Volume 32 Number 1 January 2018

Well Maintained
In response to public patient safety concerns, the American
Board of Emergency Medicine (ABEM) developed an
external assessment of cognitive skills to ensure the
highest standards of clinical care. Since 2000, ABEM-
certified physicians have been required to meet rigorous,
specialty-specific standards predicated on Maintenance
of Certification, episodic assessments of performance
that extend beyond licensure and traditional continuing
medical education. As such, it is imperative for every
practicing emergency physician to understand these key
expectations and their impact on patient care.

Clearing the Air

The emergency department observation unit has become
an effective practice environment for the evaluation
and treatment of common respiratory conditions,
including asthma, chronic obstructive pulmonary
disease, and anaphylaxis. Because these presentations
Lumbar puncture (LP) is used in the diagnostic
require multiphasic interventions and re-evaluation, it
evaluation of central nervous system (CNS) processes,
is imperative for emergency clinicians to understand the
most commonly in cases of suspected infection and
tenets of patient selection and be prepared to formulate
subarachnoid hemorrhage. Less commonly, the
a therapeutic strategy for addressing these potentially
procedure is used for therapeutic purposes (eg, in cases
life-threatening pulmonary disorders.
of idiopathic intracranial hypertension).

THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

IN THIS ISSUE
Lesson 1 n Observation of Asthma, COPD, and Anaphylaxis . . . . . . 3
Critical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Critical Decisions in Emergency Medicine is the official
Critical Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 CME publication of the American College of Emergency
Physicians. Additional volumes are available.
LLSA Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Lesson 2 n ABEM's Maintenence of Certification . . . . . . . . . . . . . . . . . . 13 EDITOR-IN-CHIEF
Michael S. Beeson, MD, MBA, FACEP
Critical ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Northeastern Ohio Universities,
CME Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Rootstown, OH

Drug Box/Tox Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 SECTION EDITORS

Andrew J. Eyre, MD
Brigham & Women’s Hospital/Harvard Medical School,
Contributor Disclosures. In accordance with the ACCME Standards for Commercial Boston, MA
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CME activity. Sharon E. Mace, MD, FACEP; Baxter Healthcare, consulting fees, fees for non- University of Maryland, Baltimore, MD
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Method of Participation. This educational activity consists of two lessons, a post-test, Christian A. Tomaszewski, MD, MS, MBA, FACEP
and evaluation questions; as designed, the activity it should take approximately 5 hours to University of California Health Sciences,
complete. The participant should, in order, review the learning objectives, read the lessons San Diego, CA
as published in the print or online version, and complete the online post-test (a minimum Steven J. Warrington, MD, MEd
score of 75% is required) and evaluation questions. Release date January 1, 2018. Expiration Orange Park Medical Center, Orange Park, FL
December 31, 2020.
Accreditation Statement. The American College of Emergency Physicians is accredited by ASSOCIATE EDITORS
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The American College of Emergency Physicians designates this enduring material for a
Walter L. Green, MD, FACEP
maximum of 5 AMA PRA Category 1 Credits™. Physicians should claim only the credit
University of Texas Southwestern Medical Center,
commensurate with the extent of their participation in the activity.
Dallas, TX
Each issue of Critical Decisions in Emergency Medicine is approved by ACEP for 5 ACEP
John C. Greenwood, MD
Category I credits. Approved by the AOA for 5 Category 2-B credits.
University of Pennsylvania, Philadelphia, PA
Commercial Support. There was no commercial support for this CME activity.
Danya Khoujah, MD
Target Audience. This educational activity has been developed for emergency physicians.
University of Maryland, Baltimore, MD

Critical Decisions in Emergency Medicine is a trademark owned and published monthly by the American Sharon E. Mace, MD, FACEP
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The American College of Emergency Physicians (ACEP) makes every effort to ensure that contributors to its George Sternbach, MD, FACEP
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Nathaniel Mann, MD
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ISSN2325-0186(Print) ISSN2325-8365(Online)
 Clearing the Air
Observation of Asthma,
COPD, and Anaphylaxis

LESSON 1

By Sangil Lee, MD, MS; Brooks J. Obr, MD;

and David Gresback, MD
Dr. Lee is an assistant professor and Dr. Obr is chief resident in the Department
of Emergency Medicine at The University of Iowa Carver College of Medicine
in Iowa City. Dr. Gresback is an emergency physician at the Mayo Clinic Health
Systems – Mankato in Mankato, Minnesota.

Reviewed by Jennifer L. Martindale, MD

OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Appropriately triage cases of asthma, COPD, and
anaphylaxis to the emergency department observation n What criteria can be used for selecting which
unit. patients with asthma, COPD, or anaphylaxis
2. Formulate a strategy for diagnosing and observing should be admitted to the emergency
patients with acute presentations of asthma, COPD,
department observation unit?
and anaphylaxis.
3. Identify when a respiratory complaint warrants inpatient n What is the ideal approach to managing asthma,
hospital admission.
COPD, and anaphylaxis in the emergency
4. Provide safe and effective discharge instructions for
asthma, COPD, and anaphylaxis patients admitted in department observation unit?
the emergency department observation unit.
n What are the treatment endpoints for asthma,
FROM THE EM MODEL COPD, and anaphylaxis prior to discharge from
16.0 Thoracic-Respiratory Disorders the observation unit?
16.4 Obstructive/Restrictive Lung Disease

The emergency department observation unit, which has provided a unique practice environment since the
1990s, was created to address the increasingly complex needs of a growing patient population.1 Several
respiratory conditions, including asthma, chronic obstructive pulmonary disease (COPD), and anaphylaxis are among
the disorders frequently — and effectively — managed in the observation unit.2-4

January 2018 n Volume 32 Number 1 3

 CASE PRESENTATIONS
■ CASE ONE
A 40-year-old black woman
presents with an acute asthma
exacerbation. She is treated with
a single nebulizer treatment, but
continues to be tachypneic with
a respiratory rate of 30. Her
ECG shows sinus tachycardia,
and her lung examination reveals
diminished lung sounds bilaterally.
The emergency physician must
decide if this patient is appropriate
for admission to the observation
unit.
■ CASE TWO
A 52-year-old woman with
a history of chronic obstructive
pulmonary disease (COPD) presents
with cough, wheezing, and dyspnea,
which began 1 week ago. Her vital
signs are blood pressure 150/115,
heart rate 120, respiratory rate 35,
temperature 37°C (98.6°F), and
oxygen saturation 89%. Her lung
examination reveals wheezing, and
the patient is subsequently provided
a nebulizer treatment. After a total
of three nebulizer treatments and
a loading dose of steroids, her
respiratory rate remains in the 20s.
The patient reports feeling better;
however, her oxygen saturation
remains 88% to 89% on room air.
■ CASE THREE
A 12-year-old boy with a history
of a food allergies presents after
accidentally ingesting a sandwich
that contained peanut butter. He is
flushed, has developed a pruritic rash
on his torso, and is dyspneic. The
patient reports feeling better after
receiving an intramuscular dose of
epinephrine, and his parents ask how
long their son needs to be monitored.

While respiratory complaints are quite
common, their endpoints are not as
clear as they are for many other acute
conditions such as chest pain, which
can be evaluated with laboratory or
provocative tests. Asthma, COPD,
and anaphylaxis require multiphasic
interventions and particularly careful
monitoring, considerations that make
them particularly good candidates for
observation management.
CRITICAL DECISION
What criteria can be used for
selecting which patients with
asthma, COPD, or anaphylaxis
should be admitted to the
emergency department
observation unit?
Asthma and COPD patients should,
first and foremost, have stable vital
signs, clear mentation, and respiratory
improvement with bronchodilator/
steroid therapy to be considered
potential candidates for observation
unit admission. In contrast, patients
with evidence of respiratory failure,
unstable vital signs (including hypoxia),
new ECG abnormalities other than
sinus tachycardia, or a poor response
to more than three nebulizer treatments
(or 1 hour of continuous nebulizer
treatment) require a higher level of care
(Table 1). 5
Due to the advanced age and intramuscular epinephrine (.3 mL of
comorbidities (eg, hypertension, a 1:1,000 solution). Out of concern
impaired mobility, etc.) that often for a biphasic reaction, guidelines
accompany COPD (Figure 1), as recommend observation for 6 hours.
many as 30% of these patients will Of note, The National Institute of
require hospital admission — a rate Allergy and Infectious Disease and
substantially higher than for those the Food Allergy and Anaphylaxis
with asthma exacerbations. If there is Network (NIAID/FAAN) criteria
any question regarding the appropriate may be a useful diagnostic adjunct
disposition of a patient with COPD, if anaphylaxis is suspected but the
serial examinations and assessments of diagnosis remains unclear (Table 2). 2
respiratory rate, arterial blood gas, and Patients in active respiratory distress
venous blood gas can be used to help and those with anaphylaxis, airway
gauge the treatment response. edema, or hemodynamic instability
Patients presenting with signs and require a higher level of care and should
symptoms of anaphylaxis require bypass the observation unit. 3
TABLE 1. Observation Unit Admission Criteria for Patients with Asthma
Inclusion Criteria
• Stable vital signs (SaO2 >89% and respiratory rate <40)
• Patient must be alert and oriented
• Intermediate response to bronchodilator therapy (improved, but still
wheezing)
• Patient must receive at least 3 nebulizers plus steroid treatments
Exclusion Criteria
• Impending respiratory failure/fatigue/lethargy
• Unstable vital signs (SaO2 <89%, respiratory rate >40, and temperature
>38.5°C)
• Inability to perform spirometry
• New ECG changes (except sinus tachycardia)
• Patient requiring continuous nebulizer treatments >3 hours without
improvement

