-

A
PAGE 2| Introduction To The
Guidelines: Acute Otitis
Media

PAGE 3| Assessment Of The

Guideline Methodology
Selected Guideline
PAGE 4| Recommendations,
With Discussion
PAGE 8| References
PAGE 9| CME Questions
Editors Note: To read more about this publication
and the background and methodologies for practice
guideline development, go to:
http://www.ebmedicine.net/introduction

Updated Guidelines For The

Diagnosis And Management Of
Acute Otitis Media

his issue of EM Practice Guidelines Update reviews the

2013 update of the guideline on the diagnosis and management of acute otitis media (AOM) for healthy children aged
6 months to 12 years. Published by the American Academy of
Pediatrics (AAP) and the American Academy of Family Physicians
(AAFP), the guideline authors emphasize the use of a specific,
stringent definition of AOM to limit unnecessary treatment with antibiotics in patients without a certain diagnosis. The management
recommendations outline which children should be treated with
antibiotics immediately and which children can be offered a watch
and wait approach. This review focuses on the recommendations
most relevant to pediatric emergency medicine practice.
Practice Guideline Impact
Emergency clinicians should make the diagnosis of AOM in
children who present with: (1) moderate to severe bulging of
the tympanic membrane (TM) or new-onset otorrhea not due
to acute otitis externa; or (2) mild bulging of the TM and recent (< 48 h) onset of ear pain or intense erythema of the TM.
The management of AOM should include assessment and
treatment of pain.
Emergency clinicians should prescribe immediate antibiotic
treatment for AOM for children with otorrhea, children with
severe symptoms, and children aged 6 months to 2 years
with bilateral AOM.
Emergency clinicians can either start immediate antibiotic
treatment or offer observation (if there is good follow-up) for
children aged 6 to 23 months with nonsevere unilateral AOM
and children aged 24 months with nonsevere unilateral or
bilateral AOM.

May/June 2014
Volume 6, Number 3
Author
Kimberly Kahne, MD

Pediatric Emergency Medicine Fellow, Department of Emergency Medicine,

Icahn School of Medicine at Mount Sinai, New York, NY

Editor-In-Chief
Sigrid Hahn, MD, MPH

Assistant Professor of Emergency Medicine, Department of Emergency

Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

Editorial Board
Luke K. Hermann, MD

Associate Professor of Emergency Medicine, Director of Quality and Finance,

Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai,
New York, NY

Andy Jagoda, MD, FACEP

Professor and Chair, Department of Emergency Medicine, Icahn School of

Medicine at Mount Sinai, New York, NY

Eddy S. Lang, MDCM, CCFP (EM), CSPQ

Senior Researcher, Alberta Health Services; Associate Professor, University of

Calgary; Adjunct Professor, McGill University, Montreal, Quebec, Canada

Trevor Lewis, MD, FACEP

Medical Director, Emergency Department, Cook County Hospital; Associate

Professor of Emergency Medicine, Rush Medical College, Chicago, IL

Gregory M. Press, MD, RDMS

Emergency Ultrasound Director, Hutt Valley Hospital, Lower Hutt, New Zealand

Christopher Tainter, MD, RDMS

Critical Care Fellow, Department of Anesthesia, Critical Care, and Pain

Medicine, Massachusetts General Hospital/Harvard Medical School, Boston,
MA

Scott M. Silvers, MD

Chair, Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL

Scott D. Weingart, MD, FCCM

Associate Professor, Department of Emergency Medicine, Director, Division of

ED Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY

Prior to beginning this activity, see CME Information

on page 9.

| print | SUBSCRIBE | WEBSITE

Updated Guidelines For Diagnosis And Management Of Acute Otitis Media

Introduction To The Guidelines: Acute Otitis Media

The recommendations in the 2004 guideline to observe rather than

to treat with antibiotics were based on studies that used nonspecific
inclusion criteria that did not represent a patient population with highly
certain AOM. Furthermore, older studies tended to exclude very young
children with severe disease and those with recent antibiotic treatment
or recent diagnosis of AOM. Thus, the studies were not reflective of
the full spectrum of patients covered by these guidelines.8 The 2013
update relied upon studies with stringent diagnostic criteria to ensure
that the patients, indeed, had AOM, and, based on these stronger
data, actually expand the recommendations for which patients can be
observed without antibiotic treatment.

his issue of EM Practice Guidelines Update reviews the guideline

entitled The Diagnosis and Management of Acute Otitis Media,
published in Pediatrics in March 2013, available at:
http://pediatrics.aappublications.org/content/131/3/e964.long
AOM remains the leading condition for which antibiotics are prescribed
for children in the United States.1,2 It accounts for 13% of all emergency department (ED) visits and 30 million clinic visits by children,
making it the second most common diagnosis in the pediatric ED after
upper respiratory infections.3 In May 2004, the AAP and AAFP published the Clinical Practice Guideline: Diagnosis and Management of
Acute Otitis Media.4 This earlier guideline used a less-stringent definition of AOM that could have led to the misdiagnosis of children having
otitis media with effusion (OME) as having AOM. The 2004 guideline
also provided management recommendations for children with an
uncertain" diagnosis. The updated guidelines removed this category,
emphasizing the importance of good visualization of the TM and excellent otoscopic skills for accurate diagnosis to guide management.

The guideline authors acknowledge that the adherence to the 2004

guidelines was quite poor, and they comment that this, unfortunately,
parallels the impact of practice guidelines across specialties. They
highlight the need for increased dissemination of guideline content.
-- Kimberly Kahne, MD

The 2004 guideline was notable for recommending observation without

the use of antibiotics in select patients. Despite awareness and significant publicity of these 2004 recommendations, evidence has shown
that clinicians are hesitant to change their practice.5 Management of
AOM with watchful waiting rather than prescription of antibiotics did
not increase after the 2004 guideline publication.6 A 2007 study reported that up to 91% of ED patients received an antibiotic prescription
for AOM.7

EM Practice Guidelines Update 2014

www.ebmedicine.net May/June 2014

| print | SUBSCRIBE | WEBSITE

Updated Guidelines For Diagnosis And Management Of Acute Otitis Media

Assessment Of The Guideline Methodology

o create this guideline, the AAP and AAFP partnered with the
Agency for Healthcare Research and Quality and the Southern
California Evidence-Based Practice Center. Using an evidence
report created by these agencies, a multidisciplinary writing committee used BRIDGE-Wiz (Building Recommendations in a Developers
Guideline Editor) software to aid in crafting action-oriented recommendations and in determining the strength of the evidence. The relationship between the strength of the evidence and the recommendation is
shown in Table 1.

Table 1. Definition Of Evidence Quality Used In American Academy of

Pediatrics Recommendations

The author of this issue of EM Practice Guidelines Update, Kimberly

Kahne, MD, as well as the Editor-in-Chief, Sigrid Hahn, MD, MPH,
graded these guidelines using the Appraisal of Guidelines for Research and Education (AGREE) II instrument (available at
http://www.agreetrust.org/). This instrument is a checklist that allows
users to grade a guideline on 23 items in 6 domains, reflecting the
degree to which the guideline developers used unbiased, best-practice
methodology in developing the guideline and writing the recommendations. The results of the AGREE assessment are presented in Figure
1, with a percentile calculated for each domain (maximumof 100%).
The score for relevance to emergency medicine is not part of the
AGREE instrument, but reflects the judgment of the author and editor
of this issue.

