inaccurate or ‘less-accurate’, and consumers of both FOAM and conventional publications, as always, should remain critical and review multiple sources. There is a broad range in teaching and practice based on region, and when we work together we can identify what is truly best practice. Hopefully this conversation and the forthcoming publication on the topic will translate into changes in practice and in the textbooks in the coming years. Luckily, utilizing the strengths of our medium, we are able to publish these corrections today.

PV Card: Acute Salicylate Toxicity

For those curious, here was the original version 1.

By Sam Shaikh, DO|2021-10-05T12:51:20-07:00Jun 15, 2015|ALiEM Cards, Expert Peer Reviewed (Clinical), Medical Education, Social Media & Tech, Tox & Medications|

Ultrasound For The Win! Case – 101M with Altered Mental Status #US4TW

Welcome to another ultrasound-based case, part of the “Ultrasound For The Win” (#US4TW) Case Series. In this peer-reviewed case series, we focus on real clinical cases where bedside ultrasound changed management or aided in diagnoses. In this case, a 101-year-old man presents after being found down with altered mental status.

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By Jeffrey Shih, MD, RDMS|2017-07-19T00:07:20-07:00May 20, 2015|Cardiovascular, Expert Peer Reviewed (Clinical), Ultrasound, Ultrasound for the Win|

Ketamine for Excited Delirium Syndrome

Excited delirium syndrome is defined as “a syndrome of uncertain etiology characterized by delirium, agitation, and hyperadrenergic autonomic dysfunction”.¹ You may have encountered a patient like this in the ED or prehospital setting. Although the etiology is impossible to determine in many cases, stimulant abuse and other drugs are involved in a majority of cases. An 8% mortality has been ascribed to Excited Delirium Syndrome, resulting from hyperthermia, severe metabolic acidosis, and cardiovascular collapse.

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2017-10-25T08:21:33-07:00May 18, 2015|Expert Peer Reviewed (Clinical), Neurology, Tox & Medications|

Trick of the Trade: IV-Push Antibiotics in the ED

Limited intravenous access is a common conundrum in the Emergency Department, with heavy implications for medication administration. Of particular concern, are the profoundly septic patients that necessitate multiple timely therapies, which require tying up a line – fluids, pressors, several antibiotics, etc. The shift away from less central line (i.e. triple lumen) placement for initial resuscitation, may serve to further exacerbate this issue.

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By Adam Spaulding, PharmD BCPS|2019-04-06T00:40:49-07:00May 11, 2015|Expert Peer Reviewed (Clinical), Tox & Medications|

Vancomycin Loading Doses in Pediatric Patients: A Missed Opportunity?

In January 2014, ALiEM featured a must-read post by Bryan Hayes regarding proper dosing of vancomycin in the emergency department, including a special note related to the recommendations regarding consideration of loading doses of vancomycin ranging from 25 to 30 mg/kg in adult patients who are critically ill with a high suspicion for MRSA infection.

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By Nadia Awad, PharmD, BCPS|2016-12-19T15:22:24-08:00May 4, 2015|Expert Peer Reviewed (Clinical), Pediatrics, Tox & Medications|

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