4 Critical Decisions in Emergency Medicine

 TABLE 2. NIAID/FAAN Criteria for Anaphylaxis

Anaphylaxis is likely when any one of these three criteria is fulfilled:

1. Acute onset of illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized
hives, pruritus or flushing, swollen lips, tongue, or uvula)
and at least one of the following:
(a) Respiratory compromise (eg, dyspnea, wheeze or bronchospasm, stridor, reduced peak expiratory flow, hypoxemia)
(b) Reduced blood pressure or associated symptoms of end-organ dysfunction (eg, hypotonia [collapse], syncope, incontinence)
2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):
(a) Involvement of the skin or mucosal tissue (eg, generalized hives, itch or flush, swollen lips, tongue, or uvula)
(b) Respiratory compromise (eg, dyspnea, wheeze or bronchospasm, stridor, reduced peak expiratory flow, hypoxemia)
(c) Reduced blood pressure or associated symptoms (eg, hypotonia [collapse], syncope, incontinence)
(d) Persistent gastrointestinal tract symptoms (eg, crampy abdominal pain, vomiting)
3. Reduced blood pressure after exposure to known allergen for that patient (minutes to several hours):
(a) Infants and children: low systolic blood pressure (age specific) or >30% decrease in systolic blood pressure*
(b) Adults: systolic blood pressure <90 mm Hg or >30% decrease from that person’s baseline
*Low systolic blood pressure for children is defined as <70 mm Hg from 1 month to 1 year, <(70 mm Hg + [2 × age]) from 1 to 10 years,
and <90 mm Hg from 11 to 17 years.

CRITICAL DECISION de-escalation in frequency to every 4 respiratory reserves. These cases

hours and rescue treatments as needed. often require the involvement of a
What is the ideal approach to
Bronchodilator weaning may be respiratory therapist, who may be
managing asthma, COPD, and possible with concomitant steroid use, best equipped to assess respiratory
anaphylaxis in the emergency and the efficacy of treatment often can function at the bedside and determine
department observation unit? be determined within the first 6 hours the treatment endpoint. Continuous/
of observation. 5 bilevel positive airway pressure may be
Asthma COPD an appropriate next step for patients
The initial management of asthma who display respiratory difficulty/
Although the strategy for
should begin with a bronchodilator fatigue (depending upon mental status),
managing exacerbations of COPD
treatment (ie, inhaled beta-adrenergic and inpatient management might be
(Figure 2) is similar to the approach
agonist) and a loading dose of steroids. warranted.
used for asthma, it can be more
Once placed in the observation unit, challenging owing to coexisting Anaphylaxis
these patients initially may require a medical conditions, the irreversibility Observation unit admission can
dose every 2 hours, with subsequent of bronchoconstriction, and limited be considered for patients with stable
vital signs and symptom improvement.
The options for treating severe allergic
reactions in the observation unit are
the same as those employed in the
emergency department. Epinephrine is
one of a few agents known to prevent
n Asthma exacerbations require treatment with bronchodilators and steroids. the progression of anaphylaxis. 3
While such cases may require up to 6 to 8 hours of observation before
Antihistamines (eg, diphenhydramine)
disposition can be determined, symptom monitoring and peak flow can
and steroids (eg, oral prednisone,
serve as indicators for treatment success or failure.
40-60 mg or IV methylprednisolone,
n COPD exacerbations can be safely monitored in the emergency department 125 mg) also can help provide
observation unit. For continuous observation, it is beneficial to request an symptomatic relief. 3
assessment from a respiratory therapist. Occasionally, a patient will require
n Most patients with anaphylaxis can be monitored safely in the emergency multiple doses of epinephrine; in such
department observation unit. Biphasic reactions are considered rare cases, prompt inpatient admission
(0.4%-14%), and can be effectively treated with epinephrine.3,4 (often to the intensive care unit) is
warranted. A minimum of 10 to 15

January 2018 n Volume 32 Number 1 5

 FIGURE 1. COPD Management Protocol for Emergency Department Observation Unit

Presumptive diagnosis of
“COPD exacerbation” in
the emergency department
Provider/primary nurse
(RN)/triage nurse page
respiratory therapy (RT)
COPD Management
Protocol Exclusion Criteria
• SpO2 <92% on 4 liters-per-
minute oxygen
• Utilization of noninvasive
positive pressure support
or mechanical ventilation
• Abnormal chest x-ray (eg,
frank pneumonia)

• Patient provided supplemental oxygen by nasal cannula versus titration of existing liters-per-
minute flow rate (goal SpO2 90%)
• Patient provided three sequential nebulized DuoNeb treatments (ipratropium .5 mg/albuterol
2.5 mg in 3 mL 0.9% NaCL)
• Supplemental oxygen may be discontinued if SpO2 >95%
• Venous blood gas measurement obtained while patient is in emergency department

Has the patient’s clinical status deteriorated during emergency department visit?
• Increased work of breathing
• Worsening hypercarbia on arterial blood gas/venous blood gas
• SpO2 <90% on supplemental oxygen
Does the patient exhibit any of the exclusion criteria of the COPD management protocol?

No Yes

• Initiate emergency department observation unit • Consider admission to inpatient floor

COPD management protocol. versus intensive care unit.
• Consider follow-up assessments of venous blood • Provide airway management at provider’s
gas/arterial blood gas. discretion.
• Consider pulmonary service consult.

Observation Unit Hours 0-12

• Nurse monitors/records vital signs every hours for 2 consecutive hours, followed by recording
vital signs every 4 hours
• Nurse administers antibiotics/glucocorticoids per physician orders
• RT/RN administers DuoNeb every 4 hours (scheduled), and every 2 hours as needed
Observation Unit Hours 13-24
• RN monitors vital signs every 4 hours
• RT/RN administers DuoNeb every 4 hours (scheduled), and every 2 hours (as needed)
• COPD specialist consult (if available)

No stabilization/improvement Stabilization/improvement
in clinical condition in clinical condition

• Consider discharge to home.

Consider admission to inpatient
floor unit versus intensive care. • Ensure patient has appropriate home-
going medication regimen and arrange
follow up.

6 Critical Decisions in Emergency Medicine

 oxygen saturation for patients with
COPD is 90%; those who require
continuous SpO 2 may necessitate
transfer to an inpatient floor.
A multidisciplinary approach,
especially with the involvement of a
n Overlooking a new ECG finding (other than sinus tachycardia) in a patient respiratory therapist, is particularly
with asthma or COPD. Such findings are a contraindication for observation helpful when determining if a patient
unit admission. with asthma or COPD is appropriate
n Discharging a patient with an epinephrine autoinjector without providing for discharge. Due to the complexity of
clear instructions on proper use. COPD, an admission rate of less than
30% is considered acceptable.8 Most
n Admitting a patient with anaphylaxis, airway edema, or hemodynamic
instability to the emergency department observation unit. These patients patients admitted to the emergency
require a higher level of care. department observation unit for
anaphylaxis become asymptomatic
within 4 to 6 hours. It is imperative
for the clinician to ensure that these
minutes should be allowed prior to CRITICAL DECISION patients are comfortable with the use
providing a second intramuscular of an epinephrine autoinjector prior to
What are the treatment
dose of epinephrine. The duration of discharge.
endpoints for asthma, COPD, and
observation will vary, as there are no
definitive guidelines that delineate anaphylaxis prior to discharge Discharge Process
the appropriate observation periods. from the observation unit? The discharge process for patients
with serious respiratory complaints
While some experts have proposed Treatment goals for any patient
can be rather complex and may take
up to 24 hours of monitoring, most being observed for a respiratory
several hours. A protocol-driven
recommendations suggest 4 to 6 disorder include weaning the patient observation unit can initiate most of
hours.6,7 Importantly, the extra time off oxygen, reducing the frequency of these procedures, which will help save
in the observation unit can be used bronchodilator treatment (maximum time in the emergency department.
to teach patients about allergen every 4 hours), and improving peak For example, when a patient with an
avoidance, and train them in the use flow measurements and reported asthma exacerbation is discharged,
of an epinephrine autoinjector. symptoms. The target supplementary it is prudent for them to be provided

FIGURE 2. Characteristics of Asthma and COPD

ASTHMA
• More intermittent airflow
obstruction
• Improvement in airways
obstruction with bronchodilators
and steroids
• Cellular inflammation
(eg, eosinophils, mast cells,
T-lymphocytes, and neutrophils)
in more severe disease
• Broad inflammatory mediator
response
• Airway remodeling
COPD
• Progressively worsening airflow
obstruction
• Often presents in sixth decade
of life or later in patients
• More permanent airflow
obstruction; less reversibility
and less normalization of airflow
obstruction
• Cellular inflammation (eg,
neutrophils, macrophases,
eosinophils, and mast cells)
• Emphysema frequently found

Adapted from Bleecker ER. Similarities and differences in asthma and COPD. The Dutch hypothesis. Chest. 2004;126(2 Suppl):93S-5S; discussion
159S-61S.

