EMFULL THE ALL-INCLUSIVE DIGITAL EMERGENCY CARE LIBRARY Administrative and CME/CE Features Advanced Administrative Functionality On demand member usage statistics and credit letter access, advanced reporting capabilities facilitate filtering by member, date range, and credit type. Access to 200+ CME/CE Credits Annually Easy CE/CME Testing Members take tests online at any time and receive credit letters instantly upon completion. Credit Letters On-Demand Each member’s testing history is conveniently stored online. Credit letters can either be printed by a single activity or a series. Website Features Responsive website design allows for easy access across all devices. Online Archives Access information from 1997-present in chronological order or by keyword search. Download and/or print articles for offline learning. Enhanced search function that allows you to search only within your subscribed content or throughout AHC Media’s entire library of published content. 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To learn more, visit AHCMedia.com or call 866-213-0844 INSIDE MARCH 2016 Vol. 27, No. 3; p. 25-36 States vary on what can be brought in as causation evidence 27 New research reveals ED practices linked to misdiagnosed abdominal pain 28 Factors that determine if missed diagnosis case is defensible 30 Common practices that put ED patients at risk in waiting rooms 31 Why a claim against an EP involving a knee injury was quickly settled 33 EDs slow on crowding interventions 34 How plaintiff could successfully argue ED was unprepared for mass shooting 35 Plaintiff Attorney Could Have Tough Time Proving Causation in ED Med/Mal Suit I t is often very difficult for the plain- tiff’s attorney to prove causation — one of the four elements of a medical malpractice claim, along with duty, breach, and damages — against an emer- gency physician (EP), says Ken Zafren, MD, FAAEM, FACEP, EMS medical director for the state of Alaska and clini- cal professor in the Department of Emer- gency Medicine at Stanford University Medical Center. “e burden of proof rests with the plaintiff,” Zafren says. e plaintiff’s attorney must prove that the EP breached the standard of care, and that the breach caused the al- leged damages. “A common way of stating this is, ‘But for the physician’s breach of the standard of care, the patient would not have sustained the alleged damages,’” patient, than in cases of omission, where it’s alleged that the EP’s failure to do something harmed the patient, Zafren says. “e defendant’s attorney can still claim that there were mitigating factors,” he explains. ere are two common mitigating factors: delay in the patient’s presenta- tion and the seriousness of the patient’s condition. “ese sometimes occur together,” Zafren notes. “A case in which the pa- tient had a critical illness or injury that led to major morbidity or death can pose great difficulty for a plaintiff’s attorney.” In cases of serious conditions causing death, the mitigating factor is sometimes referred to as the “dead man (or woman) walking” defense. “e defendant’s attorney can argue CME/CE 18 Vol. 23, Issue 12, March 2016 AHCMedia.com SPECIAL FEATURE Swallowing Dysfunction in Critical Illness By Jane Guttendorf, DNP, CRNP, ACNP-BC, CCRN Assistant Professor, Acute & Tertiary Care, University of Pittsburgh, School of Nursing Dr. Guttendorf reports no financial relationships relevant to this field of study. I mpaired swallowing in patients with critical illness is estimated to occur in about 10-93% of patients.1-6The sequela of impaired swallow- ing is aspiration, either overt or silent, with result- ing risks for pneumonia, pneumonitis, acute lung injury, reintubation, malnutrition, and dehydration. Swallowing dysfunction is associated with increased length of stay and poor patient outcomes.5,6Patients documented to have swallowing dysfunction incur additional risks related to placement of feeding tubes (nasogastric, nasoduodenal, percutaneous endoscopic gastrostomy) and prolonged enteral nutrition, which may further contribute to aspira- tion risk. Swallowing dysfunction after critical illness is in part due to conditions present prior to ICU admis- sion, including neuromuscular disorders (e.g., amyo- trophic lateral sclerosis, cerebral palsy, multiple sclerosis, myasthenia gravis, muscular dystrophy, head