Figure 1. AGREE Criteria For Acute Otitis Media Guidelines

Kimberly Kahne, MD; and Sigrid Hahn, MD, MPH

Abbreviation: AGREE, Appraisal of Guidelines for Research and Education.

EM Practice Guidelines Update 2014

www.ebmedicine.net May/June 2014

| print | SUBSCRIBE | WEBSITE

Updated Guidelines For Diagnosis And Management Of Acute Otitis Media

Selected Guideline Recommendations, With Discussion

he recommendations excerpted here are presented as they

appear in the original guidelines, including the strength of recommendation and the level of evidence. This review does not
include all recommendations provided in the original documents published by the AAP and the AAFP. Instead, it includes those recommendations most pertinent to emergency clinicians.

The guideline recommends the tools to help develop the appropriate

skills, including the following video:
http://www2.aap.org/sections/infectdis/video.cfm
These revised criteria were developed in reaction to criticisms of the
2004 definition, which lacked precision, and the fact that the guidelines
had a category of recommendations for patients with an uncertain
diagnosis, which many felt tacitly endorsed incomplete visualization
of the TM and poor otoscopic skills. The 2013 criteria were chosen to
achieve higher specificity while recognizing that the decreased sensitivity may exclude less severe presentations of AOM.

Diagnosis Of Acute Otitis Media

Key Action Statement 1A: Clinicians should diagnose AOM in
children who present with moderate to severe bulging of the TM
or new onset of otorrhea not due to acute otitis externa. (Evidence
Quality: Grade B. Strength: Recommendation)
Key Action Statement 1B: Clinicians should diagnose AOM in
children who present with mild bulging of the TM and recent (< 48
hours) onset of ear pain (holding, tugging, rubbing of the ear in a
nonverbal child) or intense erythema of the TM. (Evidence Quality:
Grade C, Strength: Recommendation)
Key Action Statement 1C: Clinicians should not diagnose AOM
in children who do not have middle ear effusion (based on pneumatic otoscopy and/or tympanometry). (Evidence Quality: Grade B,
Strength: Recommendation)

Pain Management For Acute Otitis Media

Key Action Statement 2: The management of AOM should include an assessment of pain. If pain is present, the clinician should
recommend treatment to reduce pain. (Evidence Quality: Grade B,
Strength: Strong Recommendation)
Editorial Comment: Kimberly Kahne, MD
Although many episodes of AOM are associated with pain,9 clinicians
often view it as a secondary complaint that may not require direct attention.10 Pain associated with AOM can be substantial and can last
longer in young children.11 Acetaminophen and ibuprofen are considered the mainstay of pain management for AOM.

Editorial Comment: Kimberly Kahne, MD

The challenging feature of these diagnostic criteria for many clinicians will be that they rely upon pneumatic otoscopy, and the guideline
authors call this the standard" tool for diagnosis. Although they acknowledge that many clinicians lack experience in removing cerumen
adequately or performing pneumatic otoscopy, an incomplete examination is no longer considered acceptable.

EM Practice Guidelines Update 2014

www.ebmedicine.net May/June 2014

| print | SUBSCRIBE | WEBSITE

Updated Guidelines For Diagnosis And Management Of Acute Otitis Media

Antibiotic Treatment Or Observation For Management For Acute

Otitis Media
Key Action Statement 3A: Severe AOM The clinician should
prescribe antibiotic therapy for AOM (bilateral or unilateral) in children aged > 6 months with severe signs or symptoms (ie, moderate or severe otalgia or otalgia for at least 48 hours, or temperature
39C [102.2F] or higher). (Evidence Quality: Grade B, Strength:
Strong Recommendation)
Key Action Statement 3B: Nonsevere bilateral AOM in young
children The clinician should prescribe antibiotic therapy for
bilateral AOM in children aged < 24 months without severe signs
or symptoms (ie, mild otalgia for < 48 hours, temperature < 39C
[102.2F]). (Evidence Quality: Grade B, Strength: Recommendation)
Key Action Statement 3C: Nonsevere unilateral AOM in young
children The clinician should either prescribe antibiotic therapy
or offer observation with close follow-up based on joint decisionmaking with the parent(s)/caregiver for unilateral AOM in children
aged 6 months to 23 months without severe signs or symptoms (ie,
mild otalgia for < 48 hours, temperature < 39C [102.2F]). When
observation is used, a mechanism must be in place to ensure
follow-up and begin antibiotic therapy if the child worsens or fails
to improve within 48 to 72 hours of onset of symptoms. (Evidence
Quality: Grade B, Strength: Recommendation)
Key Action Statement 3D: Nonsevere AOM in older children
The clinician should either prescribe antibiotic therapy or offer observation with close follow-up based on joint decision-making with
the parent(s)/caregiver for AOM (bilateral or unilateral) in children
aged 24 months without severe signs or symptoms (ie, mild otalgia for < 48 hours, temperature < 39C [102.2F]). When observation is used, a mechanism must be in place to ensure follow-up
and begin antibiotic therapy if the child worsens or fails to improve
within 48 to 72 hours of onset of symptoms. (Evidence Quality:
Grade B, Strength: Recommendation)

EM Practice Guidelines Update 2014

Editorial Comment: Kimberly Kahne, MD

Since the 2004 guideline, substantial research has been published on
the initial management of AOM, including randomized controlled trials
on antibiotic therapy versus placebo or no therapy.12-14 The evidencebased recommendations are summarized in Table 2.
Table 2. Recommendations For Initial Management For
Uncomplicated Acute Otitis Media
Unilateral AOM*
without otorrhea

Age

Otorrhea with
AOM*

Unilateral or
Bilateral AOM*
bilateral AOM* without otorwith severe
rhea

symptoms

6 mo 2y

Antibiotic
therapy

Antibiotic
therapy

Antibiotic therapy Antibiotic therapy

or additional
observation

2y

Antibiotic
therapy

Antibiotic
therapy

Antibiotic therapy or additional

observation

Antibiotic therapy
or additional
observation

*Applies only to children with well-documented AOM with high certainty of diagnosis.

A toxic-appearing child, persistent otalgia more than 48 h, temperature 39C (102.2F) in the

past 48 h, or if there is uncertain access to follow-up after the visit.

This plan of initial management provides an opportunity for shared decision-making with the

childs family for those categories appropriate for additional observation. If observation is offered,
a mechanism must be in place to ensure follow-up and the initiation of antibiotics if the child worsens or fails to improve within 48 to 72 h of AOM onset.
Abbreviation: AOM, acute otitis media.
Reproduced with permission from Pediatrics, Vol. 131, page e976, Copyright 2013 by the AAP.

These recommendations contrast with the 2004 guideline, which recommended antibiotic therapy for all children aged 6 months to 2 years
with a certain" diagnosis. Evidence has supported the safety of observation or delayed antibiotic usage in young children and is an appropriate management option when there is shared decision-making with the
parent.

www.ebmedicine.net May/June 2014

| print | SUBSCRIBE | WEBSITE

Updated Guidelines For Diagnosis And Management Of Acute Otitis Media

Editorial Comment: Kimberly Kahne, MD

Once the decision has been made to start antibiotics, the emergency
clinician must choose an antibiotic that will have a high likelihood of
being effective against the most likely bacterial pathogen, taking into
account cost, taste, convenience, and adverse effects.