January 2018 n Volume 32 Number 1 7

 CASE RESOLUTIONS
■ CASE ONE
The middle-aged asthmatic was
treated with oral prednisone (60 mg,
0.5 mg/kg) and two additional
bronchodilator therapies. After 1 hour,
the patient’s wheezing improved and her
breath sounds became audible; however,
her peak flow remained between 50%
and 80% of baseline. She was placed in
the observation unit, where she received
frequent bronchodilator therapy. Her
symptoms resolved within 6 hours, and
her peak flow increased to above 80%
of baseline. She was given oral fluids,
and discharged after her tachycardia
resolved.
■ CASE TWO
The woman’s COPD-related
symptoms improved after the
administration of oxygen, a dose
of steroids, and three consecutive
bronchodilator treatments in the
emergency department; however,
she remained hypoxic. A chest x-ray
revealed evidence of pneumonia. After
determining that she was at too high a
risk for treatment in the observation unit,
the clinician admitted her to the hospital
for further management.
■ CASE THREE
After the prompt administration
of epinephrine, the boy with the
allergic reaction began to feel much
better. He was admitted to the
emergency department observation
unit, where he received additional
treatment with dexamethasone and
diphenhydramine. The patient’s
parents were cautioned about the
warning signs of anaphylaxis,
and given a prescription for an
epinephrine autoinjector and
instructed on its proper use. The
boy was released home after 6 hours
of observation, and an outpatient
follow up with allergist was
arranged.

with information regarding smoking REFERENCES

cessation, instructions on the proper use
of bronchodilators, educational materials
about steroid loading/maintenance
therapy, and arrangements for timely
outpatient follow up. Patients with COPD
also may require a consultation with
a social worker and/or pulmonologist.
Anaphylaxis patients require a supply of
epinephrine autoinjectors, and a referral
to either a primary care physician or an
allergy specialist.
It is important to note that emergency
department observation stays are
billable as a part of observation service.
The clinician’s rationale for observation
unit placement and treatment plan
should be documented.
Summary
The emergency department
observation unit has become an effective
practice environment for the evaluation
and treatment of common respiratory
conditions, including asthma, chronic
obstructive pulmonary disease, and
anaphylaxis. Because these presentations
require multiphasic interventions
and re-evaluation, it is imperative for
emergency clinicians to understand
the tenets of patient selection and be
prepared to formulate a therapeutic
strategy for patients suffering from these
potentially life-threatening pulmonary
disorders.
1. Graff LG, Dallara J, Ross MA, et al. Impact on the
care of the emergency department chest pain
patient from the chest pain evaluation registry
(CHEPER) study. Am J Cardiol. 1997;80(5):563-568.
2. Rydman RJ, Isola ML, Roberts RR, et al. Emergency
department observation unit versus hospital
inpatient care for a chronic asthmatic population: a
randomized trial of health status outcome and cost.
Med Care. 1998;36(4):599-609.
3. Campbell RL, Li JTC, Nicklas RA, et al. Emergency
department diagnosis and treatment of anaphylaxis:
a practice parameter. Ann Allerg Asthma Im.
2014;113(6):599-608.
4. Salazar A, Juan A, Ballbe R, Corbella X. Emergency
short-stay unit as an effective alternative to in-
hospital admission for acute chronic obstructive
pulmonary disease exacerbation. Am J Emerg Med.
2007;25(4):486-487.
5. Graff LG. Observation units: implementation and
management strategies. American College of
Emergency Physicians; Dallas, TX: 1998.
6. Lee S, Bellolio MF, Hess EP, et al. Time of onset and
predictors of biphasic anaphylactic reactions: a
systematic review and meta-analysis. J Allergy Clin
Immunol Pract. 2015;3(3):408-416 e1-2.
7. Sampson HA, Munoz-Furlong A, Bock SA, et al.
Symposium on the definition and management
of anaphylaxis: summary report. J Allergy Clin
Immunol. 2005;115(3):584-591.
8. Ross MA, Compton S, Richardson D, et al. The use
and effectiveness of an emergency department
observation unit for elderly patients. Ann Emerg
Med. 2003;41(5):668-677.
9. Baugh CW, Venkatesh AK, Hilton JA, et al. Making
greater use of dedicated hospital observation units
for many short-stay patients could save $3.1 billion a
year. Health Affair. 2012;31(10):2314-2323.
ADDITIONAL READING
Lee S, Young I, Colletti J. Online module to improve
emergency department observation unit practice.
MedEdPORTAL Publications. 2016;12:10423. http://
dx.doi.org/10.15766/mep_2374-8265.10423.

8 Critical Decisions in Emergency Medicine

The Critical Procedure
Posterior view of the head and neck
OCCIPITAL NERVE BLOCK
Occipital nerve blocks have been used successfully for occipital neuralgia, tension headaches, cluster
headaches, migraines, and occipital neuritis. The procedure typically involves an injection of local
anesthetic, which may be combined with a corticosteroid to manage patients with occipital neuritis.
Contraindications
n Overlying infection
n Allergy to component of medication
Benefits and Risks
The primary benefit of this therapy is
its ability to treat the patient’s symptoms
while avoiding systemic medications. In
addition, greater and/or lesser occipital
nerve blocks often can be performed
very quickly, and can provide relief more
rapidly than many traditional treatment
methods.
The procedure poses minimal
risks, aside from potential failure or
allergic reactions to the medication
being used. Possible complications
include the introduction of infection or
unintentional intravascular injection.
Although uncommon, the needle tip can
break during any injection (resulting in a
retained foreign body).
Alternatives
Depending on the nature of the
patient’s symptoms, alternative
therapies include systemic anti-
A needle is inserted at the base of the skull,
and the medication is injected around the
origin of the greater occipital nerve.
inflammatory drugs, triptans, ergots,
and other pharmacological regimens.
Reducing Side Effects
Side effects can be avoided with
standard precautions such as cleansing
the site and aspirating prior to injection
to ensure proper positioning of the
needle. The risk of breaking the needle
tip theoretically can be mitigated by
using a larger 23- or 25-gauge needle
instead of a smaller one, and not fanning
or moving the needle while the tip is
deep. Ultrasound guidance also may help
increase the accuracy of the procedure.
Special Considerations
Greater and lesser occipital nerve
blocks can be performed independently
of each other or simultaneously,
depending on each patient’s clinical
presentation and examination findings.
The block, which should be placed on
the ipsilateral side of the symptoms,
can be performed with lidocaine,
bupivacaine, or other mixtures of
medications.
By Steven Warrington, MD, MEd
Dr. Warrington is director of the Emergency Medicine
Residency Program and academic chair of the
Department of Emergency Medicine at Orange Park
Medical Center in Orange Park, Florida.
TECHNIQUE
(Landmark placement of both greater
and lesser occipital nerve block)
1. Gather supplies. The author uses a
blunt-fill needle, 25-gauge needle,
alcohol swabs, 10-mL syringe, and
1% lidocaine without epinephrine.
2. Fill the syringe with 10 mL of lidocaine.
3. Identify the location for injection.
• The greater occipital nerve can be
found by tracking ≈2-3 cm lateral to
the external occipital protruberence,
and palpating for the point of
maximal severity. The nerve lies just
medial to the occipital artery.
• The lesser occipital nerve can be
found ≈2.5-3.5 cm lateral and 1 cm
inferior to the greater occipital nerve.
4. Cleanse the area, and aspirate and
inject 3-5 mL of the anesthetic in
a fan pattern (both anteriorly and
superiorly).
Note: Gentle massage over the areas
of injection may be beneficial to further
distribute the anesthetic.
January 2018 n Volume 32 Number 1 9
 The Critical Image
A 16-year-old girl presents with 6 days of severe headache, which By Joshua S. Broder, MD, FACEP
began during cheerleading practice. She denies direct trauma to the Dr. Broder is an associate professor and the
residency program director in the Division
head, and has no fever or focal neurological complaints. The headache of Emergency Medicine at Duke University
resolves completely within seconds when the patient lies supine, but is Medical Center in Durham, North Carolina.
severe again within minutes of standing.

The patient has a history of scoliosis and underwent a T3-L2 spinal fusion 6 weeks prior to her emergency department
visit. Her vital signs are blood pressure 110/71, heart rate 64, respiratory rate 18, temperature 36.7°C (98.1°F), and oxygen
saturation 100% on room air.
The patient is lying supine in bed and does not appear to be in any distress. Her fundoscopic and neurological examinations
are normal, as are assessments of her head and neck. She refuses to sit up, anticipating recurrence of her headache.
Magnetic resonance imaging (MRI) of her brain, which was performed before she arrived in the emergency department,
showed no evidence of mass or hemorrhage but demonstrated subtle dural enhancement suggesting intracranial
hypotension. A computed tomography (CT) myelogram scan was performed to assess for cerebrospinal fluid (CSF) leakage.

Contrast contained
within thecal sac Spinal cord

Sharply defined
thecal sac

A. Axial CT myelogram image at the level of T9 shows a normal spinal cord surrounded
by contrast. No contrast escapes the bounds of the thecal sac at this level.

1. Fishman RA, Dillon WP. Dural enhancement and cerebral displacement secondary to .intracranial hypotension. Neurology. 1993;43:609-611.
2. Schoffer KL, Benstead TJ, Grant I. Spontaneous intracranial hypotension in the absence of magnetic resonance imaging abnormalities. Can J Neurol Sci. 2002;29:253-257.
3. Starling A, Hernandez F, Hoxworth JM, et al. Sensitivity of MRI of the spine compared with CT myelography in orthostatic headache with CSF leak. Neurology. 2013;81:1789-1792.

