Emergency Medicine by Alexandros G. Sfakianakis: Ιουλίου 2016

Κυριακή 31 Ιουλίου 2016

Modification of Scalpel Finger Bougie Technique

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No more bougie hold-up for scalpel-finger-bougie cric

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To be g o o d , you must train - A l o t t ..! Camp Torpomoen

Training cost money... ( A 135 took a bath some years ago, during training, water-jobs :-/ -Crew OK :-) ).It is staff, and helos. enough for all bases to have serviced machines att anny time, and a dedicated training-helo, for use att training-base, or touring lokal bases, for shorter training sessions, around contry. The Gov. pays for the daily operation, but members pay for mutch of "the extra" ... Permanent trainig base, Hiering the best experts from around the world, to learn more in different skills, research, Response-car for all crews on stand-by, more... Like "HEMSwx"-Cameras:Advanced safety camera with two7three DSLR Cameras.Taking pics. every quarter.Images sent via mobile net.to all air ambulance bases in country.Images on big screen on bases operating theaters or on tablet / smartphone.Provides very good pictures,especially at night.Also provides information on temperature and airpressure.Today,deployed 32"HEMSvx"Cams. across country,goal =40 more w.i.this year.ExEMTNor

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To be g o o d , you must train - A l o t t ..! Camp Torpomoen

Training cost money... ( A 135 took a bath some years ago, during training, water-jobs :-/ -Crew OK :-) ( I can almost here "That" phone-call: Ehh, - hi boss... You know that 135 att Torpomoen, it -got a bitt wet... "Cheef- pilote": Hmmm, -OK, i`l send you a new one... ). It is staff, and helos. enough for all bases to have serviced machines att anny time, and a dedicated training-helo, for use att training-base, or touring lokal bases, for shorter training sessions, around contry. The Gov. pays for the daily operation, but members pay for mutch of "the extra" ... Permanent trainig base, Hiering the best experts from around the world, to learn more from the best in different skills, research, Response-car for all crews on stand-by, more... Like "HEMSwx" Cameras att strategic places all around contry, giving real-time info to crews, -at base, or in flight. This video full screen: https://youtube/-ySUNO7BaV8 ExEMTNor

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Cannabis Hyperemesis Syndrome in the Emergency Department: How Can a Specialized Addiction Team Be Useful? A Pilot Study

Publication date: Available online 30 July 2016
Source:The Journal of Emergency Medicine
Author(s): Fanny Pélissier, Isabelle Claudet, Peggy Gandia-Mailly, Amine Benyamina, Nicolas Franchitto
BackgroundChronic cannabis users may experience cyclical episodes of nausea and vomiting and learned behavior of hot bathing. This clinical condition, known as cannabis hyperemesis syndrome, was first reported in 2004.ObjectiveOur aim was to promote early recognition of this syndrome in emergency departments (EDs) and to increase referral to addiction specialists.MethodsCannabis abusers were admitted to the ED for vomiting or abdominal pain from June 1, 2014 to January 1, 2015 and diagnosed with cannabis hyperemesis syndrome by a specialized addiction team. Then, medical records were examined retrospectively.ResultsSeven young adults were included. Their mean age was 24.7 years (range 17−39 years) and the majority were men (male-to-female ratio 1.2). Biological and toxicological blood samples were taken in all patients. Tetrahydrocannabinol blood level was measured in 4 patients, with a mean blood concentration of 11.6 ng/mL. Radiographic examination including abdominal computed tomography and brain imaging were negative, as was upper endoscopy. Five patients compulsively took hot baths in an attempt to decrease the symptoms. Treatment was symptomatic. Five patients have started follow-up with the specialized addiction team.ConclusionsCannabis hyperemesis syndrome is still under-diagnosed 10 years after it was first described. Physicians should be aware of this syndrome to avoid repeated hospitalizations or esophageal complications. Greater awareness should lead to prompt treatment and prevention of future recurrence through cannabis cessation. Addiction specialists, as well as medical toxicologists, are experts in the management of cannabis abusers and can help re-establish the role of medical care in this population in collaboration with emergency physicians.

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LPN, Paramedic - CSL PLASMA

Job Description 1 Promotes positive customer relations with all donors. 2 Conducts confidential and effective interviews with donors to obtain necessary information regarding suitability to donate plasma. 3 In conjunction with the Center Medical Director and/or Center Physician responds to medically related questions from staff including donor suitability and provides information to staff on medically ...

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Σάββατο 30 Ιουλίου 2016

Pinnacle Conference recognizes, honors EMS leaders

SAN ANTONIO — Three EMS leaders were honored with awards last week at the 11th annual Pinnacle EMS Leadership Forum, a national conference for senior EMS leaders representing all types of service delivery.

Richard Hunt, MD, Senior Medical Advisor at National Healthcare Preparedness Programs, David Page, M.S., Director of the Prehospital Care Research Forum at UCLA and Richard Zuschlag, Founder and CEO of Acadian Ambulance Service, were each recognized for their exemplary work helping to advance EMS as a profession.

