Diabetic ketoacidosis is an endocrine emergency. A subset of diabetic patients may present with relative euglycemia with acidosis, known as euglycemic diabetic ketoacidosis (EDKA), which is often ...misdiagnosed due to a serum glucose <250 mg/dL.
This narrative review evaluates the pathogenesis, diagnosis, and management of EDKA for emergency clinicians.
EDKA is comprised of serum glucose <250 mg/dL with an anion gap metabolic acidosis and ketosis. It most commonly occurs in patients with a history of low glucose states such as starvation, chronic liver disease, pregnancy, infection, and alcohol use. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, which result in increased urinary glucose excretion, are also associated with EDKA. The underlying pathophysiology involves insulin deficiency or resistance with glucagon release, poor glucose availability, ketone body production, and urinary glucose excretion. Patients typically present with nausea, vomiting, malaise, or fatigue. The physician must determine and treat the underlying etiology of EDKA. Laboratory assessment includes venous blood gas for serum pH, bicarbonate, and ketones. Management includes resuscitation with intravenous fluids, insulin, and glucose, with treatment of the underlying etiology.
Clinician knowledge of this condition can improve the evaluation and management of patients with EDKA.
Intubation is routinely performed in the emergency department, and rapid, accurate confirmation is essential to avoid potentially serious adverse outcomes. The number of studies assessing ...ultrasonography for the verification of endotracheal tube placement has expanded rapidly in recent years. We performed this systematic review and meta-analysis to determine the sensitivity and specificity of transtracheal ultrasonography for the verification of endotracheal tube location.
PubMed, the Cumulative Index of Nursing and Allied Health, Scopus, Latin American and Caribbean Health Sciences Literature database, the Cochrane databases, and bibliographies of selected articles were assessed for all prospective and randomized controlled trials evaluating the accuracy of transtracheal ultrasonography for identifying endotracheal tube location. Data were dual extracted into a predefined worksheet and quality analysis was performed with the Quality Assessment of Diagnostic Accuracy Studies–2 tool. Data were summarized and a meta-analysis was performed with subgroup analyses by location, specialty, experience, transducer type, and technique. Time to confirmation was assessed as a secondary outcome.
This systematic review identified 17 studies (n=1,595 patients). Overall, transtracheal ultrasonography was 98.7% sensitive (95% confidence interval CI 97.8% to 99.2%) and 97.1% specific (95% CI 92.4% to 99.0%), with a positive likelihood ratio of 34.4 (95% CI 12.7 to 93.1) and a negative likelihood ratio of 0.01 (95% CI 0.01 to 0.02). Subgroup analyses did not demonstrate a significant difference by location, provider specialty, provider experience, transducer type, or technique. Mean time to confirmation was 13.0 seconds.
Transtracheal sonography is rapid to perform, with an acceptable degree of sensitivity and specificity for the confirmation of endotracheal intubation. Ultrasonography is a valuable adjunct and should be considered when quantitative capnography is unavailable or unreliable.
COVID-19 is currently the third leading cause of death in the United States, and unvaccinated people continue to die in high numbers. Vaccine hesitancy and vaccine refusal are fueled by COVID-19 ...misinformation and disinformation on social media platforms. This online COVID-19 infodemic has deadly consequences. In this editorial, the authors examine the roles that social media companies play in the COVID-19 infodemic and their obligations to end it. They describe how fake news about the virus developed on social media and acknowledge the initially muted response by the scientific community to counteract misinformation. The authors then challenge social media companies to better mitigate the COVID-19 infodemic, describing legal and ethical imperatives to do so. They close with recommendations for better partnerships with community influencers and implementation scientists, and they provide the next steps for all readers to consider. This guest editorial accompanies the Journal of Medical Internet Research special theme issue, "Social Media, Ethics, and COVID-19 Misinformation."
Racial disparities in the United States healthcare system are well described across a variety of clinical settings. The ICU is a clinical environment with a higher acuity and mortality rate, ...potentially compounding the impact of disparities on patients. We sought to systematically analyze the literature to assess the prevalence of racial disparities in the ICU.
We conducted a comprehensive search of PubMed/MEDLINE, Scopus, CINAHL, and the Cochrane Library.
We identified articles that evaluated racial differences on outcomes among ICU patients in the United States. Two authors independently screened and selected articles for inclusion.
We dual-extracted study characteristics and outcomes that assessed for disparities in care (e.g., in-hospital mortality, ICU length of stay). Studies were assessed for bias using the Newcastle-Ottawa Scale.
Of 1,325 articles screened, 25 articles were included (n = 751,796 patients). Studies demonstrated race-based differences in outcomes, including higher mortality rates for Black patients when compared with White patients. However, when controlling for confounding variables, such as severity of illness and hospital type, mortality differences based on race were no longer observed. Additionally, results revealed that Black patients experienced greater financial impacts during an ICU admission, were less likely to receive early tracheostomy, and were less likely to receive timely antibiotics than White patients. Many studies also observed differences in patients' end-of-life care, including lower rates on the quality of dying, less advanced care planning, and higher intensity of interventions at the end of life for Black patients.