10 Critical Decisions in Emergency Medicine

 B

Contrast
outside of
thecal sac Spinal cord

B. Axial CT myelogram image at the level of T10 shows a normal spinal cord
surrounded by contrast. Here, contrast is seen outside of the thecal sac,
confirming a CSF leak.

KEY POINTS
n Spinal CSF can be iatrogenic (as from lumbar puncture or spinal surgery) or spontaneous.
Headache classically is orthostatic, resolving when the patient is in a supine position.
A brain MRI can provide clues to intracranial hypotension from a CSF leak, including
downward displacement of the brain and dural enhancement; however, the test is not
100% sensitive.1,2 CASE
n Imaging of the spine to identify the site of a CSF leak is confirmatory. Modalities include RESOLUTION
CT myelography, MRI, MR myelography, radionuclide cisternography, and fluoroscopic The patient
digital subtraction myelography. Radiography and CT without the injection of contrast into underwent CT-
the subarachnoid space are not useful. guided patching
n MRI has high sensitivity compared with CT myelography (91.7%); however, the test has with autologous
wide confidence intervals due to the rarity of cases for research (the included study found
blood and fibrin
just 12 patients over a 12-year period). The sensitivity of CT myelography itself is uncertain,
glue. Her symptoms
as it is considered the reference standard.3
completely resolved
n Intermittent leaks might be missed on any modality; negative imaging tests should be
repeated if suspicion remains high.
following the
n MRI (without myelography) is less invasive than a CT myelogram scan, which requires
procedure.
lumbar puncture; however, CT myelography also offers the therapeutic option of image-
guided patching, while MRI is purely diagnostic.
n During CT or MR myelography, contrast material is injected into the spinal subarachnoid
space, outlining the spinal cord and spinal nerve roots, which do not enhance. A CSF leak
is confirmed by the presence of contrast in the extradural space, excluding the immediate
vicinity of the injection site. Thecal contrast is necessary for the detection of CSF leak.

January 2018 n Volume 32 Number 1 11

 The LLSA Literature Review
Emergency medicine physicians face
frequent clinical interruptions and,
therefore, must be proficient at task
switching, a skill that enables one to
shift between two discrete activities.
This skill is different than multitasking,
which requires the simultaneous
performance of two separate tasks. When
an interruption leads to task switching,
the primary task is less likely to be
completed, which can increase the risk of
errors. Consequently, it is important to
be cognizant of these interruptions and
the physician’s response to them.
Memory consists of both working/
short-term and long-term memory.
While long-term memory is focused on
unlimited, stored information, working
memory is capable of processing only
a finite amount of new information
(depending upon the cognitive load
inherent in completing a particular
action). In particular, short-term memory
is strained under the cognitive load of
frequent or competing interruptions.
Multitasking requires the two
tasks to be automated and solidified
in our long-term memory (eg, walking
and talking), where each is performed
almost subconsciously. However, many
activities performed in the emergency
department, especially by more novice
physicians, require deliberate attention
— and therefore use working memory.
Critical Decisions in Emergency Medicine’s series of LLSA reviews features articles articles from ABEM’s 2018 Lifelong Learning and
Self-Assessment Reading List. Available online at acep.org/llsa and on the ABEM website.
12 Critical Decisions in Emergency Medicine
Can You Multitask?
Evidence and Limitations of
Task Switching and Multitasking
in Emergency Medicine
By Jason Wong, MD, and Laura Welsh, MD
University of Washington School of Medicine, Department of Emergency
Medicine, Seattle
Skaugset LM, Farrell S, Carney M, et al. Ann Emerg Med. 2016;68:189-195.
To accommodate interruptions during
these tasks, physicians must utilize task
switching. This leads to potential errors
by increasing the time it takes to finish an
action, decreasing quality, and preventing
completion of the primary task.
To minimize the errors that result
from interruptions, focus should turn
to improving task switching at the
level of the individual provider, and
globally optimizing the emergency
department environment. Physicians can
prioritize tasks according to acuity, and
establish methods to redirect or prevent
interruptions during high-risk situations.
Cognitive load can be mitigated through
continued education and deliberate
practice. By increasing proficiency in
procedural skills and clinical knowledge,
tasks ultimately will be stored in long-term
memory, allowing physicians to multitask
in situations where they otherwise would
have had to task switch.
Environmental interventions should
focus on minimizing distractions in the
workspace and improving situational
awareness. Interprofessional teams can
work to create a consensus about the
circumstances in which interruptions
are acceptable, and provide feedback
when unnecessary intrusions occur.
Hospital policies or systems can further
offload responsibilities to decrease
interruptions. Electronic medical record
optimization, including common order
sets, alert minimization, and standard
documentation cues, also can decrease
cognitive load. Finally, the physical
space can be designed to clearly label
quiet spaces in which staff can complete
critical work with minimal distractions.
KEY POINTS
n Emergency physicians face
numerous interruptions that
necessitate frequent task
switching. These distractions can
increase the risk of errors, decrease
the likelihood of task completion,
and compromise the quality of
work.
n Task switching is the shifting
between two discrete tasks. This
skill is in contrast to multitasking,
which is the simultaneous
performance of two separate tasks.
n To reduce the risks of task
switching, a clinician can improve
his or her skills through deliberate
practice, which can decrease the
cognitive load of certain tasks
and move them into long-term
memory.
n To minimize interruptions and
the need to task switch, changes
should be made to optimize the
work environment and electronic
medical records.
 Well Maintained
ABEM’s Maintenance
of Certification

LESSON 2

By Catherine Marco, MD and Mary Nan S. Mallory, MD, MBA

Dr. Marco is a professor of emergency medicine at Wright State University in
Dayton, Ohio. Dr. Mallory is a professor of emergency medicine at the University
of Louisville in Louisville, Kentucky. Both serve as directors on the ABEM Board
of Directors.
Reviewed by Michael S. Beeson, MD, MBA, FACEP

OBJECTIVES
On completion of this lesson, you should be able to:
1. Identify the components of the ABEM MOC program.
2. Understand the evolution of ABEM’s MOC process.
3. Discuss methods to meet the Improvement in Medical
Practice requirements.
4. Discuss ways to meet the Lifelong Learning and Self-
Assessment requirements.
5. Discuss timing strategies for taking the ConCert
Examination.
FROM THE EM MODEL
20.0 Other Core Competencies of the Practice
of Emergency Medicine
20.2 Practice-Based Learning and Improvement
CRITICAL DECISIONS
n What are the four components of Maintenance
of Certification, and what are the best ways to
satisfy the requirements?
n What are the benefits and risk of taking the
ConCert Examination early?
n Why is it important to maintain certification?
n What is the best way to satisfy ABEM’s
Improvement in Medical Practice requirements?
n Are there “fun” or “easy” ways to meet
the Lifelong Learning and Self-Assessment
requirements?

In response to public patient safety concerns, the American Board of Emergency Medicine (ABEM) developed
an external assessment of cognitive skills to ensure that emergency care is meeting the highest standard.
Since 2000, ABEM-certified physicians have been required to meet rigorous, specialty-specific standards predicated
on Maintenance of Certification (MOC), episodic assessments of performance that extend beyond licensure and
traditional continuing medical education.

