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SAEM Clinical Image Series: The Hemorrhaging Bifurcated Tongue

bifurcated tongue

A 26-year-old male with no past medical history presented to the emergency department for tongue bleeding for one day. Five days prior he had an elective cosmetic tongue bifurcation completed out-of-state. About two hours prior to arrival, he had been using a swish-and-spit saltwater rinse when he felt a suture break. Ever since he has had copious bleeding, reportedly filling his sink at home with blood. Additionally, he had about 250 milliliters of blood, including large clots, in a container in the emergency department. He denied using any blood thinners. There was no syncope, dizziness, chest pain, nausea, vomiting, shortness of breath, pain of the tongue, or numbness of the tongue. He had some difficulty speaking but said it was due to needing to retrain his bifurcated tongue.

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By |2020-12-20T20:16:29-08:00Dec 21, 2020|Academic, Emergency Medicine, ENT, SAEM Clinical Images|
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SAEM Clinical Image Series: Shortness of Breath

buffalo syndrome

A 60-year-old female presented to the emergency department (ED) for respiratory distress. Emergency medical services reports that the patient was in respiratory distress upon arrival, slowly becoming unresponsive en-route. They started the patient on continuous positive airway pressure, but she lost consciousness with oxygen saturation in the thirties and they switched to bag valve mask (BVM) ventilation, which improved saturations up to 100 percent. Narcan was administered without improvement as she was on narcotics following bronchoscopy earlier today at an outside hospital.

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By |2021-01-18T19:30:33-08:00Dec 21, 2020|Academic, Emergency Medicine, Pulmonary, SAEM Clinical Images|
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SAEM Clinical Image Series: Oral Trauma and Mass

oral mass

A 38-year-old African American male without a significant past medical history presented with an oral mass. He was struck on the mouth by a wrench handle about two prior. Since then he has had a growing mass originating from the gum of his left front upper teeth. He is no longer able to eat solid foods and has to use a straw for all oral intake. The patient denies fevers, chest pain, shortness of breath, and weight loss.

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By |2020-12-11T15:18:37-08:00Dec 14, 2020|Academic, ENT, SAEM Clinical Images|
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SplintER Series: My Knee, Again!

posterior tibiofemoral dislocation knee dislocation

A 61-year-old F presents to the ED from the orthopedic clinic with acute right knee pain. She endorses that while a physical exam was being performed, she had sudden onset knee pain. Denies any trauma to the knee, radiation of pain, numbness, tingling, or swelling. The above knee radiographs were obtained (Images courtesy of John Kiel, DO).

 

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By |2020-12-04T20:18:29-08:00Dec 9, 2020|Expert Peer Reviewed (Clinical), Orthopedic, SplintER|
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ACEP E-QUAL: ACEP Non-STEMI Clinical Policy

Clinical Policy

In 2018, the American College of Physicians (ACEP) released a Clinical Policy with management recommendations for patients presenting to the emergency department (ED) with concern for non-ST-elevation myocardial infarction (NSTEMI). Dr. Jason Woods hosted an episode of the ACEP E-QUAL Network podcast highlighting key aspects of the new policy. Dr. Woods was joined by lead writer Dr. Christian Tomaszewski from the University of California San Diego, and Dr. Michael Ross, Director of the Chest Pain Center at Emory University. Below are show notes reviewing the recommendations and the process involved in creating the clinical policy.

 

How is a clinical policy different than a practice guideline?

The National Guideline Clearinghouse (NGC), a public resource initiative of the Agency for Healthcare Research and Quality (AHRQ), provides rules and frameworks for evidence-based clinical practice guidelines. ACEP refers to clinical practice guidelines in Emergency Medicine (EM) as policies to denote the more prescriptive design process.

What was the process of drafting the policy?

Development of the 2018 ACEP NSTEMI Clinical Policy was a 2-year “labor of love.” Writers, methodologies, and committee members were required to be free from both financial and intellectual conflict of interest.

The clinical policy is a result of a systematic review and critical analysis of available medical literature. Clinical studies were graded on robustness, design, and class of evidence according to the ACEP policy development process which includes internal and external review.

Recommendations were categorized as reflecting high clinical certainty (Level A), moderate clinical certainty (Level B), or mixed clinical certainty (Level C) due to the heterogeneity of results, unclear effect magnitude, bias, among other factors.

What questions did the policy address?

Four critical questions were decided by consensus methods to address the evaluation and management of adult patients presenting to the ED with concern for NSTEMI.

1) If ST-elevation myocardial infarction is excluded, can a combination of bedside and laboratory evaluation in the ED identify patients at low risk for major adverse cardiac events (MACE)?
Level B recommendation: History, ECG, Age, Risk Factors, Troponin (HEART) score < 3 can be used as a clinical prediction tool for a 30-day MACE miss rate between 0-2%.
Level C recommendation: Thrombolysis in Myocardial Infarction (TIMI) score can be used to predict risk of 30-day MACE.

