Moving the Emergency Nurse Practitioner Specialty from Resistance to Acceptance: The Wyoming Experience No abstract available

Appropriateness Criteria for Neuroimaging of Adult Headache Patients in the Emergency Department: How Are We Doing?: Erratum No abstract available

Are Pelvic Exams Necessary Anymore? This article, “Is the pelvic examination still crucial in patients presenting to the emergency department (ED) with vaginal bleeding or abdominal pain when an intrauterine pregnancy is identified on ultrasonography? A randomized controlled trial,” by J. A. Linden et al. (2017) seeks to determine whether excluding a pelvic examination among patients presenting to the ED with first-trimester vaginal bleeding or lower abdominal pain, and indication of intrauterine pregnancy recorded on ultrasound increases morbidity. The findings are discussed in the context of changing practice and patient preference. Emergency nurse practitioners should remain informed about changing practices to ensure that patients receive safe care. Although pelvic examination does provide additional information for specific clinical conditions, the current practice to always include it in the evaluation of a pregnant patient with vaginal bleeding or pelvic pain may no longer be relevant given the improved diagnostic capabilities available within the ED setting.

The Use of Ultrasonography in the Emergency Department to Screen Patients After Blunt and Penetrating Trauma: A Clinical Update for the Advanced Practice Provider Use of bedside ultrasonography to identify life-threatening injuries for patients with blunt and penetrating trauma is the standard of care in the emergency department. The “FAST” examination—focused assessment with sonography for trauma—ultrasound scan of the chest and abdomen allows clinicians to assess critical regions for free fluid without use of invasive procedures as quickly and as often as needed. In addition, ultrasonography has a high degree of sensitivity and specificity and is safe during pregnancy. For patients requiring evaluation of the pleura, the “eFAST” (or extended FAST) may be conducted, which may serve to locate pleural effusions, hemothorax, and pneumothorax. However, ultrasound quality is operator dependent and is recommended with other diagnostic measures to provide a complete clinical picture of trauma patients. Ongoing development of ultrasound competency among established clinicians and nurse practitioner students is vital to maintain diagnostic accuracy and ensure quality care for trauma patients in the emergency department.

A Practical Guide for Managing Antibiotic Allergies in the Emergency Department Up to 30% of patients report at least one antibiotic allergy, but oftentimes these antibiotic allergies are misdiagnosed. In fact, of the 10% of patients reporting penicillin allergies, 90%–98% are not truly allergic. In an era of increasing antibiotic resistance coupled with a limited number of new antibiotics, evaluating antibiotic allergies is critical in providing optimal patient care. Differentiating adverse drug reactions from antibiotic allergies may seem like a daunting task for clinicians and providers, especially in the emergency department, where decisions are made quickly. However, a systemic approach, including medical record review coupled with patient and/or family interview, is vital in managing patients with antibiotic allergies. Inappropriate, alternative antibiotics are frequently chosen due to patient allergies, and data suggest higher rates of broad-spectrum antibiotic use, antibiotic resistance, and poor outcomes as a result. Herein, we review antibiotic selection in patients reporting antibiotic allergies in the emergency department.

Encephalopathic Presentation of West Nile Virus Neuroinvasive Disease Confounded by Concomitant History of Acute Alcohol Withdrawal West Nile neuroinvasive disease (WNND) is a rare and severe manifestation of West Nile virus (WNV) infection that occurs in less than 1% of infected persons. It should be considered in patients who present with fever, neurological symptoms, and a history of recent outdoor activity where mosquitoes were active. This article highlights a case of a 55-year-old man whose history and symptoms of WNND were confounded with an alternate diagnosis, acute alcohol withdrawal. An overview of WNV infections, and important historical clues and objective findings characteristic of neuroinvasive disease, is discussed to increase readers' knowledge of WNV and awareness of when to consider WNND in the diagnostic differential.