January 2018 n Volume 32 Number 1 13

 CASE PRESENTATIONS
■ CASE ONE
K.G. is a 42-year-old ABEM
diplomate with 15 years of
experience and ABEM certification.
She has read about problems posed
by other specialties’ MOC programs
and wonders whether they are
similar to ABEM’s.
The American Board of Medical
Specialties (ABMS) requires all 24
medical specialty member boards to
provide an MOC program to promote
continuous learning, and supply a
periodic external assessment of each
board-certified physician’s cognitive
expertise. While differences in the
specifics of each program vary, a
consistent goal among all organizations
is to ensure that clinicians are
continually working to improve patient
care.
History of MOC
When the ABMS was first formed,
physicians who achieved board
certification were issued lifetime
certificates. In light of patient safety
concerns described in the 1999 Quality
of Health Care in American Committee
of the Institute of Medicine (IOM)
report, lifetime certification was felt
to be insufficient for ensuring the
highest standards of care.1 Due to
rapid advances in medicine, career-long
performance standards were no longer
guaranteed by initial certification and
annual continuing medical education
(CME) activities, which typically are
guided by the physician and may not
address gaps in competency.2
Other than a state medical
licensing board intervention, there
was no mechanism for evaluating
physician engagement in a career-long
program of continuous professional
development built on a set of national
standards. Certification and periodic,
external physician assessment became a
fundamental concern to the public. As
a result, the ABMS outlined a program
of continuous professional development
14 Critical Decisions in Emergency Medicine
■ CASE TWO
J.K. is a 38-year-old ABEM
diplomate who is required to take the
ConCert Examination for recertification
in two years. He wonders whether there
are benefits to taking the test early,
rather than waiting until the 10th year
(the recertification deadline).
known as Maintenance of Certification.
Subsequently, certification and MOC
activities have been shown to enhance
patient safety, improve the quality
of clinical care, and reduce health
care costs.3-7 Nonetheless, detractors
(mainly in other specialties) suggest
that continuous board certification is
too time-consuming, too expensive, and
irrelevant to their practices.
Other Approaches
ABEM makes changes to its MOC
program based on participation, passing
rates, and physician feedback. Annual
diplomate surveys are conducted to
evaluate the physician experience with
each component of the program, and
the ABEM MOC Committee regularly
reviews the survey data and diplomate
correspondence to determine what
improvements should be made.
Unlike diplomates of many other
boards, physicians certified by ABEM
have always been required to pass
a secure examination to renew their
certification every 10 years. ABEM
also provides MOC credit for activities
that emergency physicians are already
doing during each shift. For example,
many quality measures that The Joint
Commission requires hospitals to
monitor, including door-to-balloon
time for the treatment of an acute
myocardial infarction, can count toward
the Improvement in Practice (IMP)
requirement for MOC.
Keeping ABEM’s MOC
Program Relevant
ABEM convened an MOC
Summit of stakeholder organizations
in emergency medicine in October
■ CASE THREE
J.M. is a 40-year-old ABEM
diplomate who passed the ConCert
Examination three years ago. He
is looking for ways to satisfy the
Improvement in Medical Practice
(IMP) requirements.
2014. Summit participants included
representatives from the American
Academy of Emergency Medicine
(AAEM) and its Resident and
Student Association, the Association
of Academic Chairs of Emergency
Medicine, the American Board of
Medical Specialties, the American
College of Emergency Physicians,
the Council of Emergency Medicine
Residency Directors, the Emergency
Medicine Residents Association,
the Residency Review Committee–
Emergency Medicine, and the Society
for Academic Emergency Medicine.
Participants critically reviewed
ABEM’s MOC program as well as
ABMS’s MOC 2015 Standards.
Roundtable discussions included
recognizing strengths of the program
and opportunities for improvement,
assessing professionalism, identifying
and filling competency gaps, enhancing
relevancy, and adding value to the
requirements.
TABLE 1. Areas of ABEM
Subspecialty Certification
Anesthesiology Critical Care
Emergency Medical Services
Hospice and Palliative Medicine
Internal Medicine-Critical Care Medicine
Medical Toxicology, Pain Medicine
Pediatric Emergency Medicine
Sports Medicine
Undersea and Hyperbaric Medicine
Note: ABEM diplomates who pass one
of the subspecialty examinations receive
a certificate that is valid for 10 years.
 Some of the dissatisfaction related Cost of MOC CRITICAL DECISION
to MOC in other specialties has The ABEM Board of Directors What are the four components
stemmed from the assertion that the
is cognizant of the costs associated of Maintenance of Certification,
requirements are unrelated to daily
with MOC, including the ConCert and what are the best ways to
practice or are too resource intense.
To the contrary, ABEM is developing Examination. There has been no fee satisfy the requirements?
ways to meet reporting requirements increase for Lifelong Learning and There are four parts to Maintenance
as seamlessly as possible. For example, Self-Assessment (LLS) activities since of Certification (Figure 1):
the organization is working with ACEP 2011, and no increase in the cost of • Professionalism and Professional
to provide automatic IMP requirement the ConCert Examination or any other Standing
credit for physicians who participate in service since 2012. The current fee for • Lifelong Learning and Self-
the Clinical Emergency Data Registry Assessment
the ConCert Examination is $1,850.
(CEDR). CEDR houses data used to • Assessment of Knowledge,
The annualized cost of ABEM MOC is
comply with federal quality measure Judgement, and Skills
comparable to the cost of other ABMS • Improvement in Medical Practice
reporting, enabling participating
programs ($265 per diplomate, or about
emergency physicians to monitor and Professionalism and
assess their adherence to nationally $5 per week).
established quality measures. ABEM certification is associated Professional Standing
with higher professional reimbursement. The Professionalism and
ABEM diplomates want to have a
Professional Standing component
clear description of their pending MOC More than 11,600 ABEM diplomates
serves as a screening mechanism to
requirements. As a result, the board chose to participate in the Centers for
ensure that board-certified physicians
has created an online MOC personal Medicare & Medicaid (CMS) PQRS maintain professional behavior and
page for each diplomate, which can be MOC bonus program from 2012-2014, have no sanctions against their medical
accessed from www.abem.org. From
resulting in a total of $3.8 million in license(s) by a state medical licensing
the personal access page, diplomates board. Participants in the MOC process
added reimbursement, or an average
can view their emergency medicine must hold a current, active, valid, full,
of $7,000 for each ABEM-certified
certification, MOC requirements, unrestricted, and unqualified license
and status at any time. Physicians are physician who participated. On average,
to practice medicine in at least one
encouraged to contact ABEM directly ABEM certification is associated
jurisdiction in the United States, its
should any questions arise about their with an additional $7,000 in annual territories, or Canada, and in each
MOC requirements. compensation per physician. jurisdiction in which they practice.
Participants also must report to the
board all licenses they currently
hold and/or previously held.8 This
requirement is especially important for
physicians working in multiple states,
(eg, an emergency physician with a
locum tenens practice).
n Ideas for fulfilling the IMP component of MOC may be found in a dropdown
Any license that is conditional,
menu on the ABEM website. Most clinically active emergency physicians likely will
under probation, or limits the physician
be able to select one of the available options based on performance measures
already being tracked by their hospitals. to a specific practice setting does not
meet this MOC requirement. If even one
n Although each diplomate must complete four out of five available LLS activities
during each five-year certification period, these activities may be performed in a of these licenses fails to comply with
group setting to allow discussion and enhance the educational value of this MOC these standards, ABEM will revoke the
activity. diplomate’s certificate. Due to reporting
n Diplomates may take the ConCert Examination during the fall administration in among state medical boards through the
years six through 10 of their certification period in an effort to lessen the stress Federation of State Medical Boards, a
associated with taking a high-stakes test. sanction against a physician in one state
n CME credit may be earned for every LLS activity (from AAEM or ACEP), as well as can result in another state also revoking
both the Oral Certification Examination and the ConCert Examination (from the the physician’s medical license, even
American Medical Association). Diplomates are encouraged to take advantage of though there is no action in the second
this relatively low-cost CME option. state. Physicians also should be mindful
n There are specific pathways to regain certification. Anyone who is in this that states may choose to suspend
circumstance is encouraged to contact ABEM directly for assistance. medical licenses due to civil or criminal
matters unrelated to the clinical practice