Choice Of Antibiotics For Acute Otitis Media

Key Action Statement 4A: Clinicians should prescribe amoxicillin
for AOM when a decision to treat with antibiotics has been made
and the child has not received amoxicillin in the past 30 days or the
child does not have concurrent purulent conjunctivitis or the child
is not allergic to penicillin. (Evidence Quality: Grade B. Strength:
Recommendation)
Key Action Statement 4B: Clinicians should prescribe an antibiotic with additional beta-lactamase coverage for AOM when a
decision to treat with antibiotics has been made, and the child has
received amoxicillin in the last 30 days or has concurrent purulent
conjunctivitis, or has a history of recurrent AOM unresponsive to
amoxicillin. (Evidence Quality: Grade C. Strength: Recommendation)
Key Action Statement 4C: Clinicians should reassess the patient
if the caregiver reports that the childs symptoms have worsened
or failed to respond to the initial antibiotic treatment within 48 to
72 hours and determine whether a change in therapy is needed.
(Evidence Quality: Grade B. Strength: Recommendation)

There have been no changes to the recommendation for first-line antibiotic choice since the 2004 guideline, despite new data on the effects
of 7-valent pneumococcal conjugate vaccine (PCV7, Prevnar) and
the awareness of an increase in multidrug-resistant strains of pneumococci. High-dose amoxicillin (80-90 mg/kg per day in 2 divided doses)
yields middle ear fluid levels that exceed the minimum inhibitory
concentrations of all intermediate (and many highly resistant) strains of
Streptococcus pneumoniae. The 3 most common bacterial pathogens
in AOM remain S pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis. Since the introduction of PCV7, there
has been a shift towards H influenzae and non-PCV7 serotypes of S
pneumoniae. The antibiotic susceptibility pattern for S pneumoniae is
expected to continue to evolve with the use of 7-valent pneumococcal
conjugate vaccine (PCV13, Prevnar 13).
Tables 3 and 4 (page 7) show a number of medications that are clinically effective; however, amoxicillin remains first-line due to its effectiveness in combination with low cost, safety, acceptable taste, and
narrow microbiologic spectrum. Patients who have taken amoxicillin in
the previous 30 days, patients with concurrent conjunctivitis, or patients for whom coverage for beta-lactamase-positive H influenza and
M catarrhalis is desired should be started on amoxicillin-clavulanate
(Augmentin) at a dose of 90 mg/kg/day of amoxicillin with 6.4 mg/kg/
day of clavulanate. Alternative antibiotics vary in their efficacy against
AOM pathogens.
For children aged < 2 years and children with severe symptoms, a
standard 10-day course is recommended. A 7-day course may be recommended for children aged 2 through 5 years with mild or moderate
AOM. For children aged 6 years with mild to moderate symptoms, a
5- to 7-day course is adequate.

EM Practice Guidelines Update 2014

www.ebmedicine.net May/June 2014

| print | SUBSCRIBE | WEBSITE

Updated Guidelines For Diagnosis And Management Of Acute Otitis Media

Table 3. Recommended Antibiotics For (Initial Or Delayed) Treatment

Of Pediatric Acute Otitis Media
Recommended First-line
Treatment
Amoxicillin (80-90 mg/kg/day
in 2 divided doses)
or
Amoxicillin-clavulanate* (90
mg/kg/day of amoxicillin, with
6.4 mg/kg/day of clavulanate
[amoxicillin-to-clavulanate ratio, 14:1] in 2 divided doses)

Table 4. Recommended Antibiotics After 48-72 Hours Of Failure Of

Initial Antibiotic Treatment For Pediatric Acute Otitis Media

Alternative Treatment
(If Penicillin Allergy)

Recommended First-line
Treatment
Amoxicillin-clavulanate* (90
mg/kg/day of amoxicillin with
6.4 mg/kg/day of clavulanate
in 2 divided doses)
or
Ceftriaxone (50 mg IM or IV
for 3 days)

Cefdinir (14 mg/kg/day in 1

or 2 doses)
Cefuroxime (30 mg/kg/day in
2 divided doses)
Cefpodoxime (10 mg/kg/day
in 2 divided doses)
Ceftriaxone (50 mg IM or IV
per day for 1 or 3 days)

*May be considered in patients who have received amoxicillin in the previous 30 days or who
have the otitis-conjunctivitis syndrome.

Cefdinir, cefuroxime (Ceftin, Zinacef), cefpodoxime, and ceftriaxone (Rocephin) are highly

Alternative Treatment

Ceftriaxone, 3 days
Clindamycin (Cleocin),
30-40 mg/kg/day in 3 divided
doses, with or without a thirdgeneration cephalosporin

Failure of second antibiotic

Clindamycin (30-40
mg/kg/day in 3 divided doses)
plus third-generation cephalosporin
Tympanocentesis
Consult specialist

unlikely to be associated with cross-reactivity with penicillin allergy, on the basis of their distinct
chemical structures.

*May be considered in patients who have received amoxicillin in the previous 30 days or who

Abbreviations: IM, intramuscular; IV, intravenous

have the otitis-conjunctivitis syndrome.

Reproduced with permission from Pediatrics, Vol. 131, page e983, Copyright 2013 by the AAP.

Perform tympanocentesis/drainage if skilled in the procedure, or seek a consultation from an

otolaryngologist for tympanocentesis/drainage. If the tympanocentesis reveals

multidrug-resistant bacteria, seek an infectious disease specialist consultation.

Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to be associated with

cross-reactivity with penicillin allergy on the basis of their distinct chemical structures.
Abbreviations: IM, intramuscular; IV, intravenous
Reproduced with permission from Pediatrics, Vol. 131, page e983, Copyright 2013 by the AAP.

EM Practice Guidelines Update 2014

www.ebmedicine.net May/June 2014

| print | SUBSCRIBE | WEBSITE

Updated Guidelines For Diagnosis And Management Of Acute Otitis Media

References
1. Grijalva CG, Nuorti JP, Griffin MR. Antibiotic prescription rates for
acute respiratory tract infections in US ambulatory settings. JAMA.
2009;302(7):758-766. (Survey)

10. Schecter NL. Management of pain associated with acute medical illness. In: Schechter NL, Berde CB, Yaster M, eds. Pain in Infants, Children, and Adolescents. Baltimore: Williams & Wilkins; 1993:537-538.
(Textbook chapter)

2. McCaig LF, Besser RE, Hughes JM. Trends in antimicrobial prescribing rates for children and adolescent. JAMA. 2002;287(23):30963102. (Survey)

11. Rovers MM, Glasziou P, Appelman CL, et al. Predictors of pain and/
or fever at 3 to 7 days for children with acute otitis media not treated
initially with antibiotics: a meta-analysis of individual patient data. Pediatrics. 2007;119(3):579-585. (Meta-analysis; 824 patients)

3. Pitts SR, Niska RW, Xu J, et al. National hospital ambulatory medical

care survey: 2006 emergency department summary. Natl Health Stat
Report. 2008;7:1-38. (Survey)

12. Hoberman A, Paradise JL, Rockette HE, et al. Treatment of acute

otitis media in children under 2 years of age. N Engl J Med.
2011;364(2):105-115. (Randomized trial; 291 patients)

