Evidence-based Emergency Care

Parental Guidance in the Pediatric ED

  • My Emergency Medicine training taught me the importance of “return precautions.”
    • Educate the patients/families about the warning signs of impending doom.
    • Essentially, “come back if things get worse.”
  • In the Pediatric ED (or during acute care related complaints), I find that the combination fo the two is helpful.
    • In the ED, we are seeing only a brief period of time of the illness process. 
      • At the time you are seeing the kid, there may be no obvious emergent danger or urgent condition warranting therapy… but… 
      • Anticipate the potential trajectories that may exist and educate about them.

Normal (Abnormal) Saline vs. Ringer’s Lactate

The choice of crystalloid fluid for volume resuscitation is debated often. With rising concern about the effect of hyperchloremic metabolic acidosis associated with normal saline, clinicians more commonly are opting for balanced crystalloids, such as lactated Ringer’s solution or Plasma-Lyte. 

Oxygen therapy for acutely ill medical patients: a clinical practice guideline

What you need to know

  • It is a longstanding cultural norm to provide supplemental oxygen to sick patients regardless of their blood oxygen saturation
  • A recent systematic review and meta-analysis has shown that too much supplemental oxygen increases mortality for medical patients in the hospital
  • For patients receiving oxygen therapy, aim for peripheral capillary oxygen saturation (SpO2) of ≤ 96% (strong recommendation)
  • For patients with acute myocardial infarction or stroke, do not initiate oxygen therapy in patients with SpO2 ≥ 90% (for ≥ 93% strong recommendation, for 90-92% weak recommendation)
  • A target SpO2 range of 90-94% seems reasonable for most patients and 88-92% for patients at risk of hypercapnic respiratory failure; use the minimum amount of oxygen necessary

Caring for Adult Patients with Suicide Risk

Mental health evaluations provided during the ED visit should include comprehensive suicide risk assessment. The SAFE-T Guide, developed by the Substance Abuse and Mental Health Services Administration (SAMHSA), may be used in conjunction with the Decision Support Tool to meet this objective.

Universal Health Coverage (UHC) to include emergency services

The Government of Kenya today launched the Universal Health Coverage (UHC) Pilot Program dubbed Afya Care – Wema Wa Mkenya that will enable Kenyans to access affordable healthcare without financial hardship.

The President highlighted that with the UHC card, Kenyan residents in the four pilot counties will now access health services ranging from Emergency Services, Child Health Services, Maternal Health Services, Mental Health Services, Infectious Disease Management, Non-communicable Disease Management, Inpatient and Outpatient Services and Community Health Services across county public health facilities.

2018 Bradycardia Clinical Guidelines

Colours correspond to Class of Recommendation.
*Atropine should not be given in patients after heart transplant.
†In patients with drug toxicity and severe symptoms, preparation for pacing should proceed simultaneously with pharmacologic treatment of drug toxicity.
AADs indicates antiarrhythmic drugs; AV, atrioventricular;BB, beta blocker; CCB, calcium channel blocker; COR, Class of Recommendation;ECG, electrocardiographic; H+P, history and physical examination; IMI, inferior myocardial infarction; IV, intravenous; PM, pacemaker; S/P, status post; and VS, vital signs.

Acute MI

  • Autonomic derangements during an acute MI are common, and small case series suggest that atropine can be used to increase heart rate. Atropine appears to be safe in those patients with atrioventricular  nodal block in the absence of infranodal  conduction system disease.
  • In contrast, it is important to recognize that the use of atropine in patients with infranodal  conduction disease or block can be associated with exacerbation of block and is potentially of harm. Aminophylline/theophylline has also been examined in this setting, and in the context of very limited data appears likely to be safe if atropine is ineffective. The methylxanthines theophylline and aminophylline (a theophylline derivative) exert positive chronotropic effects on the heart, likely mediated by inhibition of the suppressive effects of adenosine on the sinoatrial node.
  • Given that the natural course of a MI with conduction system abnormalities is frequently associated with recovery of conduction – early and unnecessary pacing should be avoided.

WHO launches the Global Emergency and Trauma Care Initiative


8 December 2018 | GENEVA/DAVOS:  Today with the generous support of the Davos-based AO Foundation, WHO launches the Global Emergency and Trauma Care Initiative. Around the world, acutely ill and injured people die every day due to a lack of timely emergency care. Among them are children and adults with injuries and infections, heart attacks and strokes, asthma and acute complications of pregnancy. Many countries have no emergency access telephone number to call for an ambulance or no trained ambulance staff. Many hospitals lack dedicated emergency units and have few providers trained in the recognition and management of emergency conditions. These gaps result in millions of avoidable deaths every year.    

“No one should die for the lack of access to emergency care, an essential part of universal health coverage,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “We have simple, affordable and proven interventions that save lives. This initiative will ensure that millions of people around the world have access to the timely, life-saving care they deserve.”   

The goal of the WHO Global Emergency and Trauma Care Initiative is to save millions of lives over the next five years through improvements to emergency care systems. Its aims are two-fold: to rapidly increase capacities to provide quality emergency care in countries around the world, and to foster awareness through a global advocacy campaign about its potential to save lives. 

