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Jan Shoenberger, MD and Stuart Swadron, MD, FRCPC
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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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EMRAP 2018 07 July Vol.18 V2 Written Summary 390 KB - PDF

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Catherine M. -

i am wondering how long the agitated patient who gets ketamine 4mg/kg IM is sedated for? When will they start to wake up?

Jan S. -

HI Catherine - The typical duration of dissociation with IM ketamine in kids who get it for procedural sedation is 20-30 minutes (per ACEP clinical policy paper published May 2011 Annals of EM Authors: Green, S et al). For agitation, the answer to this question is less clear. Most of the literature published to date regarding the use of ketamine for agitated patients does not describe this particular endpoint as a primary outcome. The primary outcome that has been of most interest has been time to achieve sedation. In addition, many patients who get this drug for their agitation also receive other medications for sedation as adjuncts. The most recent paper published on this topic is Cole JB et al "A prospective study of ketamine as primary therapy for prehospital profound agitation" in Am J Emerg Med May 2018. In this study (49 patients) median time to sedation was 4.9 minutes (dose 5 mg/kg). The length of sedation is neither a primary nor secondary outcome. In addition, in several studies, some (to many) of these patients end up getting intubated so it's even harder to say.

Sean D., PA-C, MPAS -

Hey Guys -

Only download appears to be in Spanish. Do you have the English version available?

Thank you!
S. Di Paola

Mel H. -

Sean D. it is right up the top under the downloads section - just checked and downloaded it myself.

Sean D., PA-C, MPAS -


ryan harris -

Some ideas for new segments
PharmD seg: new diabetes drugs since you graduated medical school (for me 2009).
what they do, how they do it, dangers/adverse reactions to be aware of.

ED Potassium replacement: per Scott W, even in the ICU he only does PO replacement. In our ED we seem to be waiting for 4 hours!!!! for 40mEQ of IV potassium to infuse in addition to 40mEQ po for potassium of 2.9, which was an incidental finding. What' s reasonable safe strategy in the relatively healthy patient for ranges 2.5-2.9 and then for 3 and up?

David W. -

Will you guys be doing a section in the future on suboxone and ED-MAT for opioid withdrawal? There's been a lot of talk of that recently in my area especially w/ Andrew Herring from Highland here.

James S. -

Stuart's case sounds like Scombroid poisoning if the patient had fish at this buffet

Joel Butler, Sr., M.D. -

Red Meat Allergy

J Allergy Clin Immunol. Author manuscript; available in PMC 2016 Mar 1.
Published in final edited form as:
J Allergy Clin Immunol. 2015 Mar; 135(3): 589–597.
doi: 10.1016/j.jaci.2014.12.1947
PMCID: PMC4600073
PMID: 25747720
The alpha gal story: Lessons learned from connecting the dots
John W Steinke, PhD, Thomas A.E. Platts-Mills, MD, PhD, FRS,* and Scott P Commins, MD, PhD

Joel Butler, Sr., M.D. -

There is also a pod cast featuring Dr. Scott Commins available on the web From University of North Carolina department of medicine "chairs corner episodes" with the Title "Alpha-Gal Allergy - with Dr. Scott Commins"

Joel Butler, Sr., M.D. -

Red meat allergy patients have urticarial reactions with GI symptoms with all the symptoms arising 3-6 hours after red meat ingestion. This sounds very much like with Stuart's patient.

Reference laboratories can quantify the serum levels of alpha gal IgE. Patients must be warned that they must avoid all mammalian meat, as all mammalian meat has the alpha gal epitope to which the alpha gal IgE reacts. Birds, amphibians and fish do not have Alpha gal.

Yes I have seen and treated a patient having red meat allergy reactions who had an elevated alpha gal IgE.

As an aside, pit viper antivenom is derived from sheep, and has alpha gal. Therefore giving pit viper antivenom to a red meat allergy patient has the potential to make matters worse. There has been a case report. There is also concern about the zoster vaccine which has beef gelatin in it which contains alpha gal. There have been anaphylaxis case reports there also.

Allergy. 2017 May;72(5):764-771. doi: 10.1111/all.13073. Epub 2016 Nov 21.
Alpha-gal is a possible target of IgE-mediated reactivity to antivenom.
Fischer J1, Eberlein B2, Hilger C3, Eyer F4, Eyerich S5, Ollert M3, Biedermann T1,2.

Anaphylaxis after zoster vaccine: Implicating alpha-gal allergy as a possible mechanism
This study was done under institutional review board–approved protocols from Vanderbilt University, the University of Virginia, and the University of North Carolina. Cosby A. Stone, Jr, MD, MPHa Jonathan A. Hemler, MDa Scott P. Commins, MD, PhDb Alexander J. Schuyler, BS, BAc Elizabeth J. Phillips, MDd,f,g,h R. Stokes Peebles, Jr, MDa,e John M. Fahrenholz, MDa,e

Julie V. -

It would be great if you could make the history of the opioid epidemic section available to the public. I know many nurses and other healthcare providers that would find this section really useful!

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EM:RAP 2018 July Full episode audio for MD edition 229:23 min - 319 MB - M4AEM:RAP 2018 July German Edition Deutsche 120:44 min - 166 MB - MP3EM:RAP 2018 July Spanish Edition Español 90:31 min - 124 MB - MP3EM:RAP 2018 July Australian Edition Australian 35:17 min - 48 MB - MP3EM:RAP 2018 July Canadian Edition Canadian 24:10 min - 33 MB - MP3EM:RAP 2018 July French Edition Français 27:05 min - 37 MB - MP3EM:RAP 2018 07 July Individual MP3 Files 293 MB - ZIPEMRAP 2018 07 July Individual Summaries 742 KB - ZIPEMRAP 2018 07 July Spanish Summary 1 MB - PDFEMRAP Board Review Answers 2018 07 July Vol.18 07 116 KB - PDFEMRAP 2018 07 July Vol.18 V2 Written Summary 390 KB - PDFEMRAP Board Review Questions 2018 07 July Vol.18 07 407 KB - PDF

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