Skin and Soft Tissue Infections: A Case of Necrotizing Fasciitis Necrotizing fasciitis is a rapidly progressing soft tissue infection associated with a high rate of mortality. Vibrio vulnificus, a gram-negative bacillus found in warm seawater, is a rare but serious cause of necrotizing fasciitis. Definitive treatment is often delayed because of the vague clinical manifestations associated with the early stages of the disease. Delays in diagnosis are directly associated with increased mortality. Because infection with V. vulnificus progresses more rapidly than other causes of necrotizing fasciitis, patients presenting with soft tissue symptoms and who have been in contact with raw seafood or seawater should be considered at high risk for V. vulnificus-associated necrotizing fasciitis. Health care providers in northern and inland areas must be aware of patients who have recently traveled to regions where V. vulnificus is more common, such as warm coastal regions. Early fasciotomy, debridement, and culture-directed antimicrobial therapy are essential to improve survival. The case presented in this report highlights the importance of early diagnosis of V. vulnificus-associated necrotizing fasciitis.

Nursemaid's Elbow Reduction Nursemaid's elbow, also known as radial head subluxation, is a common childhood orthopedic injury that can easily be diagnosed and reduced by the advanced practice nurse. It is most common in children 1–4 years of age and typically occurs as the result of a pulling mechanism on an outstretched arm. This leads to subluxation of the radial head at the annular ligament. The child subsequently refuses to use the affected arm, leading the caregiver to present for evaluation. This article explores epidemiology, pathophysiology, clinical presentation, reduction techniques, and parent education.

Safe Management of Nausea and Vomiting During Pregnancy in the Emergency Department Nausea and vomiting during pregnancy are a frequent complaint in the emergency department, with a significant economic burden on the patient and health care system. The American College of Obstetricians and Gynecologists (ACOG) in January 2018 released an updated practice bulletin discussing the latest guidelines to managing nausea and vomiting during pregnancy. This article discusses the incidence, prevalence, and economic costs regarding medical visits for pregnancy-associated nausea and vomiting. It also discusses ACOG guidelines and furthermore outlines special considerations, management, admission, and discharge criteria for pregnant patients presenting to the emergency department for nausea and vomiting.

Implementation of a Team-Focused High-Performance CPR (TF-HP-CPR) Protocol Within a Rural Area EMS System Team-focused, high-performance cardiopulmonary resuscitation (TF-HP-CPR) improves the return of spontaneous circulation (ROSC) among patients with out-of-hospital cardiac arrest (OHCA) events. In 2010, the American Heart Association began endorsing TF-HP-CPR (Meaney et al., 2013). A rural-area Virginia emergency medical services (EMS) system receives assistant medical oversight from an emergency nurse practitioner (ENP). The ENP is responsible for assisting the physician medical director in promoting continuous quality improvement (QI) within the EMS system. In January 2018, a QI project implemented a TF-HP-CPR protocol. The QI project encompassed the provision of education for EMS personnel about TF-HP-CPR with mock code evaluations. The protocol incorporated a newly designated blind insertion airway device and integrated the routine monitoring of end-tidal carbon dioxide (ETCO2) values. The QI project also introduced postresuscitation attempt report cards that were completed by the team leader at the conclusion of each CPR event. A random 16-week sample of patients with OHCA just before implementation of the QI project was analyzed and compared with patients who experienced an OHCA event within a 16-week period after implementation of the TF-HP-CPR protocol. The preimplementation group had 13 patients compared with 11 patients in the postimplementation group. The rate of ROSC in the preimplementation group was 38.46% compared with 54.55% in the postimplementation group. Although the rate of ROSC increased by 16.09%, the findings were not statistically significant (p = 0.6824) and were perceived to be likely due to the small sample sizes. The implementation of a TF-HP-CPR protocol improved the rate of ROSC among patients with OHCA; however, the findings were not statistically significant. A more extensive study is essential for further evaluation.