4. American Academy of Pediatrics Subcommittee on Management of

Acute Otitis Media. Diagnosis and management of acute otitis media.
Pediatrics. 2004;113(5):1451-1465. (Clinical practice guidelines)

13. Thtinen PA, Laine MK, Huovinen P, et al. A placebo-controlled

trial of antimicrobial treatment for acute otitis media. N Engl J Med.
2011;364(2):116-126. (Randomized double-blind trial; 319 patients)

5. Vernacchio L, Vezina RM, Mitchell AA. Management of acute otitis

media by primary care physicians: trends since the release of the
2004 American Academy of Pediatrics/American Academy of Family
Physicians clinical practice guideline. Pediatrics. 2007;120(2):281287. (Survey)

14. Le Saux N, Gaboury I, Baird M, et al. A randomized, double-blind,

placebo-controlled noninferiority trial of amoxicillin for clinically diagnosed acute otitis media in children 6 months to 5 years of age.
CMAJ. 2005;172(3):335-341. (Randomized double-blind placebocontrolled noninferiority trial; 512 patients)

6. Coco A, Vernacchio L, Horst M, et al. Management of acute otitis

media after publication of the 2004 AAP and AAFP clinical practice
guideline. Pediatrics. 2010;125(2):214-220. (Survey)
7. Fischer T, Singer AJ, et al. National trends in emergency department
antibiotic prescribing for children with acute otitis media, 1996-2005.
Acad Emerg Med. 2007;14(12):1172-1175. (Retrospective database
study)
8. American Academy of Pediatrics Steering Committee on Quality Improvement and Management. Classifying recommendations for clinical
practice guidelines. Pediatrics. 2004;114(3)874-877. (Statement)
9. Hayden GF, Schwartz RH. Characteristics of earache among children
with acute otitis media. Am J Dis Child. 1985;139(7):721-723. (Prospective; 335 cases)

EM Practice Guidelines Update 2014

www.ebmedicine.net May/June 2014

| print | SUBSCRIBE | WEBSITE

Updated Guidelines For Diagnosis And Management Of Acute Otitis Media

CME Questions
To take the CME test, visit: www.ebmedicine.net/G0514 or scan the QR code below with a smartphone:

1. Which of the following patients meets criteria for the diagnosis of AOM?
a. A 3-year-old girl with otorrhea and evidence of acute otitis externa on examination
b. A 3-year-old girl with mild bulging of the TM and complaints of ear pain for the past 24 hours
c. A 3-year-old girl with moderate erythema of the TM and complaints of ear pain for the past 24 hours
d. A 3-year-old girl with upper respiratory infection symptoms and complaints of right-sided otalgia
2. Which of the following patients meets criteria for the diagnosis of AOM?
a. A 6-month-old boy with mild bulging of the TM and ear-pulling for 2 weeks
b. A 6-month-old boy with mild bulging of the TM
c. A 6-year-old boy with severe bulging of the TM
d. None of the above
3. Which antibiotic should be initiated in a 15-month-old girl diagnosed with uncomplicated bilateral AOM?
a. Amoxicillin 45 mg/kg/day divided into 2 doses
b. Amoxicillin 80-90 mg/kg/day divided into 2 doses
c. Ceftriaxone 50 mg/kg intramuscular injection x 1
d. Clindamycin 30-40 mg/kg/day in divided into 3 doses
4. In which patient is observation an inappropriate form of management?
a. A 3-year-old with unilateral AOM and severe otalgia for 48 hours
b. A 10-month-old with unilateral AOM and fever to 38.5C for 48 hours
c. A 10-month-old with bilateral AOM and fever to 38.5C for 48 hours
d. A and B
e. A and C

EM Practice Guidelines Update 2014

www.ebmedicine.net May/June 2014

| print | SUBSCRIBE | WEBSITE

Updated Guidelines For Diagnosis And Management Of Acute Otitis Media

CME information for EM Practice Guidelines Update

To take the CME test, visit: www.ebmedicine.net/G0514

To contact the Editor-In-Chief, email Sigrid Hahn, MD, MPH at:

[email protected]

Date of Original Release: May 1, 2014. Date of most recent review: April 15, 2014. Termination date: May
1, 2017.
Accreditation: EB Medicine is accredited by the Accrediting Council for Continuing Medical Education (ACCME)
to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the ACCME.

EM Practice Guidelines Update (ISSN Online: 1949-8314) is published bimonthly

(6 times per year) by EB Medicine
5550 Triangle Parkway, Suite 150; Norcross, GA 30092
Telephone: 1-800-249-5770 or 1-678-366-7933; Fax: 1-770-500-1316
Email: [email protected] Website: www.ebmedicine.net

Credit Designation: EB Medicine designates this enduring material for a maximum of 2 AMA PRA Category 1
Credits. Physicians should claim only credit commensurate with the extent of their participation in the activity.
Needs Assessment: The need for this educational activity was determined by a survey of practicing
emergency physicians and the editorial board of this publication; knowledge and competency surveys; and
evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.

CEO and Publisher: Stephanie Williford

Director of Editorial: Dorothy Whisenhunt
Content Editor: Erica Carver
Editorial Projects Manager: Kay LeGree
Director of Member Services: Liz Alvarez
Office Manager: Kiana Collier
Member Services Representative: Paige Banks
Director of Marketing: Robin Williford
Marketing Coordinator: Katherine Johnson
Marketing Communications Specialist: Aron Dunn

Goals: Upon completion of this article, you should be able to: (1) demonstrate medical decision-making
based on the strongest clinical evidence, (2) cost-effectively diagnose and treat the most critical ED presentations, and (3) describe the most common medicolegal pitfalls for each topic covered.
Objectives: Upon completion of this article, you should be able to: (1) apply knowledge of criteria for diagnosing AOM and recognize differences between AOM and other ear infections, such as OME; (2) identify patients
that can be observed for a period versus prescribing immediate antibiotics; and (3) assess patient history and
local susceptibility to prescribe the most appropriate medication.
Discussion of Investigational Information: As part of the newsletter, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration-approved
labeling. Information presented as part of this activity is intended solely as continuing medical education
and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning
or implementation of a sponsored activity are expected to disclose to the audience any relevant financial
relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to
complete a full disclosure statement. The information received is as follows: Dr. Kahne, Dr. Hahn, Dr.
Jagoda, and their related parties reported no significant financial interest or other relationship with
the manufacturer(s) of any commercial product(s) discussed in this educational presentation.

Opinions expressed are not necessarily those of this publication. Mention of products
or services does not constitute endorsement. This publication is intended as a general
guide and is intended to supplement, rather than substitute, for professional judgment.
It covers a highly technical and complex subject and should not be used for making
specific medical decisions.

Commercial Support: This issue of EM Practice Guidelines Update did not receive any commercial support.
Method of Participation: Current, paid subscribers of Emergency Medicine Practice and EM Practice
Guidelines Update who read this EM Practice Guidelines Update CME article and complete the online CME
Evaluation survey at www.ebmedicine.net/CME are eligible for up to 2 hours of Category 1 credit toward
the AMA Physicians Recognition Award (PRA). Hints will be provided for each missed question, and participants must score 100% to receive credit. Results will be kept confidential. CME certificates may be printed
directly from the website.