This systematic review found significant differences in the care and outcomes among ICU patients of different races. Mortality differences were largely explained by accompanying demographic and patient factors, highlighting the effect of structural inequalities on racial differences in mortality in the ICU. This systematic review provides evidence that structural inequalities in care persist in the ICU, which contribute to racial disparities in care. Future research should evaluate interventions to address inequality in the ICU.
Coronavirus disease of 2019 (COVID-19) has resulted in millions of cases worldwide. As the pandemic has progressed, the understanding of this disease has evolved.
This first in a two-part series on ...COVID-19 updates provides a focused overview of the presentation and evaluation of COVID-19 for emergency clinicians.
COVID-19, caused by Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), has resulted in significant morbidity and mortality worldwide. Several variants exist, including a variant of concern known as Delta (B.1.617.2 lineage) and the Omicron variant (B.1.1.529 lineage). The Delta variant is associated with higher infectivity and poor patient outcomes, and the Omicron variant has resulted in a significant increase in infections. While over 80% of patients experience mild symptoms, a significant proportion can be critically ill, including those who are older and those with comorbidities. Upper respiratory symptoms, fever, and changes in taste/smell remain the most common presenting symptoms. Extrapulmonary complications are numerous and may be severe, including the cardiovascular, neurologic, gastrointestinal, and dermatologic systems. Emergency department evaluation includes focused testing for COVID-19 and assessment of end-organ injury. Imaging may include chest radiography, computed tomography, or ultrasound. Several risk scores may assist in prognostication, including the 4C (Coronavirus Clinical Characterisation Consortium) score, quick COVID Severity Index (qCSI), NEWS2, and the PRIEST score, but these should only supplement and not replace clinical judgment.
This review provides a focused update of the presentation and evaluation of COVID-19 for emergency clinicians.
Rhabdomyolysis is a medical condition caused by muscle breakdown leading to potential renal damage. This can result in significant morbidity and mortality if not rapidly identified and treated.
This ...article provides an evidence-based narrative review of the diagnosis and management of rhabdomyolysis, with focused updates for the emergency clinician.
Rhabdomyolysis is caused by the breakdown of muscle cells leading to the release of numerous intracellular molecules, including potassium, calcium, phosphate, uric acid, and creatinine kinase. There are a number of potential etiologies, including exertion, extreme temperature changes, ischemia, infections, immobility, drugs, toxins, endocrine causes, autoimmune reactions, trauma, or genetic conditions. Findings can include myalgias, muscle weakness, or dark-colored urine, but more often include non-specific symptoms. The diagnosis is often determined with an elevated creatinine kinase greater than five times the upper-limit of normal. Severe disease may result in renal failure, electrolyte derangements, liver disease, compartment syndrome, and disseminated intravascular coagulation. Treatment includes addressing the underlying etiology, as well as aggressive intravenous hydration with a goal urine output of 300 mL/h. Bicarbonate, mannitol, and loop diuretics do not possess strong evidence for improved outcomes. Renal replacement therapy should be determined on a case-by-case basis. Most patients are admitted, though some may be appropriate for discharge.
Rhabdomyolysis is a potentially dangerous medical condition requiring rapid diagnosis and management that may result in significant complications if not appropriately identified and treated. Emergency clinician knowledge of this condition is essential for appropriate management.
Urolithiasis is a common condition in the U.S. Patients frequently present to the emergency department (ED) for care, including analgesia and treatments to facilitate stone passage.
With the new ...evidence concerning the evaluation and treatment of urolithiasis, this review summarizes current literature regarding the ED management of urolithiasis.
Urolithiasis occurs primarily through supersaturation of urine and commonly presents with flank pain, hematuria, and nausea/vomiting. History, examination, and assessment with several laboratory tests are cornerstones of evaluation. Urinalysis is not diagnostic, but it may be used in association with other assessments. Risk assessment tools and advanced imaging can assist with diagnosis. Computed tomography (CT) is often considered the gold standard. Newer low-dose CT imaging may reduce radiation. Recent studies support ultrasound as an alternate diagnostic modality, especially in pediatric and pregnant patients. Nonsteroidal anti-inflammatory drugs remain first-line therapy, with opioids or intravenous lidocaine reserved for refractory pain. Tamsulosin can increase passage in larger stones but has not demonstrated benefit in smaller stones. Nifedipine and intravenous fluids are not recommended to facilitate passage. Surgical intervention is based upon stone size, duration, and modifying factors. Patients who are discharged should be advised on dietary changes.
Urolithiasis is a common disease increasing in prevalence with the potential for significant morbidity. Focused evaluation with history, examination, and testing is important in diagnosis and management. Understanding the clinical features, risk assessment tools, imaging options, and treatment options can assist emergency physicians in the management of urolithiasis.
