RAP 51

1) Resource Reviewed: Vaccine Passports, NEJM

Reviewed by: Ben Willenbring, MD

I scored the above BEEM rating because:

This article is a discussion on the merits and risks of using COVID vaccination passports to regulate domestic and international travel and social/business venue entrance, and has limited/no direct applicability to Emergency Medicine practice. It is, however, interesting and new. And as Emergency Physicians who are practicing during the COVID pandemic, our opinions are valid and relevant to the discussion.

The educational pearls include: 

This article is educational in a general sense, but again, not directly applicable to the practice of Emergency Medicine. It discusses legal, ethical, and public health considerations surrounding the possible implementation of national/international COVID vaccination passports.

I chose the above EBM rating because: 

This article does not use scientific data as evidence, because the argument is not primarily a scientific/medical one.

2) Resource reviewed: Miracle 2 Trial, REBEL EM

Reviewed by: Matt Dummer, PGY-2 MD

I scored the above BEEM rating because:

The MIRACLE2 Risk Score is a promising clinical decision-making tool for predicting neurologic outcomes in OHCA patients presenting to resource-rich academic emergency departments. However, additional validation studies in larger and more diverse cohorts are required before it can be regularly used, especially in community settings.

The educational pearls include: 

1. Neurologic prognostication of out of hospital cardiac arrest patients is very difficult and current prognostication tools are too cumbersome for Emergency Department Use. 

2. The MIRACLE2 has the potential to become a validated practical risk score for early accurate prediction of poor neurological outcome after OOHCA, which has been developed for simplicity of use on admission.

I chose the above EBM rating because: 

1. The MIRACLE2 score was derived and validated in retrospective cohorts as opposed to prospective cohorts.

2. Certain measurements, such as zero flow times and pupillary reflexes, can have problems with inter-rater reliability. 

3. Predictive accuracy of the MIRACLE2 score may not transfer to community hospitals and institutions that don’t have 24-hour access to coronary angiography. 

4. External validity is limited to countries with more widespread CPR education and robust pre-hospital EMS systems.

3) Resource Reviewed: Annie are you A-OK? (Amniotic Fluid Embolism), ERRx

Reviewed by: Brett Millbrandt, PGY-1 MD

I scored the above BEEM rating because:

Standard of care for amniotic fluid embolism (AFE) is resuscitation (cardiopulmonary support, control bleed, reverse coagulopathy). Even with the best care, prognosis is poor. The "A-OK" protocol (Atropine, Ondansetron, Ketorolac) is a possible direct treatment of the pathophysiology of AFE (targeting pulmonary vasoconstriction, consumptive coagulopathy, vagal tone). While more study is needed, these medications are generally safe and readily available, making them a potentially useful adjunct.

The educational pearls include: 

1. Atropine blocks vagal stimulation, reversing bradycardia, pulmonary vasoconstriction/ spasm.

2. Ondansetron reduces pulmonary vasoconstriction.

3. Ketorolac inhibits thromboxane, platelet activation.

I chose the above EBM rating because: 

While the mechanistic explanation behind the protocol makes sense, more study is needed to determine if this actually has significant clinical outcome. This podcast references a case report where this protocol was used with good effect, however the patient who clinically appeared to have AFE did not meet the clinical criteria for AFE based on SMFM definition.

4) Resource Reviewed: Terminal Extubation, EMRA.Org

Reviewed by: Melanie Mercer, PGY-3 MD

I scored the above BEEM rating because:

Providing end-of-life care in the ED is an essential skill for EM providers (ABEM Model of Clinical Practice includes palliative care as an essential part of residency training). Includes important information & educational pearls on process of terminal extubation in the ED, though is not necessarily new information.  

The educational pearls include: 

1. Clear communication, setting expectations, and ensure understanding of the dying process. 

2. Establishing an appropriate environment & considerations in preparing patient for terminal extubation. 

3. Anticipate symptoms that may occur after extubation - emesis, aspiration, pain, dyspnea, stridor, secretions, agitation, anxiety.

4. Medication indication, dosing, and frequency medications such as opiates, benzodiazepines, and anticholinergics should be given early and as frequently as needed. 

5. Techniques for removing patient from ventilator support - terminal extubation & terminal wean.

I chose the above EBM rating because: 

Largely informative, but not meant to be research. Article does include 27 references to support learning points, preparatory steps, and post-extubation care.

5) Resource Reviewed: Delayed antibiotics, EMLitofNote.com

Reviewed by: Matt Knealing, PA-R

I scored the above BEEM rating because:

It has some value to EM, moreso urgent care. It takes into consideration the value of less antibiotic use for children with URI including AOM, pharyngitis and rinosinusitis. Obviously with any antibiotic use, adverse effects can occur, mainly GI issues. This study of 436 children showed that patients randomized to the delayed antibiotic use compared to immediate antibiotic use remained symptomatic on average the same amount of time and only 25% of patients in the delayed arm used the prescription.

The educational pearls include: 

1. Not every AOM, URI or sinusitus patient needs antibiotics. 

2. It is still reasonable to adhere to guidelines of prescription practice on certain patient populations (ie the very young, the toxic appearing or those who have limited access to reasonable follow up). 

I chose the above EBM rating because: 

I do believe this is more appropriate for UC>EM. Although the idea of less antibiotics for less severe infections is great antibiotic stewardship it unfortunately does not take into effect the general patient population view on antibiotics for something like AOM is needed or the parents strong parental concern and desire for antibiotics. Overall severity of infection, appearance of child and illness duration should be taken into consideration for no antibiotics, delayed antibiotics or immediate antibiotics.