and neck cancer, esophageal disorders). The elderly are more likely to experience swallowing difficulty. In one study of critically ill elderly pa- tients intubated for ≥48 hours, researchers detected aspiration in 52% of patients (age > 65 years) as compared to 36% of patient controls (age < 65 years), and the elderly continued to exhibit persis- tent swallowing deficits at 2 weeks. In a multivariate analysis, only preadmission functional status was a determinant of delayed resolution of swallowing deficit (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.26-3.97).3 Additional factors related to the etiology for ICU admission and the course of critical illness may contribute to the development of subsequent swallowing dysfunction. For example, patients suffering stroke, facial burns or inhalation injury, trauma, acute alterations of mental status (such CME/CE 27 Vol. 11, Issue 1, March 2016 AHCMedia.com Evidence-Based Information for Hospitalists Intensivists, and Acute Care Physicians ABSTRACT & COMMENTARY Prescribers Are Continuing Opioids in Patients After Overdose By Deborah J. DeWaay, MD, FACP Associate Professor, Medical University of South Carolina, Charleston, SC Dr. DeWaay reports no financial relationships in this field of study SYNOPSIS: Most opioid prescriptions are continued after a patient overdoses accidentally, and these patients are at higher risk for a recurrent overdose compared to those who have their prescriptions stopped. SOURCE: Larochelle M, Leibschutz J, Zhang F, Ross-Degnan D, Wharam J. Opioid Prescribing After a Nonfatal Overdose and Association with Repeated Overdose. Annals of Internal Medicine2016; 164:1-9. O pioid use to treat non-cancer pain has been on the rise for several decades. In turn, there has been a significant rise in opioid addiction, overdoses and deaths. The number of emergency room visits because of nonmedical use of opioids was over 300,000 in 2008, double the amount in 2003. Patients with opioid overdose are more likely to have an opioid use disorder or to have a high opioid dose prescribed to them. Although opioid overdose and misuse is an indication to stop long-term opioid therapy, the effects (ED) or are admitted inpatient for an opioid overdose. This retrospective study used the Optum database to select a cohort of patients that had a non-fatal opioid overdose while being treated with long-term opioids. This database included pharmacy, inpatient, and outpatient records of over 50 million patients from 50 states who have coverage through a major U.S. health insurance company. The cohort was sampled from records between May 2000 and December 2012. The patients had a median follow up of 15 months. CME 27 MARCH 1, 2016 VOL. 37, NO. 5 AUTHORS Dennis Hanlon, MD, Emergency Medicine Attending, Quality Site Director, Allegheny General Hospital, Pittsburgh, PA. Kirby Black, MD, Emergency Medicine, Allegheny General Hospital, Pittsburgh, PA. PEER REVIEWER Howard A. Werman, MD, FACEP, Professor of Emergency Medicine, Vice Chair of Academic Affairs, Medical Director, MedFlight, Ohio State University, Columbus. STATEMENT OF FINANCIAL DISCLOSURE To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, we disclose that Dr. Farel (CME question reviewer) owns stock in Johnson & Johnson. Dr. Stapczynski (editor) owns stock in Pfizer, Johnson & Johnson, Walgreens Boots Alliance Inc., GlaxoSmithKline, Bristol Myers Squibb, and AxoGen. Dr. Schneider Emergency Airway Management: A Targeted Review of Difficult Trauma Situations Introduction Airway management is one of the cornerstones of emergency medicine prac- tice and resuscitation. After a brief review of the history of airway management in trauma patients, this article will discuss the literature concerning several dif- ficult clinical scenarios. Although these patients will most often eventually be transferred to a trauma center, a difficult or failed airway initially can present to any emergency department, and can be extremely challenging. An emergency clinician must have a strategy for these situations based on clinical skills, avail- able devices, urgency of the situation, and potential consultants, if any. History In the United States, the care of trauma patients has evolved into special- ized, regional trauma centers. However, major trauma can occur anywhere, so all emergency departments