Understanding ACEP’s Clinical Policy on Seizures

Understanding ACEP’s Clinical Policy on Seizures

ACEP's 2014 Seizure Guidelines

A point-by-point review by Dr. Rhonda Cadena  

Mid-Level Providers

Mid-Level Providers

Who they are, what they do, and why they’re changing emergency medicine

How to make sense of the puzzle and improve your practice.

When Patients Lie

When Patients Lie

How to Spot Deception, What You Can Do, and Why it Matters

Accusing anyone of lying is serious business, but when that person is your patient, the stakes are even higher. 

Raves and Saves

Raves and Saves

Advanced Emergency Management at Mass Gatherings

EM is crucial at drug-fueled electronic dance festivals, like this month’s Electric Zoo in New York.  

Transfusion Confusion

Transfusion Confusion

Knowing the Real Risks of Blood Transfusion

This routine procedure bears real risks and should be handled accordingly.

The ABCs (and T) of Rural EM

The ABCs (and T) of Rural EM

Situational Awareness is Key

When you’re practicing in the middle of nowhere, planning out a timely patient transfer can be as critical as securing…

DNR Means Do Not Treat . . . and Other End-of-Life Care Myths

DNR Means Do Not Treat . . . and Other End-of-Life Care Myths

Debunking 5 Fallacies

Improve your EOL care and communicate more effectively.

Through the Looking Glass

Through the Looking Glass

Three Novel Use Cases for Google Glass in the ED

How might augmented reality change your practice?

Augmented ED

Augmented ED

The future of emergency medicine?

EPs in Rhode island overcome hurdles to trial Glass for telemedicine and consider other applications.

All About Metoclopramide (Reglan)

All About Metoclopramide (Reglan)

Know the risks

Reglan should be used with caution if patients have Parkinson’s disease or are on antipsychotics.

Physicians Won't Be Silenced

Physicians Won't Be Silenced

ACEP's Gag Order Rejected

EPM readers speak out against ACEP’s new ruling prohibiting incoming leaders from answering questions from non-ACEP publications.

Changemaker

Changemaker

How One EP Transformed Mental Health Admissions in Virginia

Debra Perina combined her experience as a coroner with her time leading an ED to challenge the establishment.

Get the Gear Off

Get the Gear Off

Removing the Helmet and Pads is Crucial to Treating Spinal Injuries from Football

Up to 25% of c-spine injuries from football collisions may be exacerbated by the poor removal of helmet and pads.

The War on Death

The War on Death

by Greg Henry, MD

The guns and butter debate is really over, I guess.

How Do I Know if I'm Being Paid Fairly?

How Do I Know if I'm Being Paid Fairly?

Trust is key

I get paid based on my productivity, but I don't trust that my company is paying me accurately.

The Stethoscope of the Future

The Stethoscope of the Future

Bedside Ultrasound

The applications of bedside ultrasound have gone well beyond scanning the gallbladder . . . to the lungs?

The Medical Malpractice Rundown: A State-by-State Report Card

The Medical Malpractice Rundown: A State-by-State Report Card

When it comes to medical liability laws and culture, where you live matters.

Find out how your state stacks up against the other 49.

Gag Order

Gag Order

New ruling prohibits would-be ACEP leaders from answering questions from non-ACEP publications.

Greg Henry seldom fails to deliver on a promise. But this time, it looks like it’s out of his control.

Oxygen is a Drug— Act Accordingly

Oxygen is a Drug— Act Accordingly

Understanding the dangers of indiscriminate oxygenation in the ED setting

As with many things in medicine, dogma seems to overpower the evidence in this arena. 

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Nurses or other ancillary staff routinely perform the task of acquiring IV access, but at times they are unable to obtain access, which is important for laboratory evaluation or fluid or medicine administration. When this occurs, such as in an obese patient or a patient with IV drug abuse history, the onus falls on the physician to achieve intravenous access.

While several studies have shown increased success rates using ultrasound guidance during the establishment of central venous access, Costantino et al. sought to determine if ultrasound guidance for peripheral IV access in difficult to access patients would have similar results.

The study was designed to prospectively randomize patients who had a history of difficult access—due to obesity, history of intravenous drug use, or chronic medical problems—and had failed at least three attempts at access by a nurse. All patients who had a need for central venous access were excluded, as were pregnant patients, children, and those unable to consent. The patients were allocated to the ultrasonography-guided or the landmark and palpation (control) group based on the presentation to the ED on an odd or even day, respectively. The primary endpoints measured were IV access success rate, time from first percutaneous perforation to successful cannulation, time from request for physician-performed IV access to successful establishment of intravenous access (in order to also take into account time to find and set up the ultrasound machine), number of percutaneous perorations required, patient satisfaction, and complications from intravenous access.

A total of 60 patients were enrolled—39 into the US-guided IV access group, and 21 into the landmark and palpation group. The success rate for the ultrasonographic group was 97%, versus 33% for the control group. Patients undergoing US-guided required less overall time to establish IV access (13 minutes versus 30 minutes). The US-guided group also had less time to successful access from the first percutaneous puncture (4 minutes versus 15 minutes), had fewer percutaneous punctures (1.7 versus 3.7), and had a greater patient satisfaction (8.7 versus 5.7). There were no significant complications reported in either group.

While this study showed ultrasonography is an invaluable tool in aiding the physician in establishing IV access, it is notable that this study did employ a two-operator approach. Castantino et al. addressed this, mentioning a previous study showing no difference in success with US-guided peripheral IV access using either one or two operators. However, although it may not affect overall success of the peripheral IV placement, a single operator approach may or may not prolong the time to achieve access. Another limitation listed in the study was that, although there were three additional “odd” days, a larger than expected group was enrolled into the US-guided IV access group. The authors best explain this as a probable selection bias. In addition, the authors also thought it important to mention that those in the traditional group were allowed to attempt cannulation of the external jugular vein—as that is often what takes place in the “real world”. While this may introduce more bias, it would favor the control group and not the ultrasound group.
 

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