The materials contained herein are not intended to establish policy, procedure, or
standard of care. EM Practice Guidelines Update is a trademark of EB Medicine.
Copyright 2014 EB Medicine. All rights reserved. No part of this publication may be
reproduced in any format without written consent of EB Medicine. This publication is
intended for the use of the individual subscriber only and may not be copied in whole
or part or redistributed in any way without the publishers prior written permission
including reproduction for educational purposes or for internal distribution within a
hospital, library, group practice, or other entity.

EM Practice Guidelines Update 2014

Hardware/Software Requirements: You will need a PC or Macintosh to access the online archived articles
and CME testing. Adobe Reader is required to view the PDFs of the archived articles. Adobe Reader is
available as a free download at www.adobe.com.
Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit:
http://www.ebmedicine.net/policies.

10

www.ebmedicine.net May/June 2014

| print | SUBSCRIBE | WEBSITE

Updated Guidelines For Diagnosis And Management Of Acute Otitis Media

Check Out The EM Practice Guidelines Update Archives

Publication Date

Issue Title

Link

# Free CME
Credits

February 2012

Low-Risk Chest Pain In The ED: Current Guidelines

www.ebmedicine.net/ChestPain

March 2012

Neck Trauma: Current Guidelines For Emergency Clinicians

www.ebmedicine.net/NeckTrauma

April 2012

Unstable Angina And Non-ST-Elevation Myocardial Infarction In The ED: Current Guidelines

www.ebmedicine.net/NSTEMI

May 2012

Current Guidelines On Atrial Fibrillation In The ED

www.ebmedicine.net/Afib

June 2012

Current Guidelines For The Management Of Hypertension In The ED

www.ebmedicine.net/Hypertension

July 2012

Current Guidelines For The Management Of Pneumothorax In The ED

www.ebmedicine.net/Pneumothorax

August 2012

Guidelines For The Management Of Cystitis And Pyelonephritis In The ED

www.ebmedicine.net/Cystitis

September 2012

Current Guidelines For Management of Acute Altitude Illness, Frostbite, And Snake Envenomation (Trauma CME)

www.ebmedicine.net/Envenomation

October 2012

American Heart Association Guidelines For The Emergency Clinician: Cardiac Arrest In
Special Situations And First Aid (Trauma CME)

www.ebmedicine.net/CardiacArrest

November 2012

Percutaneous Coronary Intervention: Current Guidelines For The ED

www.ebmedicine.net/PCI

December 2012

Current Guidelines For Evaluating And Managing Symptomatic Early Pregnancy In The ED

www.ebmedicine.net/EarlyPregnancy

January 2013

Current Guideline For The Neurodiagnostic Evaluation Of The Child With A Simple Febrile
Seizure

www.ebmedicine.net/PedFebSeizure

February 2013

Current Guidelines For The Evaluation And Management Of Community-Acquired Pneumonia In The ED

www.ebmedicine.net/CAP

March 2013

Current Guidelines For Management Of Bell Palsy And Herpes Zoster In The ED

www.ebmedicine.net/BellPalsy

April 2013

Current Guidelines For The Management Of Severe Sepsis And Septic Shock

www.ebmedicine.net/Sepsis

May 2013

Current Guidelines For The Management Of Community-Acquired Pneumonia In Children

www.ebmedicine.net/PedCAP

June 2013

Guidelines For The Evaluation And Management Of Upper Gastrointestinal Bleeding

www.ebmedicine.net/UGIBleeding

July 2013

Guidelines For The Evaluation And Management Of Acute Cerebrovascular Syndrome Part
I: Diagnosis And Evaluation Of Transient Ischemic Attack (Stroke CME)

www.ebmedicine.net/TIA

August 2013

Guidelines For The Evaluation And Management Of Acute Cerebrovascular Syndromes Part
II: Evaluation And Management Of Acute Ischemic Stroke (Stroke CME)

www.ebmedicine.net/Stroke

September 2013

Guidelines For The Management Of Pediatric Severe Sepsis And Septic Shock

www.ebmedicine.net/PedSepsis

October 2013

Current Guidelines On HIV Postexposure Prophylaxis For Nonoccupational Exposures,

Including Sexual Assault

www.ebmedicine.net/HIVPostexposure

Nov/Dec 2013

Current Guidelines For The Evaluation And Management Of Concussion In Sport

www.ebmedicine.net/SportConcussion

Jan/Feb 2014

Current Guidelines For The Evaluation And Management Of Heart Failure

www.ebmedicine.net/HeartFailure

Mar/April 2014

Current Guidelines For The Diagnosis, Treatment, And Prevention Of Clostridium difficile
Infection

www.ebmedicine.net/CdiffGuidelines

EM Practice Guidelines Update 2014

11

www.ebmedicine.net May/June 2014

| print
| SUBSCRIBE|| WEBSITE
| WEBSITE
|| PRINT
|| SUBSCRIBE
PRINT
SUBSCRIBE
WEBSITE

Updated
Guidelines
For Acute
Diagnosis
And
Management
Of AcuteGuidelines
Otitis Media
Benign
Benign
Paroxysmal
Positional
Vertigo
and
Otitis
Externa
the
Benign
Paroxysmal
Positional
Vertigo
And
Acute
Otitis
Externa
Inin
The
ED: Current
Current Guidelines
BenignParoxysmal
ParoxysmalPositional
PositionalVertigo
VertigoAnd
andAcute
AcuteOtitis
OtitisExterna
ExternaIn
inThe
the ED:

Want to receive EM Practice Guidelines Update free?

Years

Subscribe
Subscribe to
to Emergency
Emergency Medicine
Medicine Practice
Practice and
and youll
youll receive
receive EM
EM Practice
Practice Guidelines
Guidelines Update
Update at
at no
no additional
additional charge!
charge! Plus,
Plus, you
you
receive
receive all
all the
the benefits
benefits of
of Emergency
Emergency Medicine
Medicine Practice:
Practice:

A chief-complaint focus: Every issue starts with a patient complaint just like your daily practice. Youre guided step-by-step
A chief-complaint focus: Every issue starts with a patient complaint just like your daily practice. Youre guided step-by-step
in reaching the diagnosis often the most challenging part of your job.
in reaching the diagnosis often the most challenging part of your job.

An evidence-based medicine approach: The degree of acceptance and scientific validity of each recommendation is assessed
An evidence-based medicine approach: The degree of acceptance and scientific validity of each recommendation is assessed
based on strength of evidence.
based on strength of evidence.

Diagnosis and treatment recommendations solidly based in the current literature.
Diagnosis and treatment recommendations solidly based in the current literature.