In an initial phase, WHO and partners will support 10 low- and middle-income countries to assess their national emergency care systems, identify any shortcomings and implement proven interventions to address these gaps. Activities at the national level include the development of national plans and key policies, such as laws addressing the role of bystanders and access to care without regard to ability to pay; and implementation of WHO standards addressing the way emergency care systems are organized and resourced.    

WHO and partners will also facilitate low-cost improvements in the way that emergency care is delivered. These include implementing triage and WHO checklists that ensure a systematic approach to the care of every patient. In addition, frontline providers will be trained through  WHO-ICRC Basic Emergency Care and other courses. The initiative will support systematic data collection on acutely ill and injured people and how their conditions are managed, including via the WHO International Registry for Trauma and Emergency Care.   

The launch of this initiative is made possible through a CHF 10 million grant from the AO Foundation, which promotes excellence in patient care through a network of thousands of practitioners in 100 countries. It is one of a number of partners poised to contribute to the WHO Global Emergency and Trauma Care Initiative, including others in the WHO Global Alliance for Care of the Injured. This work executes the mandate established by the World Health Assembly resolution WHA 60.22 on emergency-care systems.

Related links

WHO Global Emergency and Trauma Care Initiative https://www.who.int/emergencycare/en/   

WHO Trauma Care Checklist https://www.who.int/emergencycare/trauma-care-checklist-launch/en/    

WHO-ICRC Basic Emergency Care (BEC): Approach to the acutely ill and injured https://www.who.int/emergencycare/publications/Basic-Emergency-Care/en/    

WHO International Registry for Emergency and Trauma Care https://www.who.int/emergencycare/irtec/en/    

WHO Global Alliance for Care of the Injured https://www.who.int/emergencycare/gaci/en/   

World Health Assembly Resolution WHA 60.22 http://apps.who.int/gb/ebwha/pdf_files/WHASSA_WHA60-Rec1/E/reso-60-en.pdf?ua=1

New WHO report highlights insufficient progress to tackle lack of safety on the world’s roads


7 DECEMBER 2018 | Geneva, Switzerland – A new report by the World Health Organization (WHO) indicates road traffic deaths continue to rise, with an annual 1.35 million fatalities. The WHO Global status report on road safety 2018 highlights that road traffic injuries are now the leading killer of children and young people aged 5-29 years.   

“These deaths are an unacceptable price to pay for mobility,” said WHO Director-General, Dr Tedros Adhanom Ghebreyesus. “There is no excuse for inaction. This is a problem with proven solutions. This report is a call for governments and partners to take much greater action to implement these measures.”  

The WHO Global status report on road safety 2018 documents that despite an increase in the overall number of deaths, the rates of death relative to the size of the world population have stabilized in recent years. This suggests that existing road safety efforts in some middle- and high-income countries have mitigated the situation.   

“Road safety is an issue that does not receive anywhere near the attention it deserves – and it really is one of our great opportunities to save lives around the world,” said Michael R Bloomberg, Founder and CEO of Bloomberg Philanthropies and WHO Global Ambassador for Noncommunicable Diseases and Injuries. “We know which interventions work. Strong policies and enforcement, smart road design, and powerful public awareness campaigns can save millions of lives over the coming decades.”      

In the settings where progress has been made, it is largely attributed to better legislation around key risks such as speeding, drinking and driving, and failing to use seat-belts, motorcycle helmets and child restraints; safer infrastructure like sidewalks and dedicated lanes for cyclists and motorcyclists; improved vehicle standards such as those that mandate electronic stability control and advanced braking; and enhanced post-crash care.   

The report documents that these measures have contributed to reductions in road traffic deaths in 48 middle- and high-income countries. However, not a single low-income country has demonstrated a reduction in overall deaths, in large part because these measures are lacking.   

In fact, the risk of a road traffic death remains three times higher in low-income countries than in high-income countries. The rates are highest in Africa (26.6 per 100 000 population) and lowest in Europe (9.3 per 100 000 population). On the other hand, since the previous edition of the report, three regions of the world have reported a decline in road traffic death rates: Americas
, Europe and the Western Pacific.   

Variations in road traffic deaths are also reflected by type
 of road user. Globally, pedestrians and cyclists account for 26% of all road traffic deaths, with that figure as high as 44% in Africa and 36% in the Eastern Mediterranean. Motorcycle riders and passengers account for 28% of all road traffic deaths, but the proportion is higher in some regions, e.g. 43% in South-East Asia and 36% in the Western Pacific.   

RELATED LINKS:   

Global status report on road safety 2018 http://www.who.int/violence_injury_prevention/road_safety_status/2018/en    

WHO fact sheet on road traffic injuries http://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries    

WHO website on road traffic injuries http://www.who.int/violence_injury_prevention/road_traffic/en/    

SaveLIVES: a road safety technical package http://www.who.int/violence_injury_prevention/publications/road_traffic/save-lives-package/en/