J Emerg Med
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At our institution, there were a number of adverse patient events related to an unstable airway that led to the formation of a designated critical airway response team (CAT). It was hoped that this would improve patient outcomes in such matters. ⋯ The creation of a critical airway has been considered a success in terms of patient management at our institution. It has been most commonly used in the management of life-threatening angioedema in the ED.
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In 2007, an update was released to the pediatric and neonatal septic shock guidelines, which emphasized early use of therapies, specifically, first-hour fluid resuscitation and inotrope therapy. This has led to increased use of intraosseous (IO) access as a source of vascular access. Previously, IO access could be obtained only via a manual IO placement. New semi-automatic devices, such as EZ-IO(®) (Vidacare, Shavano Park, TX), allow for safer and quicker IO access. Data support the use of semi-automatic devices during the acute resuscitation period. ⋯ The patient was a 7-month old girl with VACTERL association (Vertebral defects, Anal atresia, Cardiac defects, Tracheo-Esophageal fistula, Renal anomalies, Limb abnormalities) and complex past medical history. The patient experienced a "choking episode," which led to subsequent apnea and cyanosis. The patient presented in shock to a local pediatric emergency department. After multiple unsuccessful intravenous line attempts, IO access was obtained using the EZ-IO(®). Once in the pediatric intensive care unit with venous access, the IO device was removed and the site had "red bulls-eye target shape" damage to the skin, which appeared consistent with the EZ-IO(®) flange. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: IO device use is increasing due to the most recent pediatric and neonatal septic shock guidelines, which emphasize first-hour fluid resuscitation and inotrope therapy. It is vital that emergency physicians be aware of the adverse effects of semi-automatic IO devices, including dermal abrasion, which has not been reported previously. With proper training and familiarity, it is possible to avoid dermal abrasion as an adverse effect of the semi-automatic IO device.
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Case Reports
Metformin-Associated Lactic Acidosis Presenting as Acute ST-Elevation Myocardial Infarction.
Metformin-associated lactic acidosis (MALA) is a rare but life-threatening adverse drug reaction of metformin, the most frequently prescribed medication for patients with type 2 diabetes mellitus. The diagnosis of MALA is difficult to make because of diverse clinical presentations that can masquerade as other critical illnesses. ⋯ A 52-year-old woman presented with altered mental status, hypoglycemia, and shock. A prehospital electrocardiogram showed findings consistent with posterolateral ST-elevation myocardial infarction, and the cardiac catheterization laboratory was activated before patient arrival. On arrival to the emergency department, she was found to have severe metabolic derangements and hypothermia, and the catheterization laboratory was canceled. Aggressive supportive measures and emergent hemodialysis were instituted. A metformin concentration was sent from the ED and returned at 51 μg/mL (therapeutic range 1-2 μg/mL), making MALA the most likely diagnosis. She recovered after prolonged critical illness and was discharged in good condition. No alternate diagnoses were found despite extensive work-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Metformin is the most prescribed antidiabetic drug in the world. Although MALA is a rare complication, it is important for emergency physicians to keep MALA on the differential for diabetic patients presenting with severe metabolic acidosis.
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Version 1 (V1) of the National Emergency Medicine Fourth-year Student (EM M4) Examination was released in 2011 and revised along with release of V2 in 2012. Each examination contains 50 multiple-choice questions designed to assess knowledge in the EM M4 clerkship curriculum. Development and initial performance data were described previously. ⋯ Performance data for V1 remain stable after 2 years. Revisions of poorly performing questions improved question performance on V2. Questions with low rpb or low pdiff will continue to be revised annually. While examination forms differ statistically, the practical utility of the differences is not defined.
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There is a continued interest in global emergency medicine (EM) training, research, and clinical program development. There are many opportunities for "voluntourism" in medicine, but many of these experiences do not have standard goals and objectives. ⋯ Global training experiences can have clear benefits. Students go to places to "learn," but can also "teach" at the same time. Setting goals and objectives helps to assure that students are gaining specific core competencies as part of the experience. Other global rotations would benefit from having a defined structure.