2) Can repeat Troponin testing in the ED be used to identify patients at low risk for MACE?
Level C recommendations:

    • Conventional troponin testing at hour 0 and 3 in low risk (HEART score < 3) patients can predict and acceptable low risk for 30-day MACE.
    • A single high-sensitivity troponin less than the detectable limit on arrival to the ED or negative serial high-sensitivity troponin at hour 0 and 2 is predictive of a low rate of MACE.
    • Patients deemed to be low risk with a non-ischemic ECG and negative high-sensitivity troponin at 0 and 2 hours can be considered low risk for 30-day MACE, allowing for accelerated discharge from the ED.

3) In patients who have been ruled out for acute coronary syndromes (ACS), does advanced cardiac provocative testing prior to discharge from the ED reduce MACE?
Level B recommendation:  Do not routinely use advanced cardiac testing in low-risk patients who have been ruled out for ACS to further reduce 30-day MACE.
Level C recommendation: Arrange follow-up in 1-2 weeks for low-risk patients in whom ACS has been ruled out. If unable to arrange follow-up, consider observation and advanced testing prior to discharge.

4) Should patients with NSTEMI receive antiplatelet therapy in addition to aspirin in the ED?
Level C recommendation: P2Y12 inhibitors and glycoprotein IIb/IIIa inhibitors can be given in the ED or delayed until cardiac catheterization.

What questions remain?

  1. The clinical policy does not address the “delta factor” involved in assessing changes to the cardiac marker levels that may be seen with repeat testing at set time points.
  2. Duration of pain was not discretely addressed, and differences in real-world practice can exist depending on whether the time of onset or time of presentation is considered for defining repeat testing and observation length.
  3. Shared decision-making was not factored into the selection of management steps.

Important points for consideration:

The 2018 ACEP Clinical Policy for NSTEMI was written for the evaluation of patients with suspicion for ACS who presented with chest pain. It does not apply to those presentations of ACS that are considered atypical in nature.

Read a more in-depth summary of the ACEP Clinical Policy on ALiEM. 

Interested in more of the ACEP-EQUAL Podcast?

By |2021-09-15T11:34:21-07:00Dec 7, 2020|Academic, ACEP E-QUAL, Cardiovascular|
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ACEP E-QUAL: The Electronic ICU

 

eICU

Building on already increasing interest in telehealth, the COVID-19 pandemic accelerated the development and implementation of telemedicine services in a variety of clinical settings. In 2018, Dr. Jason Woods hosted an episode of the ACEP E-QUAL Network podcast highlighting the creation of an electronic intensive care unit (eICU) through Emory Healthcare. In this episode, Dr. Tim Buchman and Critical Care Nurse Cheryl Hiddelson share their innovative approach to delivering critical care services via telehealth. We present highlights from this discussion below.

 

 

What is an eICU?

The eICU allows for critical care oversight, without having to be on site. It provides comprehensive monitoring and data analysis and online audio or video support for patients and families. Utilizing advanced information technology (IT) platforms and approaching with a business strategy, telehealth allows for innovative ways to provide critical care services remotely.

Why is there a need for an eICU?

The US population is aging, with the number of Americans age 65 or older increasing steadily. Demand for critical care services increases with age. The availability of critical care physicians is limited in large areas of the US. Similarly, as more nurses are reaching retirement than those entering the workforce, critical care providers are becoming hard to come by. Recruiting and maintaining critical care providers is only one part of the issue, with staffing on nights, weekends, and holidays creating a constant challenge. Telehealth poses a contemporary solution to the scarcity of healthcare providers.

What does the eICU setup look like?

The eICU is akin to airline control towers. There is 24/7 coverage by nursing and physician staff, overseeing more than a hundred beds. Various screens facilitate a “sentry” role in which surveillance monitoring algorithms allow staff to detect problems possibly even before the bedside staff. The eICU integrates bedside monitor data with additional system-wide data to create different views of what is occurring in the unit being monitored. Staff can track discharge readiness and filter lists by system or condition.

Camera sessions allow for bi-directional communication with patients and families, but also for just-in-time-training with staff as well as consultation with specialists.

What unique challenges has the eICU been able to address?

  • On-site advanced practice providers (APPs) such as physician assistants, nurse-practitioners, can be supervised by critical care nurses and physicians to provide in-person care.
  • Alternative staffing from geographic areas that are in a different time zone can help fill night shifts. The Emory group used travel nurses and physicians who were stationed in Australia.
  • Distance and delay to care become irrelevant when an intensivist can be available 24/7.

What benefits have been observed with the eICU?

The Emory eICU was able to realize decreased mortality, decreased transfer rates, decreased length of stay, and an increase in patient experience metrics for the hospitals it covered compared to other local facilities. Analysis of costs suggested savings of thousands of dollars per patient and increased revenue for small community hospitals that could retain and increase their daily census of critical care patients.

Can this concept be applied to Emergency Medicine?

There may be a role in applying telehealth data monitoring to emergency department waiting rooms in an attempt to identify patients at high risk for sudden deterioration or decompensation.

Interested in more ACEP-EQUAL podcasts?

Listen to the other ACEP E-QUAL podcasts on our Soundcloud account.

By |2020-12-03T19:56:27-08:00Dec 4, 2020|Academic, Critical Care/ Resus, Podcasts|
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