Evidence-B
ased Appro
ach
ToEv
Dia
idegn
nce
os-Ba
is An
sedd Ap
Mapro
nage
OfTo
achment
AnDia
eugn
rysosi
maslAn
SudbaMa
rac
nag
HeOf
hnem
moAn
oident
rrheur
agysm
e InalThSu
e bar
Emach
ergno
DeHe
enid
pamo
cy
rtmrrh
enage
t In The

Year

s
Improving Patien

t Care

Improving Patient

July 2009

Authors

Care

Number 7

July 2009

Volum
s, MD
Departm
Authorsent of Emerge e 11, Number
7
Hospital &
ncy Medicin
Massac
e, Brigham

husetts Genera
Lisa Thoma
& Women
Jonath
s
l Hospital,
an Edlow
s, MD
ADD
Boston, MA
, MD

Vice Chair,
Department
Jonath
Beth
Israel
anDeacon
Edlow, MDof Emergency Medicin
ADD
ess Medica
[_auth
Medicin
e
orname]
e, Harvard
l Center;
Associate
Medica

Emergency

Department

Volume 11,

Lisa E. Thoma

You walk into

Peer Review
l School,
Joshu
a N. Golds
Boston, MA Professor of
a crowded
ers
tein, MD,
Instructor
Your first patien
evening shift
PhD, FAAEM
in Surgery
ADD
in the emerg
(Emergency
School,
t is a middl
You walk into
her head,
Medicine),
ADD Department of
ency depart
Genera
Harvard Medica
complaining
Emergency
a crowdede-aged woman lying
Medicine,
evening shift
ADD l Hospital, Boston,
with her handsment (ED).
aboutYour
first patien of the
Massachusetts l
wors
MA
a subara
Peer
t headain the
is a middle
ADD Reviewers
chnoidt hemor
ency departclutching
head, compl
-aged womache ofemerg
her life.
noncoher
ntrast
aining of rhage
n lying
(SAH). You
CME
(ED).
head compu
arement
E.
Objectives
with herYou
about a subara
worrie
the wors
Brads
haw Bunne
d
says that
ted tomog
hands clutch
t headachetreat her pain
Associa
her headachnoid
y, MD, FACEP
raphy
of her life. and order
hemorrhage
Upon complet
te Profess
(CT), which
che is better
ntrast head
aing
ion ofor,this
You are worrie
kids. nonco
Residen
(SAH
Emerge
is
Does
1.
).
cy
article,
and
negati
ncy
compu
You
Director Departm
Describe
Medicin
she really need ted tomog
that she needstreat her pain ve. She nowd
says that
the e, Univers you should, be
Chicago
ent of
able to:
her headac a lumba
raphy (CT), to go home and order
presenta
ity of
to stay
, IL the classic
discuss
for an LP,
he is better r punct
of an SAH
at Chicago
wide spectrum tionIllinois
which is negati
kids.
to pick up a
2. Describe
Neal
as well, as
Does shewhich
Little, MD,
and thature
of presenta
(LP)?
her
the
need any additi
ve.
also
really is
diagnos
She
she
tion.
FACEP
Adjunct
needs to goeventually She now
need a negati
of having
Clinical Assista tic approach to a
lumbarve.
onal worku
She eventu
Can she
agrees
patient suspect
3. Identify SAH.
punctu
Medicin
go home home
ally agrees
pick
p? to
While
re (LP)?
e, Univers
up her
the major nt Professor, Departm
ed
now?toDoes
go home
you
stay for an
are thinki
modalities. ity oflimitation
ent of Emerge
Michiga
now?
s
she
in
interpret
n
migraine arrive
CME
Does she
ng need
LP, which
Medical School,
aboutany
Objectives
ing the diagnos ncy
4. Discuss
this,
is also negati
While you
Ann Arbor,
anoth
s compl
general principle
tic MI
additio
er worku
ainingngof sudde
patient with
ve.
are thinki
lastedgraine
nal
Uponthe
s of acute
ED.
12 hours
she
comple
p?
SAH manage
about this,
a historyCan
tion of this
n-ons
arrive
. Iss compl
Identify common
this heada
et, severe
1.5. Describ
ment in
of
article,
anothe
SAH?
aining
r patien
cheofher
heada
e the
pitfalls in you should be
12After
hours.furthe
chea that
t with
sudden
usual
the diagnos
able to:
Is this
discuss the classic present
migra
-onset
r histor
history
hasof miation of an
is of SAH.
headacyheisher
, severe
ine orheadac
and you
wide spectru
You obtain
SAH as well
obtain
2. Describ
couldhethis
are concer
usual
m
ed,
of
present
as
e
a
you
migra
that
be
the
CT,
Date diagnos
nedwhich
anlasted
are
has
ation.
ine concer
of original
after furthe
someobtain
or could
tic approac
having an
is norma
clearinagCT,
ned
r history
this
h to patient
about
SAH.of most release:
July
l. Youisperfor
be anan
of red
which
3. Identify Date
SAH?
SAH
obtainmedan
recent review: 1,a 2009
blood
suspected
is norma
it may
the Termina
cells (RBC
of have
about
major limitatio
red blood
of
l. perfor
LP,
ADD
tion
an
which
date:
beencells
modalit
s)
SAH
m
ns July
from
an LP,
shows
a traum
in interpre
ies. Medium
(RBCs
and you
1, 2012
tubewhich
pondebeen
) from
atic
1 to tube
4. Method
shows4,some
tap, tube
Discussofgeneral
ringathis,
participation:: Print and online ting the diagnostic
traum
but how
1 to tube
and you
atic
the
clearin
Print or online
principle
can you
labtap,
4, and
buttohow
think
g
the ED.
calls
diagnthe
s of acute answer
you
be
sure?
can
osislab
say
calls
think
evaluati
Prior
SAH
form
be is
of SAH.
there
to After
Justitas
sure?
5. Identifyto beginnin
manageand
on
say there is
may
Just
xanth
youhave
ment in
common g this activity,
as you
After
are
ochrom
should
callingxanthochrom
see Physici
Informapitfalls
youcalling
ponde
You
tion oninthe
do for ED urgicafor neuro
the diagnos
ia. You make ia.are
ring
make
CME
surgic
back page.
thethis,
is ofan
ED to treatin the neuros
al consuthe diagno
SAH.
Date of original
l consultation
this patiento treat this
sis ofelse
patient? , what elseltation
, what
release: July
Date of most
SAH.
t?
1, 2009
should
recent
you do in the

Editor-in-Ch

ief
Andy Jagoda,
Editor-in-Chie
MD, FACEP
f
Professo
Andy
Jagoda,
r and
Chair,MD,
Departm
of Emergen
FACEP
Professor
cy Medicine
and Vice-Chaent
Sinai School
, Mount
Academic
ir of
Affairs, Departme
of Medicine
Director,ofMount
; Medicalnt
Emergency
Sinai Medicine
Sinai School
York, NY
Hospital,, Mount
of Medicine New

Director, Mount
; Medical
Editorial
Sinai Hospital,
York,

Chattano
oga, TN
Professor
Michael
, UT College
A. Gibbs,
of Medicine Charles V. Pollack,
MD,
Chief,Chattano
, FACEP
Jr., MA, MD,
Departmoga, TN FACEP
Charles V.
Pollack, Jr.,
Michael A. ent of Emergen
Medicine
cy
, Maine
Chairma
FACEP
MA, MD,
Gibbs,
Medical
MD,Center,
n, Departm
Chief,
Portland
FACEP
Departme
ent
, ME
Chairman
Emergen
nt of Emergen
, Departme of
cy Medicine
Medicine

Termination review: April 27,

2009
date: July
1, 2012
Medium:
Prior to beginni
Print and
online
ng this activity,
see Physic
Information
ian CME
on page 27.

