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INSIDE

Financial Disclosure: The following individuals disclose that they have no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study: Arthur R. Derse, MD, JD, FACEP (Physician Editor); Stacey Kusterbeck (Contributing Editor); Shelly Morrow Mark (Executive Editor); Jonathan Springston (Associate Managing Editor), and Kay Ball, RN, PhD, CNOR, FAAN, (Nurse Planner).

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MARCH 2016 Vol. 27, No. 3; p. 25-36

TM

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

It 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.

“The burden of proof rests with the plaintiff,” Zafren says.

The 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,’” Zafren adds.

It is generally easier for a plaintiff’s attorney to establish causation in cases of commission, where it’s alleged that the EP did something that harmed the

patient, than in cases of omission, where it’s alleged that the EP’s failure to do something harmed the patient, Zafren says.

“The defendant’s attorney can still claim that there were mitigating factors,” he explains.

There are two common mitigating factors: delay in the patient’s presenta-tion and the seriousness of the patient’s condition.

“These 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.

“The defendant’s attorney can argue that the condition was so serious at the time of initial presentation, that the EP could not have done anything to prevent the patient’s inevitable death,” Zafren says.

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CME/CE18

Vol. 23, Issue 12, March 2016AHCMedia.com

[INSIDE]

Financial Disclosure: Critical Care Alert’s Editor Betty Tran, MD, MSc, Nurse Planner Jane Guttendorf, DNP, RN, CRNP, ACNP-BC, CCRN, Peer Reviewer William Thompson, MD, Executive Editor Leslie Coplin, and Associate Managing Editor Jonathan Springston report no financial relationships relevant to this field of study.

New Insights Into Alveolar Mechanics and Gas Exchange

page 92

Rapid Response System and Real-time Automated Clinical Alerts

page 93

Saline vs Buffered Crystalloid

page 94

SPECIAL FEATURE

Swallowing Dysfunction in Critical IllnessBy Jane Guttendorf, DNP, CRNP, ACNP-BC, CCRNAssistant Professor, Acute & Tertiary Care, University of Pittsburgh, School of Nursing

Dr. Guttendorf reports no financial relationships relevant to this field of study.

Impaired swallowing in patients with critical illness is estimated to occur in about 10-93% of patients.1-6 The 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.5,6 Patients 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, and Parkinson’s disease), cognitive dysfunction (e.g., Alzheimer’s disease and other dementias, psychiatric diagnoses), and preexisting physical conditions (e.g.,

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 as delirium, weakness, and deconditioning), survivors of multiple system organ failure, sepsis, and particularly those experiencing prolonged intubation (usually defined as ≥ 7 days) are at

CME/CE27

Vol. 11, Issue 1, March 2016AHCMedia.com

[INSIDE]

Evidence-Based Information for HospitalistsIntensivists, and Acute Care Physicians

Financial Disclosure: Hospital Medicine Alert’s Physician Editor, Kenneth P. Steinberg, MD, Peer Reviewer Rachael Safyan, MD, Managing Editor Jill Drachenberg, and Associate Managing Editor Dana Spector have no relevant relationship related to the material presented in this issue.

Early Chest CT Can Improve Treatment for Community-acquired Pneumoniapage 3

Blood Transfusion in Cardiac Disease Patients

page 4

Fecal Microbiota Transplantation:Patients Need No Convincing

page 5

ABSTRACT & COMMENTARY

Prescribers Are Continuing Opioids in Patients After OverdoseBy 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 Medicine 2016; 164:1-9.

Opioid 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 of continuation of opioids after overdose had not been characterized. This study analyzes opioid use and subsequent overdoses after patients being treated for non-cancer pain present to an emergency department

(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.

This study identified 14,725 patients, age 18-64, who had an opioid (index) overdose requiring an inpatient stay or an ED visit. Patients were excluded if they weren’t enrolled 90 days prior to the initial

CME27

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 (editor), Ms. Fessler (nurse planner), Dr. Hanlon (author), Dr. Black (author), Dr. Werman (peer reviewer), Ms. Mark (executive edi-tor), Ms. Leslie Coplin (executive editor), and Mr. Landenberger (editorial and continuing education director) report no financial relationships with companies related to the field of study covered by this CME/CE activity.

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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.

HistoryIn 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. The 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.1 The 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%.2,3 The 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. These scenarios are reviewed below.

Cervical Spine InjuryA standard principle is that all trauma patients have the potential for a

cervical spine injury and should be managed as if one is present until proven otherwise. However, even in Level 1 Trauma Centers, only 4% of patients with major trauma have cervical spine fractures.4 Clinical decision tools, such as the NEXUS Criteria or the Canadian C-Spine Rules, can be used in selected patients to exclude a clinically relevant cervical spine fracture without

CME/CE72

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.

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Electrical and Lightning Injuries

Electrical InjuriesAlthough 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.

EpidemiologyElectrical injuries (both low and high voltage) account for approximately

1000 deaths per year in the United States.1,2 Low-voltage injuries are sustained predominantly by children and high-voltage injuries by young adults in occupa-tional exposures. The overall mortality rate is 3% to 5%.1,2 Among 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. The “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.1 When 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 high and low voltage, low voltage can be further subdivided into low voltage and intermediate voltage. Intermediate voltage is defined from 600 to 1000 V. Intermediate voltage is used in some train systems, such as the third rail in sub-way systems.4

In the human body, resistance is impedance to the flow of electrons based on the electrolyte and water content of tissues. Nerves, blood, mucous membranes, and muscles have low resistance and therefore conduct electricity well, while bones, fat, and tendons have high resistance and do not conduct electricity.

CME/CE18

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

To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, we disclose that Dr. Dietrich (editor), Dr. Skrainka (CME question reviewer), Ms. Wurster (nurse planner), Dr. Sawaya (author), Dr. Ravandi (author), Dr. Haines (peer reviewer), Ms. Coplin (executive editor) and Ms. Mark (executive editor) report no relationships with companies related to the field of study cov-ered by this CME activity.

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Fluids and Electrolyte Management, Part 1: Fluids,

Dehydration, and Sodium Homeostasis

Disorders of Fluids in Children Normal Fluid Requirements in Children. The 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. The 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).The 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. This 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. This combination of elevated ADH levels and hypotonic intravenous (IV) fluids results in hyponatremia.2 Hospital-acquired hyponatremia has led to significant neurologic sequelae such as coma and death.3 Evidence from systematic reviews and meta-analyses shows that

We Need Your Help!The Pediatric Emergency Medicine Reports editors are planning topics for 2016 issues and would like your feedback on topics recently covered. Please help us by answering two questions at the following link: https://www.surveymonkey.com/r/PDMR2016. Thank you for your help!

CME/CE36

INSIDE

Financial Disclosure: Author Dorothy Brooks, Executive Editor Shelly Morrow Mark, Associate Managing Editor Jonathan Springston, and Nurse Planner Diana S. Contino report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Executive Editor James J. Augustine discloses he is a stockholder in EMP Holdings and U.S. Acute Care Solutions and is a retained consultant for Masimo. Caral Edelberg, guest columnist, discloses that she is a stockholder in Edelberg Compliance Associates.

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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 diversionHospital leaders pledge to make a ban on diversions stick, but some outsiders question whether a voluntary pact will work

Most 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 they don’t have the capacity or staff to accommodate incoming ambulance traffic. A handful of communities have determined that ambulance diversion is a practice they can do without. At

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-tem called a meeting in late November [2015], and said that this was really not working well for them,” explains Alfred Connors, MD, chief clinical officer for MetroHealth Medical Center, one of

CME/CE15

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