must be able to provide initial stabilization of the sick trauma patient. e first priority in stabilization starts with assessment and management of the airway. As recently as the mid-1980s, Advanced Trauma Life Support (ATLS) advocated blind nasotracheal intubation as the preferred method of definitively controlling the airway in trauma patients without con- traindications because of concern about cervical spine movement. Currently, the recommended trauma airway management is oral endotracheal intubation with in-line cervical stabilization using rapid sequence induction to optimize intubating conditions.1e success rate with this strategy is very high, and the necessity of emergent cricothyrotomy has significantly decreased. In fact, the failure rate of rapid sequence intubation in the emergency department is approximately 1%.2,3e debate between direct visualization with standard laryngoscopy and video laryngoscopy is ongoing. Despite the high success rate, there are certain circumstances in the management of trauma patients that may require adjustments to this strategy. ese scenarios are reviewed below. CME/CE 72 MARCH/APRIL 2016 VOL. 17, NO. 2 AUTHORS Feras Khan, MD, Clinical Assistant Professor, University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore. Christina Tupe, MD, University of Maryland, Department of Emergency Medicine, Baltimore. PEER REVIEWER Dennis Hanlon, MD, FAAEM, Associate Professor of Emergency Medicine, Quality Site Director, Allegheny General Hospital, Pittsburgh, PA. STATEMENT OF FINANCIAL DISCLOSURE To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, Dr. Dietrich (editor in chief), Dr. Khan (author), Dr. Tupe (author), Dr. Hanlon (peer reviewer), Ms. Behrens (nurse reviewer), Ms. Mark (executive editor), Leslie Coplin (executive editor), and Mr. Landenberger (continuing education and editorial director) report no relationships with companies related to this field of study. Electrical and Lightning Injuries Electrical Injuries Although electrical injuries are rare, patients who present with these injuries to emergency departments pose particular challenges to emergency physi- cians and trauma surgeons. Electrical injuries can cause a spectrum of disease, from minor burns to significant injuries and multi-organ system dysfunction. Children and the working young are most commonly affected. Epidemiology Electrical injuries (both low and high voltage) account for approximately 1000 deaths per year in the United States.1,2Low-voltage injuries are sustained predominantly by children and high-voltage injuries by young adults in occupa- tional exposures. e overall mortality rate is 3% to 5%.1,2Among patients who survive to hospitalization, the most common causes of death are multi-organ failure and infection. Patients with larger burns have a higher mortality rate, have a longer length of stay in the hospital, and are more likely to require inten- sive care, need intubation, and have renal failure requiring dialysis.3 Pathophysiology Electricity is the flow of electrons, expressed as current. Current is equal to voltage divided by resistance. Current, measured in amperes, expresses the amount of energy that flows through the body. It becomes perceptible at approximately 1 milliampere (mA); the safe range for human exposure is 0.2 to 0.4 mA. e “let-go” current (the maximum current that a person can grasp and release prior to the onset of muscle tetany) is 6 to 9 mA for adults and 3 to 5 mA for children.1When the “let-go” level is exceeded, tetanic contractions of the flexors of the hand, for example, grasp firmly on the electrical source, not allowing the patient to “let go.” High voltage is defined as more than 1000 volts (V). High-voltage injuries typically occur in occupational settings and in situations involving high-tension power lines. (See Table 1.) Low-voltage injuries are usually associated with household electricity, which in the United States is 110 V for general appli- ances and 240 V for high-powered appliances. Although generally divided into CME/CE 18 EMFULL INCLUDES: March 2016 VOL. 21, NO. 3 AUTHORS Rasha D. Sawaya, MD, Assistant Professor of Pediatrics and Emergency Medicine, George Washington University Medical Center, Washington DC; Attending Physician, Children’s National Health Systems, Washington, DC Bahareh Ravandi, MD, Pediatric