From Evidence to Practice: Managing Pain, Agitation and Delirium in the ICU

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Dr. Kim Medlej

Kamal (Kim) Medlej, MD, is an attending physician at the department of emergency medicine at Massachusetts General Hospital and fellowship-trained in critical care, and a longtime contributor to MDCalc. Here’s Dr. Medlej’s take on applying evidence on managing pain, agitation, and delirium to his patients in the ICU.

Pain, agitation, and delirium (the ICU triad) are common in critically ill patients, and can be challenging for clinicians to manage, both in (1) ruling out and treating potential underlying causes, and (2) choosing appropriate sedatives and analgesics in those patients who need them.

This is a fascinating area of critical care medicine, although it can also be difficult and frustrating. While our insight and screening tools have improved, the management of patients with pain, agitation, and/or delirium remains difficult. This is a large topic with a significant amount of literature and opinions. This brief overview is in no way comprehensive, but more a personal view, approach and practice.

Continue reading “From Evidence to Practice: Managing Pain, Agitation and Delirium in the ICU”

Centor’s Corner: FeverPAIN versus Centor Score

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Centor’s Corner

Editor’s note: Centor’s Corner is a new Paging MDCalc column featuring our favorite pharyngitis guru, blogger extraordinaire, and Scientific Advisory Board member Dr. Robert Centor, with regular insights from Dr. Centor on the applications of evidence to practice and musings from an experienced clinician. To comment on Centor’s Corner articles, please e-mail the editor at [email protected] or tweet directly to Dr. Centor @medrants.

On Twitter recently, several British tweeters discussed whether they should use the FeverPAIN Score or the Centor Score.  Obviously I have a bias here, but I will try to discuss this issue dispassionately.

Continue reading “Centor’s Corner: FeverPAIN versus Centor Score”

Interview with Dr. Ilene Claudius, Part 2 of 2: Pediatric Mass Casualty and Systemic Failures in Child Abuse

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Dr. Ilene Claudius

Can you tell us about your research in pediatric mass casualty incidents (MCI)? How did you develop an interest in pediatric mass casualty? Was there a particular patient experience that you had?

I haven’t had a personal experience with it, necessarily—we’ve certainly had some overwhelming car accidents, but nothing to the level that I would call a true pediatric mass casualty incident. These are always tragic events, and especially after Sandy Hook, it became clear that kids could make up a sizable portion if not the entirety of the victim population of an MCI.

We’ve done a lot of work in the PEM [pediatric emergency medicine] community on general community hospitals being ready to see a lot of kids in general. I work with an organization called COPEM [Committee on Pediatric Emergency Medicine] that looks at our pediatric receiving hospitals and makes sure they’re up to standard in terms of delivering pediatric care and having the appropriate supplies. And that’s just for a single routine pediatric patient. So the thought of how a group of very traumatized pediatric patients simultaneously is going to be handled is something we discuss a lot. Continue reading “Interview with Dr. Ilene Claudius, Part 2 of 2: Pediatric Mass Casualty and Systemic Failures in Child Abuse”

Interview with Dr. Ilene Claudius, Part 1 of 2: Managing Suspected Child Abuse in an Emergency Setting

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Dr. Ilene Claudius

Ilene Claudius, MD, is an associate professor of clinical emergency medicine and chief of pediatric emergency medicine at the Keck School of Medicine of the University of Southern California. She is editor-in-chief of Pediatric Emergency Medicine Practice, and her clinical research interests include pediatric mass casualty, non-accidental trauma (child abuse), and pediatric mental health.

Dr. Claudius has also studied apparent life-threatening events (ALTE) and brief resolved unexplained events (BRUE). She has authored or co-authored dozens of studies in peer-reviewed journals, and is an active contributor to the EM:RAP podcast. We talked to Dr. Claudius about her research and clinical expertise in pediatric emergency medicine.

Continue reading “Interview with Dr. Ilene Claudius, Part 1 of 2: Managing Suspected Child Abuse in an Emergency Setting”

The PEWS Score: Can an Algorithm Predict Worsening Illness in a Hospitalized Child?

By Jeff Russ, MD, PhD – Pediatric/Child Neurology Resident, UCSF

Dr. Jeff Russ

A major task of any pediatric ward provider is to regularly assess a patient’s appearance, vital signs, labs, and risk factors, and integrate these data into a cohesive clinical picture to determine the patient’s acuity and potential need for intervention. This can be especially challenging on busy services or night shifts, where, for example, nurses may divide their time among up to four patients, and a single physician may care for 10–20 patients. Particularly with children, a lot can change between sporadic assessments, making it difficult to triage acuity.