University
Medical Center,
University
Nashville
, TN
Medical Center,
Nashville

Internationa

Steven A.
,
Hospital,
Jenny Walker,
Godwin,
University Pennsylv
Board
Center,
NY
International l Editors
, Pennsylvania
Hospital,
ME MD, FACEP
NewAssistan
MD,
Health
William J.
Universityof Pennsylv
Assistan
ania Jenny
System,
Walker, MD, MPH, MSW
t Professo
Peter Camero Editors
Brady, MD
Philadelp
of Pennsylvania
Steven
Editori
Health System,
r and Emergen
MPH, MSW
Medicine
Assistantt Professo
A. Godwin,
hia,
n, MD
al Board
Professo
Peter
Family
Residenc
Professorr; Division
Cameron
Chair,
r of Emergen
Medicine
MD, FACEPcy Michael S. Radeos,Philadelphia,PA ania
Assistant
Emergen
William
y Director,
; Division Chief,
, MD
Universit
Michael S.
Professor
and Medicine
J. Brady,cy Medicine
ofFamily
cy Medicine
Chair,
Medicine,, Departm
MD, MPH PA
Commun
y of Florida
Assistan
entChief,
Monash
Emergen
Radeos,
and Emergen
MD
Medicine
Departme
t Professo
Vice Chair
Professor
HSC,
of Community and
cy Medicine ,
Universit
Jacksonv
Assistant
Residenc
Preventiv
Emergen
cy Medicine
nte
Monash
MPH
Medicine
r ofMD,
of Emergen
of
ille, FL
ity and Preventiv
Emergen
, Hospital,
y Director,
Professor
Melbourn
cy Medicine
University y; Alfred
University
Medicine
and
cy Medicine
, Weill
Medicine,, Mount
cy
of Emergen
; Alfred Hospital,
Medicine
Sinai Medical
of Florida
Medical
, Universit
Melbourn e, Australia
of Virginia
e
Center,
Mount Sinai
Gregory
Cornell
, Weill
cy
HSC,
e, Australia
Jacksonv
y
School of Vice Chair of
MedicalCollege
Emergen
Universit
L. Henry,
Center, New
York, NY Medical
Amin Antoine
Cornell
ille, MD,
Collegeof
Medicine,
cy Medicine
Charlotte
New York,
FL FACEP
y, New York,
University
Amin Antoine
Kazzi, MD,
NY
, University CEO,
of sville,
Medical
, New York,NY. of Ron
Robert L.
Virginia
VASchool
Gregory
Associat Kazzi,
Ron M.
FAAEM
NY.
Rogers, MD,
Robert L.
M. Walls,
Henry, MD,
MD, FAAEM
Assessment,L. Practice
Associate e Professo
of Medicine
Walls, MD
Risk
Peter DeBlieux
Charlotte
Professo
Rogers,
FAAEM, FACP
CEO, Medical
Professor r and
FACEP
Chair, Departm
,
sville, VA
Inc.; Clinical
Professor andMD
Vice
, MD
FAAEM, FACP MD,FACEP,
FACEP,
Chair, Departm
Chair, Departme
of Emergen
PracticeProfesso
r and Chair,
Vice
Professo
ent and
of
Assessm
of Emergen
Assistan
Risk
Peter
cyent,
Medicine,
r ofDeBlieux
of Emergen
Department
Medicine
nt of Emergen
ent
Emergency Medicine
Clinical, Medicine
Assistant
t Professo
Medicine
of Michigan
Inc.; , Universit r
Universit
LSU Health
cy Medicine Brigham
MD
and
Professo
cy cy
, University
r of
of Emergen
Medicine
Professo
of California
Irvine; American
, AnncyArbor,Clinical
Professor
y
and Womens
,
r ofEmergen
Science
Medicine
Womens Hospital ,,Brigham
ofy California
Emergen
Irvine;
, The
r of Clinical
cy
MI ,
Universit
American Universit
DirectorLSU
Center;
, The
Hospital,,Harvard
cy
Medical
of Michigan Medicine
, ,
Universit
Medical School,
Lebanon
y yofof
of Emergen
University y, Beirut,
Harvard
Health Science Medicine, John M.
Maryland
Howell, MD,
Lebanon
, Ann Arbor, University Maryland
School
School, Boston,
, Beirut,
Boston,
cy Medicine
School
Services
ofof
Director
Medicine
Center;
FACEPMI
Clinical
Baltimor
MA
John
, Universi
Scott
Medicine
Baltimore
MA
of
Professo
Scott
M.
e,
,
Weingar
Emergen
Hugo Peralta,
MD
Howell,
,
ty Hospital
, MD
Weingart,
Hugo
Orleans,
r of MD,
cy ,Medicine
t, MD
Services
Peralta, MD
Emergen
Medicine
MD
FACEP
Clinical
New
MD
LA
Assistan
, Universit
cy
Alfred
Assistantt Professo
, George
Professor
Alfred
Chairofof Emergen
Chair
Sacchet
y Hospital,
Sacchett
Professo r of
Washing
of Emergen
Emergency cy
Medicine
ti, MD,
Wyatt W.Orleans, LA
Medicine
ton cy
r of Emergen
i, MD,
NewUniversit
Medicine,
Emergen
y, Washing
Assistan
FACEP
, George
Services,
Assistant
FACEP
Hospital Italiano,
Services,
Decker, MD
Hospital
, Elmhurs
cy
Elmhurstt Hospital
cy
t Clinical
ton,Washington
Clinical
of Academi
Italiano, Buenos
University
Chair Wyatt
Center,
Hospital
Center, Mount
Professo
Professor
Buenos
Departm
, WashingtDC;Direc
W. Decker,
Departme
and Associat
c Affairs,
tor
Argentina
Argentina
Mount Sinai
r, ,
Aires,
Aires,
ent nt
Beston,
Sinai School
Inc, Inova
of Academic
MD
of of
DC;Director Thomas
Emergency
Emergen
Practices
Chair and e Professo
Emergen
Medicine
Schoolofof
Medicine
Thomas Jefferson
Fairfax Affairs,
cy Medicine
r of
cy Medicine
,
Associate
Medicine,
,, New
New York,
Hospital,
Jefferson University
Maarten
Best
Inc, Inova
Maarten
Church,
York, NY
Practices Philadelp
, Resea
, MayoProfessor
CollegeEmergen
Falls
NY
Simons,
University, ,
Philadelp
VA
Simons,
Fairfax Hospital,
cy Medicine
Clinic of
,
of Medicine
Research
MD,
MD,
Church,
hia,hia,
Emergen
PhD
rch Editor
Emergen
PhD
, Mayo Clinic
PAPA
College
Falls
, Rocheste
Editorss
cycy
Medicine
of Medicine
Medicine
Francis M.
r, MN Keith A. Marill,VA
Scott Silvers,
Scott
Director,
Residenc
, Rocheste
Director,
Residenc
Silvers, MD,
MD
Fesmire,
Keith A. Marill,
OLVG
Nicholas
y y
MD, FACEP
Francis
OLVG
Assistant
Nicholas
r, MN
Hospital,
MD, FACEP
Director,
Medical Director,
Genes, MD,
FACEP
Hospital,
M. Fesmire,
Amsterda
Medical
Professor,MD
Genes,
Amsterdm,
Heart-St
Assistant
Director, Departm
MD, PhD
Chief Resident,
MD, FACEP Emergen
The
Department
am,
Departme
roke Center,
Chief
Netherlan
The
Emergen
Professor
ErlangerDirector,
Netherla
Resident, MountPhD
cy Medicine
Emergen
dsnds
, Departmeof
MedicalHeart-Str
Emergenc
Medicine, entntofof
Emergency
Mount Sinai
cy cy
Erlanger
, Massach
Center,
General
Medicine
Center;oke
nt
Emergen
y
Jacksonv
Mayo
of
Sinai
Medicine
Professo
Medical
Medicine
Hospital,
Assistant
usetts
Clinic,
Jacksonv ille, FL , Mayo Clinic,
cy Medicine Residenc
r, UT College Center;
General Hospital,
New York,
Harvard, Massach
ille, FL
Assistant School,
Residency,
New
Medical usetts
of Medicine
NY
Boston, MA Harvard
York, NY
y,
School,
Corey M.
Medical Corey
,
Boston, MA
Slovis, MD,
Lisa Jacobso
Accreditation:
M. Slovis,
Accredi
FACP, FACEP Lisa Jacobso
Professo
n, MD
tation: This This activity
FACP, FACEP
Mount Sinai n,
Professor r andMD,
(ACCME
Chair,
MD
of Emergen
Departme
Chief Resident
and Chair,
activity has has been planned
) through
(ACCME)
of Medicine
Emergency School
cy Medicine
of Emergen
Departmentnt
the sponsors
been planned
through
, Mount
and impleme
,
of
, Vanderbi
cy Medicine
Sinai School
Medicine,Medicine
hip
Thomas, Thomas, Dr. the
sponsor
Edlow,
New
implementednted in accordan
Medicine
Dr.
York, NYEmergenResidenc
, Vanderb lt Residenc
and ship of EBof EB and
y,
ilt
ce with the
Medicin
discussed Edlow, Dr. Bunney, their related
in accorda
y, New York, cy Medicine
parties e. EB. EB Medicine
is accredite
Essentials
Dr. Little,
nce with
in this educatio educatio
Medicin
NY
nal presenta
and their report no
and Standard
significa
d by the
e isntaccredit
the Essentia
nal presenta
tion.related
ACCME to
financialed
ls and
Comme
parties
by the ACCME
tion. Dr. Goldste
Standardss of the Accredit
interest
provide
rcial Support
report no
or other relations
ofg the
to provide continuin
Council
significa
in has received
: This
Accreditation
medical
issuent
hip with
continui
ation Councilfor Continuing
of financia
Emergen
consulti
the manufac
ng medical educatio
l interest
n for physicia
cy
for Continu Medical Educatio
or other
turer(s)
educatio
Practice did ng fees from GenenteMedicine
Practice
ing Medical
of any ncommer
relations
n
for physicians. Faculty
did not
hip with the
not receive
ch
ns. FacultyDisclosuEducatio
re:
any commer and CSL Behring. receive
manufac cial product(
any
s) discusse
Disclos Dr. n
Commercial commerturer(s)
cial support
cial support.
of any commer d inure:
thisDr.
Suppor
.
Portland,