January 2018 n Volume 32 Number 1 15

 of medicine, including being charged
with driving under the influence,
domestic violence, or failure to pay
child support.
Lifelong Learning
and Self-Assessment
ABEM’s requirement for meeting
the Lifelong Learning and Self-
Assessment component is twofold.
The first element is completion of four
LLS activities within each five-year
period of certification; the second is to
obtain at least 25 American Medical
Association (AMA) PRA Category 1
Continuing Medical Education (CME)
credits per year. Of note, ABEM has
removed the requirement for each
physician to report an average of at
least eight hours of annual of self-
assessment activities.
To enhance the value of this
MOC requirement, ABEM provides
a seamless option for obtaining CME
credit for completed LLS activities
from an external provider. The
physician can obtain an average of 7 to
15 AMA PRA Category 1 Credits for
each LLS activity, and may choose to
receive these credits from the American
Academy of Emergency Medicine or
the American College of Emergency
Physicians (ACEP). Sixty percent of
diplomates take advantage of this CME
opportunity.
The Lifelong Learning and Self-
Assessment component is specifically
designed to promote continuous
learning for the practicing emergency
physician. A list of 10 to 15 emergency
medicine–relevant articles is released
annually. The activity is designed to
be self-study; however, many find that
discussing the LLS readings in a group
setting enhances the learning and
retention of topics highlighted by the
questions; this approach is encouraged
by ABEM.
Each diplomate then takes an
open-book test based on the readings,
which consists of 20 to 30 questions. A
physician has up to three opportunities
per registration to pass each LLS test;
a score of 85% or higher is considered
passing. ABEM diplomates also may
take the subspecialty LLS examinations
16 Critical Decisions in Emergency Medicine
for emergency medical services, of the diplomate’s cognitive skills. It is
pediatric emergency medicine, and a carefully designed examination with
medical toxicology if the physician has a approximately 205 multiple-choice
particular interest in one of these areas. questions written by clinically active
These subspecialty activities also count emergency physicians. Focusing on
toward meeting MOC requirements areas of everyday emergency medicine
(Table 1). practice, more than 60% of the test’s
Ninety-eight percent of emergency questions require diagnostic processing,
physicians report that the LLS readings not simply fact recall.
are relevant to emergency care, and Content for the examination is
92% maintain that the information derived from The Model of the Clinical
they learned changed their practices.9 Practice of Emergency Medicine, the
Additionally, in response to diplomate outline of the knowledge, skills, and
feedback about how to improve abilities required of an ABEM-certified
the MOC experience, ABEM now emergency physician. The model,
provides the answer rationale for the which is reflective of clinical care,
LLS questions after the physician has is developed and routinely updated
completed and passed a given test. through a collaboration between the
key stakeholder emergency medicine
Assessment of Knowledge, organizations.
Judgement, and Skills The test questions are written by a
Physicians must pass the ConCert team of trained volunteer question (or
Examination during any one of years “item”) writers, all of whom are board-
six to 10 of their certification. Taken certified emergency physicians. Items
at a proctored computer-testing center, are then reviewed and edited by ABEM
the test is ABEM’s external assessment directors, who are clinically active
FIGURE 1. Four Components of the ABEM MOC Program
Professionalism
and Professional
Standing
Assessment
Lifelong Learning
of Knowledge,
and
Judgment,
Self-Assessment
and Skills
Improvement
in
Medical Practice
TABLE 2. Acceptable Types of Patient Care Practice Improvement (PI) Activities
Diplomates may complete PI efforts related to any of the measures or activities below. Others that are not listed may be acceptable,
provided they follow the four steps ABEM requires.
Time-Related (throughput time, length of stay, and other
process time measures)
• Door-to-doctor times (door-to-provider, door-to-evaluation)  • Improving patient understanding of discharge instructions
• Emergency department length of stay for discharged
psychiatric and transferred patients
• Throughput time improvement
• Time to disposition decision (admit, discharge, etc.)
Infectious Disease-Related
• Goal-directed sepsis pathway, use of the Sepsis DART toolkit,
other sepsis guidelines
• Appropriate testing for children with pharyngitis
• Appropriate treatment for children with upper respiratory
infection
• Antibiotic treatment for adults with acute bronchitis:
avoidance of inappropriate use
• Antibiotic stewardship (includes selection, administration
time, local resistance pattern identification, etc.)  • Completion of “Prescribing Opioids in the Emergency
• Blood culture before antibiotics
Stroke-Related
• Head CT within 45 minutes of arrival of stroke patient
• Thrombolytic consideration or use in eligible patients
• Door to puncture time for endovascular stroke treatment
• Stroke activations and care pathways
Cardiac-Related
• Door-to-balloon times for acute myocardial infarction (AMI)
• Fibrinolysis for AMI (median time and within 30 minutes)
• Transfer time to another facility for AMI intervention
• Aspirin at arrival for AMI or chest pain
• Median time to electrocardiogram (ECG) for AMI or chest
pain
• Assessment for chest pain (including risk stratification,
non-invasive testing and stress testing, diagnostic protocols
for early rule-out, TIMI risk assessment)
• Improving care for patients with chest pain
• Cardiac resuscitation and post-resuscitation care
• Screening for high blood pressure and documented
follow up
• Coagulation studies in patients presenting with chest pain
with no coagulopathy or bleeding
Appropriate Imaging
• Appropriate CT use in minor blunt head trauma
• Appropriate CT use for abdominal pain in adults
• Appropriate imaging for renal and ureteral colic
• Appropriate imaging for trauma patients (includes NEXUS
Criteria and Ottawa Rules)
• Use of imaging for low back pain
• Use of ultrasound for diagnosis for abdominal pain, pediatric
• Ultrasound determination of pregnancy location for pregnant
patients with abdominal pain
• Appropriate use of neuroimaging for patients with primary
headache, a normal neurological examination, and no trauma
Communication — Patient Care
• Patient call-back system
• Improvements in response to Patient Experience of Care
Survey results
• Safe sign-out between emergency physicians
• Transfer of care to other care provider (consultant,
admitting physician, etc.)
Pain Management and Sedation
• Time to pain management for all pain, including long-
bone fractures
• Reassessment of pain after administration of analgesia
• Procedural sedation safety (includes appropriate
medication selection, checklists, etc.)
• Adherence to opioid prescribing recommendations for
chronic pain
Department” from EMPainline.org
• Use of statewide electronic pain medication prescribing
system
• Evaluation for risk of opiate misuse
Patient Safety, Error Reduction, and Complication
Avoidance
• Adherence to indications for central line insertion
• Prevention of central venous catheter-related blood
stream infections
• Ultrasound use for central line insertion
• Appropriate Foley catheter use in the emergency
department
• Medication error reduction, including ACEP module,
“Preventing Medication Errors”
• Appropriate use of restraints and seclusion
• Reassessment of vital signs at discharge
• Planning safer and more effective aftercare, including
ACEP module
• Reducing discrepancies between emergency physician
and radiologist x-ray interpretation
• Notification of regional poison control center for
poisoned patient
Additional Common Measures and Activities
• Left without being seen
• Unscheduled return visits to emergency department
(including 72-hour returns)
• Ongoing Professional Practice Evaluation (OPPE) and
Focused Professional Practice Evaluation (FPPE) processes
• Improvement of difficult airway management
• Management of the intoxicated or alcohol withdrawal
patient
• Tobacco use screening and cessation
• Asthma pathways
• Emergency Medical Associates (EMA) Clinical
Performance Improvement Program
• Unhealthy alcohol use: screening and brief counseling
January 2018 n Volume 32 Number 1 17
 in their field. Along with previously reassess performance in achieving the CRITICAL DECISION
validated questions, new questions practice performance metric.
Why is it important to maintain
are field tested and undergo statistical A prior IMP activity was
analyses to measure the level of difficulty certification?
communication/professionalism
and discrimination. Comments from test (C/P). However, in June 2016, ABEM Although ABEM board
takers also are factored into the review implemented a pilot that no longer certification is voluntary, the reality
process, and are evaluated before any required completion of a C/P activity is that many hospitals, medical
new question is included in the ConCert for the MOC program. This pilot will staffs, and third-party payors
Examination. require it. Generally speaking, the
conclude December 31, 2018, at which
The test is criterion referenced, patient does not choose his or her
time it will be evaluated by ABEM
meaning there is no curve. However, emergency physician. In light of this,
and ABMS to determine whether
more than 90% of emergency physicians maintenance of ABEM certification
this requirement will be permanently
who took the ConCert Examination publicly demonstrates a career-
report that preparing for and taking the removed from the MOC program.
long commitment to continuous
test added to and/or reinforced medical professional development.
knowledge.10 CRITICAL DECISION
Certification also is an important
What are the benefits and risk of element of professional self-regulation.
Improvement in
taking the ConCert Examination Historically, physicians did not
Medical Practice adequately address health care costs or
early?
Improvement in Medical Practice quality; as a result, federal statutes and
emphasizes advancements that There are significant advantages
regulations were imposed. To maintain
diplomates make in their work settings and no downside to taking the
the privilege of professional self-
by focusing on areas of practice-based ConCert Examination early. Moreover, regulation, medicine must demonstrate
learning related to patient care and diplomates who pass the test in the that specialty certification boards
professionalism. ABEM offers IMP sixth year of their certification will such as ABEM perform a summative
credit for practice improvement, or remain certified until the end of their assessment of physician cognitive
Practice Improvement (PI) projects that current certification period. That is, the skills and knowledge. The ConCert
emergency medicine groups are already
certificate renews for another 10 years Examination does this effectively.
doing (Table 2).
after the end of the physician’s current In addition, there is a learning
First, the PI activity is required
10-year cycle, regardless of when benefit to the ConCert Examination.
to be completed once during the first
the ConCert Examination is passed, Physicians who took the 2015
five years and once during the second
provided that the other components of test completed a voluntary, post-
five years of each 10-year certification
MOC continue to be fulfilled. Taking examination survey (96.5% response
period. The four required steps include
the test early also can reduce anxiety rate). Of the 2,511 respondents,
1) measure 10 or more patients with a
and may lead to more security in 92.0% reported a benefit to
specific condition or clinical situation;
2) compare this metric to a national length of board certification. In fact, preparing for and taking the ConCert
standard of care; 3) implement an a physician may make five attempts Examination. Among all respondents,
improvement in medical practice; and 4) before losing certification. 90.4% reported that their medical
knowledge was reinforced and/or
improved.
There are pathways to regaining
ABEM certification for physicians
who allow it to lapse.11 If less than
five years have passed since the date
a certificate has expired and four or
n Failing to avoid negative actions against your medical license, including those fewer LLS test requirements were
unrelated to the practice of medicine, which may result in the loss of ABEM missed while certified, certification
board certification. may be regained by making up missed
n Waiting until your final year of certification to take the ConCert Examination, requirements. If it has been longer
turning the test into a high-stakes situation that could have been avoided by than five years since a certificate
taking it earlier.
expired, or if more than four LLS
n Forgetting to register in advance—before taking the LLS test—for the relatively
test requirements were missed while
inexpensive CME activities offered by AAEM and ACEP.
n Falling behind on annual LLS tests. Procrastination makes it difficult and time certified, a physician must pass the
consuming to catch up in year five; keep up annually! ConCert Examination and then the
Oral Certification Examination to