Resident, Children’s National Health Systems, Washington, DC PEER REVIEWER Christopher J. Haines, DO, FAAP, FACEP, Chief Medical Officer, Children’s Specialized Hospital, New Brunswick, NJ; Associate Professor of Pediatrics and Emergency Medicine, Drexel University College of Medicine; Attending Physician, St. Christopher’s Hospital for Children, Philadelphia, PA STATEMENT OF FINANCIAL DISCLOSURE Fluids and Electrolyte Management, Part 1: Fluids, Dehydration, and Sodium Homeostasis Disorders of Fluids in Children Normal Fluid Requirements in Children. e unique physiology of children results in relatively higher fluid requirements for children than adults. Infants and young children have a greater surface area to weight ratio, which means proportion- ally larger insensible losses. In addition, children may be less likely to hydrate them- selves depending on their developmental level. Maintenance fluid requirements are based on expenditure, which is proportional to surface area. When calculating maintenance fluid requirements, weight is used as a surrogate for surface area. e ratio of surface area to weight for babies is greater than for older children, which explains the need for proportionally more fluid for the first 20 kg of weight. Maintenance fluid requirements are calculated based on the Holliday-Segar formula1: • 100 mL/kg/d for the first 10 kg (roughly 4 mL/kg/hr); • 50 mL/kg/d for the second 10 kg (roughly 2 mL/kg/hr); • 20 mL/kg/d for the rest of the weight of the child (roughly 1 mL/kg/hr). e following 4:2:1 formula is used to rapidly calculate a child’s maintenance fluid requirements: For example, a 12 kg child would require: (4 x 10 kg) + (2 x 2 kg) = 44 mL/kg/hr of maintenance fluid. Traditionally, the use of hypotonic fluids, such as dextrose 5% with 0.25% normal saline (D5 ¼ NS) for infants and dextrose 5% with 0.5% normal saline (D5 ½ NS) for older children, was recommended. is was based on calculations of electrolyte requirements and caloric expenditures. However, more recent evidence from com- mon clinical scenarios in hospitalized children, such as respiratory illness, central nervous system disturbances, pain, and emesis, show an increase in antidiuretic hormone (ADH) levels, which leads to free water retention. is combination of elevated ADH levels and hypotonic intravenous (IV) fluids results in hyponatremia.2 CME/CE 36 INSIDE MARCH 2016 Vol. 28, No. 3; p. 25-36 How do you put patients at the center of the discharge planning process? See what CMS has in mind 30 It’s true: Drug shortages worsening 32 Coding Update: See how policy changes on observation will affect emergency medicine in 2016 33 Cleveland hospitals increase capacity, hire additional staff to help end ambulance diversion Hospital leaders pledge to make a ban on diversions stick, but some outsiders question whether a voluntary pact will work M ost EDs have some experi- ence with ambulance diver- sion, the practice of turning away ambulances for a period of time so that emergency staff can better manage surges in demand. However, while this tactic may help clinicians better care for patients who are already in the ED, few argue with the notion that diversion likely delays care for incoming patients who must now travel to a second- or third-choice facility that may be far- ther away. Further, there is no question that delays in care can adversely affect outcomes, and cause problems for EMS providers as well as other hospitals in the area that must pick up the slack. In short, nobody likes diversion, and yet the practice persists in many communities around the country when ED administrators determine that least some of these efforts have clearly demonstrated that when the issue is addressed collectively as a community, diversion can not only be eliminated, but looking more closely at the problem can also force hospitals to finally address the deeper throughput issues that often prompt the need for diversion in the first place. (See also: “Cleveland can learn from Boston,” page 28.) Consider effect on incoming patients Hospital leaders in Cleveland are the latest to come to the realization that ambulance diversion must end, and that they have the tools and the capacity to make it happen. “Our local emergency transport sys- CME/CE 15 Want to learn more? 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