Context
There have been significant advances in competency‐based medical education (CBME) within health professions education. While most of the efforts have focused on competency, less attention has ...been paid to the role of confidence as a factor in preparing for practice. This paper seeks to address this deficit by exploring the role of confidence and the calibration of confidence with regard to competence.
Methods
This paper presents a conceptual review of confidence and the calibration of confidence in different medical education contexts. Building from an initial literature review, the authors engaged in iterative discussions exploring divergent and convergent perspectives, which were then supplemented with targeted literature reviews. Finally, a stakeholder consultation was conducted to situate and validate the provisional findings.
Results
A series of axioms were developed to guide perceptions and responses to different states of confidence in health professionals: (a) confidence can shape how we act and is optimised when it closely corresponds to reality; (b) self‐confidence is task‐specific, but also inextricably influenced by the individual self‐conceptualisation, the surrounding system and society; (c) confidence is shaped by many external factors and the context of the situation; (d) confidence must be considered in conjunction with competence and (e) the confidence‐competence ratio (CCR) changes over time. It is important to track learners’ CCRs and work with them to maintain balance.
Conclusion
Confidence is expressed in different ways and is shaped by a variety of modifiers. While CBME primarily focuses on competency, proportional confidence is an integral component in ensuring safe and professional practice. As such, it is important to consider both confidence and competence, as well as their relationship in CBME. The CCR can serve as a key construct in developing mindful and capable health professionals. Future research should evaluate strategies for assessing CCR, identify best practices for teaching confidence and guiding self‐calibration of CCR and explore the role of CCR in continuing professional development for individuals and teams.
@MGottliebMD @TChanMD @fzaver @drellaway review the concepts of confidence, competence, and the intersectionality between the two in this 'State of the Science' paper on "Self" in medical education.
Acute Pancreatitis: Updates for Emergency Clinicians Waller, Anna; Long, Brit; Koyfman, Alex ...
The Journal of emergency medicine,
December 2018, 2018-Dec, 2018-12-00, 20181201, Letnik:
55, Številka:
6
Journal Article
Recenzirano
Acute pancreatitis is a frequent reason for patient presentation to the emergency department (ED) and the most common gastrointestinal disease resulting in admission. Emergency clinicians are often ...responsible for the diagnosis and initial management of acute pancreatitis.
This review article provides emergency clinicians with a focused overview of the diagnosis and management of pancreatitis.
Pancreatitis is an inflammatory process within the pancreas. While the disease is often mild, severe forms can have a mortality rate of up to 30%. The diagnosis of pancreatitis requires two of the following three criteria: epigastric abdominal pain, an elevated lipase, and imaging findings of pancreatic inflammation. The most common etiologies include gallbladder disease and alcohol use. After the diagnosis has been made, it is important to identify underlying etiologies requiring specific intervention, as well as obtain a right upper quadrant ultrasound. The initial management of choice is fluid resuscitation and pain control. Recent data have suggested that more cautious fluid resuscitation in the first 24 h might be more appropriate for some patients. Intravenous opiates are generally safe if used judiciously. Appropriate disposition is a multifactorial decision, which can be facilitated by using Ranson criteria or the Bedside Index of Severity in Acute Pancreatitis score. Complications, though rare, can be severe.
Pancreatitis is a potentially deadly disease that commonly presents to most emergency departments. It is important for clinicians to be aware of the current evidence regarding the diagnosis, treatment, and disposition of these patients.
Toxic shock syndrome (TSS) is a severe, toxin-mediated illness that can mimic several other diseases and is lethal if not recognized and treated appropriately.
This review provides an emergency ...medicine evidence-based summary of the current evaluation and treatment of TSS.
The most common etiologic agents are Staphylococcus aureus and Streptococcus pyogenes. Sources of TSS include postsurgical wounds, postpartum, postabortion, burns, soft tissue injuries, pharyngitis, and focal infections. Symptoms are due to toxin production and infection focus. Early symptoms include fever, chills, malaise, rash, vomiting, diarrhea, and hypotension. Diffuse erythema and desquamation may occur later in the disease course. Laboratory assessment may demonstrate anemia, thrombocytopenia, elevated liver enzymes, and abnormal coagulation studies. Diagnostic criteria are available to facilitate the diagnosis, but they should not be relied on for definitive diagnosis. Rather, specific situations should trigger consideration of this disease process. Treatment involves intravenous fluids, source control, and antibiotics. Antibiotics should include a penicillinase-resistant penicillin, cephalosporin, or vancomycin (in methicillin-resistant S. aureus prevalent areas) along with either clindamycin or linezolid.
TSS is a potentially deadly disease requiring prompt recognition and treatment. Focused history, physical examination, and laboratory testing are important for the diagnosis and management of this disease. Understanding the evaluation and treatment of TSS can assist providers with effectively managing these patients.
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