18 Critical Decisions in Emergency Medicine

regain certification. Physicians in these
situations are encouraged to contact
ABEM directly for assistance.
CRITICAL DECISION
What is the best way to satisfy
ABEM’s Improvement in
Medical Practice requirements?
Many consider Improvement in
Medical Practice to be the easiest
component of MOC to satisfy. Every
emergency department, regardless
of size or location, is beholden to
performance metrics that monitor
and guide practice changes designed
to improve patient care. Sometimes,
however, emergency physicians are
unaware of the metrics that are being
monitored by their particular hospital
or department.
Examples of emergency
department measures that meet this
MOC requirement cover the entire
spectrum of care, from tracking door-
to-balloon times for the treatment
of acute myocardial infarction, to
CASE RESOLUTIONS
■ CASE ONE
The ABEM MOC program
meets the requirements set forth
by the ABMS. In an effort to make
the requirements relevant and less
burdensome, ABEM incorporates
the work that emergency physicians
already are performing into MOC.
LLS articles may be submitted
to ABEM by any diplomate for
consideration. Multiple ABEM
LLS test editors and physician
representatives from AAEM
and ACEP review each article to
determine the relevance, likelihood
to change practice, and suitability
for CME. The list of potential
articles is then narrowed to the
best 10 to 15 articles relevant to
emergency medicine practice.
CME activities historically were
selected by the physician, with no
assurance of addressing individual or
screening for hypertension at the time
of discharge. For physicians working
in lower-acuity settings such as urgent
care centers, meeting IMP requirements
may be more challenging.
You can meet the PI requirement
using your practice group data,
provided that physician-specific data,
including your own, is among the
information tracked for improvement
through your emergency department.
ABEM has provided a dropdown
menu of options from which you may
attest your participation.
Should you choose to do so, ABEM
allows you to submit individualized
practice improvement attestations,
which must include pre- and post-
intervention data. Externally
developed practice improvement
activities also are available if you are
not able to identify an appropriate
option from ABEM’s list.
specialty-specific gaps in competency.
The only time a physician’s practice
was assessed was in the event of a
negative action taken by a state medical
board. The selected LLS readings, with
their associated optional CME, aim to
ensure that physicians are up to date
in their respective specialties and are
maintaining the highest standards of
care.
■ CASE TWO
Physicians may take the ConCert
Examination as early as year six of their
certification period. Taking the test
early, rather than waiting until the final
(or 10th) year of certification, offers
several potential advantages and no
downside. If you fail the examination
prior to your certification end date,
your board certification status is
maintained—you are not decertified.
If you pass the ConCert Examination
in year six of your certification, for
CRITICAL DECISION
Are there “fun” and “easy”
ways to satisfy the Lifelong
Learning and Self-Assessment
requirements?
The Lifelong Learning and Self-
Assessment component of MOC
affords diplomates the option to
enhance knowledge retention while
networking with other emergency
physicians. ABEM diplomates are
encouraged to complete the LLS
activities as a group, using the
questions to help facilitate discussions
of the reading content.
Many emergency medicine faculty
and emergency department groups set
aside time annually to complete the
LLS requirement — tackling it over
pizza, or converting the activity into a
journal club for advanced physicians.
The articles, which are relevant
to the daily practice of emergency
medicine, also provide an opportunity
for earning CME credit — an added
bonus.
example, you remain certified, and
your certification will renew at the
end of your current 10-year period.
In essence, you are creating your own
timeframe in which to pass the test.
■ CASE THREE
Satisfying the PI activity of the
Improvement in Medical Practice
component of MOC should be
relatively easy for most emergency
physicians. Whether you are
working in an urgent care or in
a busy trauma center, tracking
physician performance is a common
denominator. Measurements
can include, for example, a Joint
Commission’s Core Measure, an
improvement in documentation,
a doctor-patient communication
measurement, or patient safety event
reporting.
January 2018 n Volume 32 Number 1 19
 Summary
Maintenance of Certification for
ABEM-certified physicians aims to
ensure the highest standards for the
specialty of emergency medicine. ABEM
continues to incorporate diplomate
feedback into improvements in the
MOC process in an effort to make the
requirements more relevant and less
burdensome.
Developed as a response to public
patient safety concerns, the various
components of MOC assess varied
aspects of physician performance
beyond licensure and traditional CME.
Unrestricted state licensure remains the
foundation of professionalism. The LLS
activity features articles relevant to the
day-to-day clinical practice of emergency
medicine, and now allows ABEM
diplomates to concentrate on particular
subspecialties interest.
Taking the ConCert Examination
early will not reduce your certification
period, and could lessen the anxiety
commonly associated with high-stakes
examinations. The IMP component
allows diplomates to select from a
variety of options to document the
numerous quality improvement activities
many emergency physicians are doing
already. ABEM will continue to monitor
its MOC program, and welcomes any
suggestions about how to improve the
process.
Editor’s Note:
After this article was written,
ABEM convened a retreat of its
Board of Directors, followed by
an MOC Summit that specifically
addressed the Part III requirements
of Assessment of Knowledge,
Judgment, and Skills. This compo­
nent is satisfied by passage of the
ConCert Examination. Although
no changes have been formalized
as of the time of this printing, the
next 18 months are likely to bring
further adjustments or additions to
the Part III requirements.
REFERENCES
1. Committee on Quality Healthcare in America,
Institute of Medicine. Crossing the Quality
Chasm: A New Health System for the 21st Century.
Washington, D.C.: National Academy Press; 2001.
20 Critical Decisions in Emergency Medicine
2. Davis D, O’Brien MA, Freemantle N, et al. Impact
of formal continuing medical education: do
conferences, workshops, rounds, and other
traditional continuing education activities change
physician behavior or health care outcomes? JAMA.
1999;282(9):867-874.
3. Holmboe ES, Wang Y, Meehan TP, et al. Association
between maintenance of certification examination
scores and quality of care for Medicare beneficiaries.
Arch Intern Med. 2008;168(13):1396-1403.
4. Galliher JM, Manning BK, Petterson SM, et al.
Do professional development programs for
maintenance of certification (MOC) affect quality of
patient care? J Am Board Fam Med. 2014;27(1):19-25.
5. Gray BM, Vandergrift JL, Johnston MM, et al.
Association between imposition of a maintenance
of certification requirement and ambulatory care-
sensitive hospitalizations and health care costs.
JAMA. 2014;312(22):2348-2357.
6. Brennan TA, Horwitz RI, Duffy FD, et al. The role of
physician specialty board certification status in the
quality movement. JAMA. 2004;292(9):1038-1043.
7. Marco CA, Counselman FL, Korte RC, et al.
Emergency physicians maintain performance on the
American Board of Emergency Medicine Continuous
Certification (ConCert™) examination. Acad Emerg
Med. 2014;21(5):532-537.
8. American Board of Emergency Medicine. Policy on
Medical Licensure. Available at: https://www.abem.
org/public/docs/default-source/policies/policy-
on-medical-licensure.pdf?sfvrsn=20. Accessed
December 5, 2016.
9. Jones JH, Smith-Coggins R, Meredith JM, et al.
Lifelong learning and self-assessment is relevant to
emergency physicians. J Emerg Med. 2013;45(6):935-
941.
10. Marco CA, Wahl RP, Counselman FL, et al. The
American Board of Emergency Medicine ConCert™
examination: emergency physicians’ perceptions
of learning and career benefits. Acad Emerg Med.
2016;23(9):1082-1085.
11. American Board of Emergency Medicine. Policy on
Regaining Certification. Available at: https://www.
abem.org/public/docs/default-source/policies/
policy-on-regaining-certification.pdf?sfvrsn=16.
Accessed December 5, 2016.
12. Davis D, O’Brien MA, Freemantle N, et al. Impact
of formal continuing medical education: do
conferences, workshops, rounds, and other
traditional continuing education activities change
physician behavior or health care outcomes? JAMA.
1999;282(9):867-874.
 A 61-year-old woman with dyspnea and hypoxia.

The Critical ECG

Multifocal atrial tachycardia (MAT), rate 115, left ventricular By Amal Mattu, MD, FACEP
Dr. Mattu is a professor, vice chair, and
hypertrophy (LVH), diffuse ischemia. When the rhythm is an irregularly director of the Emergency Cardiology
Fellowship in the Department of
irregular tachycardia, the main diagnostic considerations are atrial
Emergency Medicine at the University
fibrillation, atrial flutter with variable atrioventricular conduction, and of Maryland School of Medicine in
Baltimore.
MAT. The presence of distinct P waves excludes the diagnosis of atrial
fibrillation. On the contrary, P waves are present with at least three
different morphologies and they occur at irregular intervals, confirming the diagnosis of MAT and excluding the
diagnosis of atrial flutter. MAT is often associated with pulmonary disease — this patient was suffering from an acute
exacerbation of emphysema. Slight ST-segment depression is noted in multiple leads and resolved with treatment of
the patient’s hypoxia.

From Mattu A, Brady W, ECGs for the Emergency Physician 2. London: BMJ Publishing; 2008:11,23. Reprinted with permission.

January 2018 n Volume 32 Number 1 21

 CME
Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive

CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1
Credits™, and 5 AOA Category 2-B credits for completing this activity in its entirety.

QUESTIONS Submit your answers online at acep.org/newcriticaldecisionstesting; a score of 75%

or better is required. You may receive credit for completing the CME activity any time
within three years of its publication date. Answers to this month’s questions will be
published in next month’s issue.