Continue reading “The PEWS Score: Can an Algorithm Predict Worsening Illness in a Hospitalized Child?”

300

We’ve just hit 300 calculators on our website (and iPhone and Android apps), and we thought it might be a good time for reflection.

By the Numbers:

  • The Los Angeles Motor Scale (LAMS) was our 300th calculator!
  • We’ve added over 120 calculators in the past year alone.
  • MDCalc has been around for 12 years.
  • We estimate that we’ve helped with over 15 million patient decisions across the world through our calculators and content in 2016.
  • We’re used in 210 countries.
  • Despite only having been prospectively validated in 2013, the HEART Score is already our 6th most popular calculator.
  • We receive about 5 new calculator requests per week.
  • We have 46 featured interviews with calculator creators that give insight into their thinking about their own scores.
  • We provide calculators for 50+ specialties.
  • We are used by at least 75% of US medical students in their clinical rotations.

Continue reading “300”

Heads Up on Head Injury Algorithms: The Cost of High Sensitivity

By Jeff Russ, MD, PhD – Pediatric/Child Neurology Resident, UCSF

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Dr. Jeff Russ

Children presenting with head injury are as unremitting in children’s hospitals as the “Frozen” soundtrack, and any physician in a pediatric ED inevitably manages their fair share. The ramifications of missing significant injury to a child’s delicate, developing brain are unnerving. A head CT is central to catching intracranial pathology, but widespread use is not benign, given the risk of malignancy from unnecessary radiation. However, criteria for judiciously navigating this tradeoff remain debated. When is CT appropriate for children with GCS scores of 13-15 and mild symptoms like transient loss of consciousness or vomiting?
Continue reading “Heads Up on Head Injury Algorithms: The Cost of High Sensitivity”

Insights from Dr. Lise Nigrovic, Creator of the Bacterial Meningitis Score for Children

Bacterial meningitis is a rare but serious disease, with mortality approaching 100% when left untreated. On the flip side, many children with mild viral illness are admitted with questionable benefit. The Bacterial Meningitis Score can help support a clinician’s decision to discharge a child safely. We talked with Dr. Lise Nigrovic, first author on the derivation and validation studies.

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Dr. Lise Nigrovic

Why did you develop the Bacterial Meningitis Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians? 

When I was a resident in pediatrics, I found myself admitting well-appearing children who had meningitis, spent two days in the hospital, and then went home after their cultures were negative. Doing that over and over again made me wonder if we could do better and distinguish between children who

Continue reading “Insights from Dr. Lise Nigrovic, Creator of the Bacterial Meningitis Score for Children”

Insights from Dr. Robert M. Centor, Creator of the Centor Score for Strep Pharyngitis

Antibiotic overuse and misuse is a growing public health concern, and foregoing the administration of antibiotics in cases where they are not needed can be a challenging decision to defend without good evidence to back it up. The Centor Score for Strep Pharyngitis is one of the most practical and useful evidence-based decision tools that helps support clinicians in making those decisions. We interviewed Dr. Robert Centor on developing and using the Centor Score.

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Why did you develop the Centor Score? Was there a clinical experience that inspired you to create a this tool for clinicians?
In 1979, while working in the “non-acute” adult emergency room, a resident asked me how to evaluate a sore throat patient. Having just finished my residency, I started to give a definitive answer, but had a moment of humility and told him that I did not know. We made a treatment decision at the time, and I went to the library to learn more. Continue reading “Insights from Dr. Robert M. Centor, Creator of the Centor Score for Strep Pharyngitis”

Insights from Dr. Jeffrey Perry, Creator of the Ottawa Subarachnoid Hemorrhage Rule

Subarachnoid hemorrhage, if undiagnosed, can have devastating consequences. While headache is a common presenting complaint in emergency departments, only about 1% of these patients are diagnosed with SAH. The Ottawa SAH Rule helps rule out SAH with 100% sensitivity, to better identify which patients do and do not need further workup. We talked with Dr. Jeffrey Perry, first author of the Ottawa SAH Rule derivation study.

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Dr. Jeffrey J. Perry

How did you develop the Ottawa SAH Rule? Was there a particular patient or clinical experience you had?

Two things: One was the apparent subjectivity I noticed as a resident in evaluating patients for SAH, where the criteria for which patients we would investigate seemed to be very different. Some of the patients I thought were very low risk, other physicians would want to still investigate them for SAH, including doing a CT, which didn’t bother me too much, but then they would go on to do an LP, which is very uncomfortable, and time-consuming, and it seemed to contribute to already very prevalent ED overcrowding. So that was the clinical side of things. Continue reading “Insights from Dr. Jeffrey Perry, Creator of the Ottawa Subarachnoid Hemorrhage Rule”