, Maine Medical

cy

Emergency

Medicine

nt of

, TN

Abundant clinical pathways, figures, and tables: Youll find reliable solutions quickly. The easy-to-read format delivers solid
Abundant clinical pathways, figures, and tables: Youll find reliable solutions quickly. The easy-to-read format delivers solid
information appropriate for real-time situations.
information appropriate for real-time situations.

Unlimited online access: Search and access each monthly issue of Emergency
Unlimited online access: Search and access each monthly issue of Emergency Medicine
Medicine Practice since inception in June 1999 plus print and read
Practice since inception in June 1999 plus print and read
each new issue before it even hits the mail.
each new issue before it even hits the mail.

All the CME you need at no extra charge: Earn up to 48
All the CME you need at no extra charge: Earn up to 48 AMA
AMA PRA
PRA Category
Category 11 Credits, 48 ACEP Category 1, 48 AAFP Prescribed, or 48 AOA Category
Credits, 48 ACEP Category 1, 48 AAFP Prescribed, or 48 AOA Category
2B credits over the coming year-plus up to 144 credits from the online repository of articles!
2B credits over the coming yearplus up to 144 credits from the online repository of articles!
t: This issue

cial
of Emergen product(s)
cy Medicin
e

Subscribe to Emergency
Subscribe to Emergency Medicine
Medicine Practice today and receive EM
Practice today and receive EM Practice
Practice Guidelines
Guidelines Update at no additional charge! Or, subscribe to
Update at no additional charge! Or, subscribe to
EM
Practice
Guidelines
Update only at the discounted rate below. To subscribe, complete the order form below and mail or fax it to EB Medicine,
EM Practice Guidelines Update only at the discounted rate below. To subscribe, complete the order form below and mail or fax it to EB Medicine,
or visit www.ebmedicine.net/subscribe.
or visit www.ebmedicine.net/subscribe.

Do
Do you
you like
like what
what youre
youre reading?
reading?

askspecial
a colleague
to become
subscriber
year
at this
rate:
Just $279
for a full
year
(12receive
issues)EM
of Emergency
MedicineUpdate
Practice.
Then subscribeThen
at this
discounted
rate: a
Just
$249 fortoo
a full
(12special
issues)introductory
of Emergency
Medicine
Practice.
Plus,
you
Practice Guidelines
absolutely FREE!
Plus, you receive 3 free issues for each colleague you refer. Emergency Medicine Practice subscribers receive EM Practice Guidelines Update FREE!
Please choose your subscription preference
Please choose your subscription preference

First & Last Name: _________________________________________________________

Name of new subscriber: ____________________________________________________

1-Year subscription to Emergency Medicine Practice, includes

1-Year subscription to Emergency Medicine Practice, includes
EM Practice Guidelines Update - $249 (a $50 savings)
EM Practice Guidelines Update - $279 (a $50 savings)
1-Year subscription to EM Practice Guidelines Update - $99
1-Year subscription to EM Practice Guidelines Update - $99

Address line 1: ___________________________________________________________

Address line 1: ___________________________________________________________
Address line 2: ___________________________________________________________
Address line 2: ___________________________________________________________

Please choose a payment option

Please choose a payment option

Check enclosed (payable to EB Medicine)

Check enclosed (payable to EB Medicine)
Charge my:
Visa
MC
AmEx: ________________________________________ Exp: _____
Charge my:
Visa
MC
AmEx: ________________________________________ Exp: _____
Signature: _______________________________________________________________________
Signature: _______________________________________________________________________
Bill me
Bill me

City, State, Zip: ___________________________________________________________

City, State, Zip: ___________________________________________________________
Email: __________________________________________________________________
Email: __________________________________________________________________
Colleagues name who referred you: __________________________________________

Promotion Code: NE12AD

Promotion Code: ISSUEG

Send to: EB Medicine / 5550 Triangle Pkwy, Ste 150 / Norcross, GA 30092. Or fax to: 770-500-1316.
Send to: EB Medicine / 5550
Pkwy,
Ste Code
150 / Norcross,
30092.
Or call:
fax to:
770-500-1316.or 678-366-7933.
Or visit: www.ebmedicine.net/subscribe
and Triangle
then enter
Promo
NE12AD inGA
your
cart. Or
1-800-249-5770
Or visit: www.ebmedicine.net/subscribe and then enter Promo Code ISSUEG in your cart. Or call: 1-800-249-5770 or 678-366-7933.

EM Practice
Practice Guidelines Update
Update 2014
EM
EM Practice Guidelines
Guidelines Update 2009
2009

11 12

www.ebmedicine.net
May/June 2014
EBMedicine.net
ebmedicine.net November
EBMedicine.net
November 2009
2009