1 What is the appropriate concentration and dose

of intramuscular epinephrine for managing
anaphylaxis?
6 What is the minimum length of time recommended for
observing a patient with anaphylaxis?
A. 0 to 2 hours
A. .3 mL of 1:1,000 solution B. 4 to 6 hours
B. .3 mL of 1:10,000 solution C. 12 hours
C. 1 mL of 1:1,000 solution D. 24 hours
D. 1 mL of 1:10,000 solution

2 What is the appropriate dosage of intravenous (IV)

methylprednisolone for treating anaphylaxis or
7 Which of the following reflects the target SpO2 when
providing supplementary oxygen to a patient with a
COPD exacerbation?
asthma in an adult patient? A. 90%
A. 1 mg B. 92%
B. 10 mg C. 95%
C. 125 mg D. 99% to 100%
D. 1,000 mg

3 Which of the following criteria can help confirm the

diagnosis of anaphylaxis?
8 You are treating a woman in the emergency department
with a likely COPD exacerbation. You have attempted
oxygen by nasal cannula and facemask, but the patient
A. Centor criteria continues to have respiratory difficulty, including visible
B. Duke criteria retractions; her oxygen saturation is 86% on 15 liters
C. Light criteria oxygen via facemask. There is no evidence of stridor and
D. NIAID/FAAN criteria she is alert and oriented. What would be an appropriate

4 A 25-year-old woman presents with an apparent

anaphylactic reaction after accidentally eating a
dessert that contained peanuts. She initially
reports having some difficulty swallowing. After
being treated with intramuscular (IM) epinephrine
and IV steroids, she is transferred to the observation
unit. Three hours later, her symptoms recur,
requiring multiple doses of IM epinephrine and
9 Which of the following characteristics helps differentiate
an epinephrine drip. What is the appropriate
disposition for this patient?
A. Continue observation, and check vital sign every
2 hours
B. Discontinue drip after 90 minutes, and discharge
with a prescription for an IM epinephrine injector
C. Initiate immediate allergen testing
next step to improve her respiratory status?
A. Attempt oral and/or nasal airway
B. Initiate immediate endotracheal intubation
C. Initiate continuous/bilevel positive airway pressure
D. Perform a jaw thrust
asthma from COPD?
A. Asthma often is accompanied by emphysema
B. Asthma is caused by a narrow inflammatory mediator
response
C. COPD is marked by more intermittent airflow
obstruction
D. COPD may be evidenced by cellular inflammation (eg,
neutrophils, macrophases, eosinophils, and mast cells)

10

D. Transfer to inpatient (potentially ICU) bed A 25-year-old man presents with an acute asthma

5
How long should you generally wait prior to attack. Which of the following should exclude him from
administering a second dose of intramuscular admission to the emergency department observation
epinephrine to a patient with asthma or unit?
anaphylaxis? A. Continued wheezing, despite bronchodilator treatments
A. 3 minutes B. New sinus tachycardia noted on ECG
B. 5 minutes C. New ST-segment elevations noted on ECG
C. 10 to 15 minutes D. Requires three nebulizer treatments before
D. 30 minutes improvement is seen

22 Critical Decisions in Emergency Medicine

11
In outlining an MOC program for its member boards to
tailor and implement, the ABMS was responding not only
to the rapid advances in medicine, but also to patient
16
How much does it cost to take the ConCert
Examination (once every 10 years)?
A. $1,850
safety concerns raised by which organization in 1999? B. $2,250
A. American Medical Association C. $2,850
B. Centers for Medicare & Medicaid Services D. $3,250
C. Institute of Medicine
D. The Joint Commission

17 The IMP component emphasizes practice-based
learning activities related to patient care and

12
In 2014, nine emergency medicine stakeholder
organizations participated in a critical review of the
specialty’s continuous certification program. This MOC
Summit was convened by which organization?
A. American Academy of Emergency Physicians (AAEM)
B. American Board of Emergency Medicine (ABEM)
C. American College of Emergency Physicians (ACEP)
D. American Medical Association (AMA)
professionalism. Which of the following best
represents ABEM’s current requirements for these
activities?
A. Five continuous years of data are required
B. Improvement projects are verified by ABEM every
year
C. Patient satisfaction survey data must be uploaded
to ABEM website

13 What is the best way for an ABEM diplomate to locate D. Quality improvement projects that emergency
a clear, up-to-date description of his completed and department groups are already doing

18

pending MOC requirements? A physician wishes to take the ConCert Examination
A. Ask a colleague who has recently completed early, in her sixth year of certification. Which of the
requirements following statements best represents her options?
B. Call member services at AAEM or ACEP A. If she takes the examination and does not pass,
C. Consult your ABEM MOC personal page at she will lose ABEM certification
www.abem.org B. She can take the examination early; if she passes,
D. Refer to the ABEM annual report she will remain certified for 10 years beyond her

14
At least one active, valid, and unrestricted license is
required for MOC. When holding multiple state licenses,
which of the following statements does not reflect the
Professionalism and Professional Standing requirement?
A. All active medical licenses must meet ABEM’s policy on
licensure
B. All surrendered licenses must have meet ABEM’s policy
on licensure
19
C. Licenses limiting a physician to a practice setting do not
meet MOC
D. Sanctions in one state do not affect a diplomate’s license
in another state
current certification date
C. She can take the examination early; if she passes,
she will be certified for the ensuing 10 years
D. She cannot take the examination until her final
year of certification
According to 2016 data published in Academic
Emergency Medicine, what percentage of
emergency physicians who took the ConCert
Examination found that it added to and/or
reinforced medical knowledge?
A. 20%
B. 50%

15
The prior Improvement in Medical Practice (IMP) C. 78%
communication/professionalism (C/P) requirement D. 90%
typically was measured by patient satisfaction surveys.
What piloted changes did ABEM make regarding this
component in 2016?
20
Once a physician allows his ABEM certification
to lapse, what activities are required to become
recertified?
A. Indefinitely deleted the C/P component of MOC A. Register for and pass the ConCert and Oral
B. Piloted a process for direct third-party C/P reporting to Examinations
ABEM B. Register for and pass the Qualifying and Oral
C. Substituted approved C/P didactic module for the Examinations
patient survey data C. Requirements vary; the physician should contact
D. Until pilot reassessment in 2018, no C/P attestation is ABEM staff directly
required D. There is no pathway for recertification after a lapse

ANSWER KEY FOR DECEMBER 2017, VOLUME 31, NUMBER 12

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
D C C D B B C A B D C B D C B D A B C B

January 2018 n Volume 32 Number 1 23

 Drug Box
DEXMEDETOMIDINE
By Ryan Fisher, MD, and Katie Fisher, PA, Maricopa Medical
Center, Phoenix, Arizona
Reviewed by Frank Lovecchio, DO, MPH, FACEP
Indicated for the short-term sedation (<24 hours) of ICU patients
on mechanical ventilation, and the sedation of non-intubated
patients prior to and/or during surgery or other procedures.
Mechanism of Action
The agent, which has a high affinity for alpha-2 receptors, is
a relatively selective central alpha 2-adrenergic agonist with
sedative properties. This effect appears to be due to G-protein
activation in the brainstem, which inhibits norepinephrine
release, and decreases sympathetic tone and peripheral vascular
resistance. Alpha-1 and alpha-2 activity, which results in transient
vasoconstriction, can be observed with high doses or with rapid
intravenous administration.
Dosing
Adult
Initial loading infusion (optional) of 1 mcg/kg over 10 minutes,
followed by a maintenance infusion of 0.2-0.7 mcg/kg/hr; titrate
no more frequently than every 30 minutes. Maintenance doses
between 0.2 and 1.5 mcg/kg/hr have been used. Consider dose
reduction for geriatric patients and those with hepatic impairment.
Pediatric
Neonatal (limited data): loading dose (optional) 0.1-0.5 mcg/kg
over 10-20 minutes, followed by a maintenance dose of
0.1-0.3 mcg/kg/hr
Infants, children, adolescents (limited data): loading dose
(optional) 0.5-1 mcg/kg over 10 minutes, followed by a mainten­
ance infusion of 0.2-0.5 mcg/kg/hr
Side Effects
Most common: hypotension, bradycardia and sinus arrest,
transient hypertension with loading dose administration
Less common: agitation, constipation, nausea, anxiety,
xerostomia, anemia, withdrawal syndrome (use >6 hours),
tolerance, and tachyphylaxis (use >24 hours)
Precautions
Contraindicated in patients with hypersensitivity to the drug or a
component of its formulation.
Tox Box
SCOMBROID POISONING
By Richard A. Koch, MD, FACEP, and Christian A. Tomaszewski, MD,
MS, MBA, FACEP, University of California, San Diego
Scombroid (ie, histame fish) poisoning is the most common seafood-
borne illness in the US, and often is confused with allergic reactions.
Toxicity most commonly is due to ingestion of inadequately frozen fish
from the Scombridae family, or another dark-fleshed fish.
Etiology
Histamine is produced by the decarboxylation of histidine, which is
naturally present in fish muscle. The responsible enzyme, histidine
decarboxylase, is released by enteric bacteria (Escherichia, Klebsiella,
Proteus, Vibrio, Pseudomonas, etc.) in poorly refrigerated fish.
Mechanism
Histamine activates H1, H2, H3, or H4 histamine receptors.
• H1 activation produces allergic symptoms.
• H3 activation leads to neurotransmitter release with nausea,
vomiting, and headaches.
Presentation
Symptom onset occurs 10–60 minutes after ingestion. Some patients
report noticing a metallic, bitter, or peppery taste. Symptoms
generally resolve in <24 hours (usually 6-8 hours), rarely lasting days.
• Hives, urticarial, erythematous rash, facial flushing and swelling
• Abdominal cramps, nausea, vomiting, diarrhea
• Headache, dizziness, dry mouth, palpitations
• Orthostatic hypotension, wheezing, respiratory distress
Evaluation
• Evaluate orthostatic vital signs due to possible fluid losses.
• Consider electrolytes to treat losses to due to vomiting and
diarrhea.
• Histamine levels are not rapidly available and do not guide
treatment.
• Tryptase level may help distinguish allergic reactions.
Management
• Decontamination generally is not required, and is contraindicated
in vomiting patients.
• Mainly with antihistaminic medications (IV or IM):
­ — H1 blockers: diphenhydramine, cetirizine, etc.
­ — H2 blockers: famotidine, ranitidine, etc.
• Provide antiemetics for persistent vomiting (eg, promethazine,
chlorpromazine, odansetron).