Hunt received the Joseph P. Ornato Award for Clinical Leadership in EMS. The award—named after the luminary professor, researcher and medical director for the Richmond Ambulance Authority —is presented each year to an individual who exemplifies both an unwavering commitment and an innovative approach to advancing clinical leadership in EMS.

“Rick is a natural leader, and it springs from a patient-centered approach to every job he’s ever taken, whether at the CDC, the White House, or as a medical director,” Keith Griffiths, a long-time colleague of Dr. Hunt said as he presented the award.

Dr. Hunt serves as Senior Medical Advisor for the National Healthcare Preparedness Programs in the Office of the Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services. Previously, Dr. Hunt was Distinguished Consultant and Director of the Division of Injury Response at the National Center for Injury Prevention Control at the Centers for Disease Control and Prevention.

Page was presented with the Pinnacle EMS Leadership Award. Presented each year, the award recognizes an individual who has made an outstanding contribution to advancing the EMS profession through a leadership role.

“David has been the inspiration behind the Freedom House EMT training initiative, providing opportunities for individuals from diverse and disadvantaged backgrounds to enter the EMS field,” Jay Fitch, PhD, founding partner of Fitch & Associates said. “Pinnacle recognizes the importance of this program and Page’s leadership to make it a reality.”

Page is the director of the Prehospital Care Research Forum at UCLA. He has over 30 years of active service in EMS and continues to work as a field paramedic for Allina Health EMS in the Minneapolis/Saint Paul area.

Zuschlag was honored with the Lifetime Achievement Award. This award, presented only once before in Pinnacle history, recognizes an individual who has made a significant impact on EMS over his or her career.

“At his core, Richard is an innovator — and some of those innovations have truly shaped our profession,” Fitch said. “Much of Acadian’s focus on service, growth and innovation has been a result of Richard’s ideas, business sense and tenacity.”

Richard Zuschlag founded Acadian Ambulance in 1971 after working for Greenville Broadcasting Company and Westinghouse Electric Company Space and Defense Center. Acadian now employs more than 4,000 people, providing ambulance services as well as security, training and more

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Designing and conducting a cluster-randomized trial of ICU admission for the elderly patients: the ICE-CUB 2 study

The benefit of ICU admission for elderly patients remains controversial. This report highlights the methodology, the feasibility of and the ethical and logistical constraints in designing and conducting a clu...

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Lingual Abscess in the Setting of Recent Periodontal Antibiotic Injections

Publication date: Available online 29 July 2016
Source:The Journal of Emergency Medicine
Author(s): Joshua E. Lefler, Lawrence N. Masullo
BackgroundLingual abscess is a rare clinical entity, with posterior involvement being much less common than anterior involvement. Typical inciting events include trauma or direct inoculation to the area. The clinical diagnosis can be difficult, and early imaging and specialist consultation should be pursued to make a definitive diagnosis and to prevent patient deterioration.Case ReportWe present a case of posterior lingual abscess in a 62-year-old man after he received antibiotic injections to the lower molars for periodontal disease.Why Should an Emergency Physician Be Aware of This?Lingual abscess is a rare condition that is difficult to diagnose clinically. Misdiagnosis or delayed diagnosis can lead to acute airway compromise and increased morbidity.

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Bilateral Quadriceps Femoris Tendon Rupture in a Patient With Chronic Renal Insufficiency: A Case Report

Publication date: Available online 29 July 2016
Source:The Journal of Emergency Medicine
Author(s): Chris H.L. Lim, Kara J. Landon, Gar M. Chan
BackgroundSimultaneous bilateral quadriceps femoris tendon rupture is a relatively rare occurrence. As such, patients frequently experience a delay in receiving an accurate diagnosis. It is often associated with significant morbidity and loss of function. We report a case of simultaneous bilateral quadriceps tendon ruptures in a patient with chronic renal insufficiency.Case ReportA 46-year-old white man presented to the Emergency Department (ED) via ambulance, reporting sudden onset of bilateral lower limb weakness. He had a medical history of renal insufficiency due to immunoglobulin-A-induced glomerulopathy, with secondary hyperparathyroidism and gout. Examination of his lower limbs revealed significant swelling in his distal thighs anteriorly and suprapatellar defects at the insertion of the quadriceps tendon. No other palpable deficits were identified. The patella was in a normal position and there was minimal tenderness on palpation. He had complete loss of active knee extension. Bilateral patella reflexes were absent. Lower-limb sensation was intact bilaterally and no other neurovascular deficits were elicited. Thompson test was negative and the rest of the clinical examination was unremarkable.Why Should an Emergency Physician Be Aware of This?The inability to walk is a common ED presentation. The differential diagnosis is vast and includes but is not limited to: spinal cord injury, Guillain-Barré syndrome, myopathies, and even malingering. This case report details an uncommon cause for a common ED presentation. Furthermore, this case illustrates the importance of a detailed clinical history and physical examination, which narrowed the differential diagnosis and ultimately led to the clinical diagnosis. Knowledge of the patient's past medical history combined with simple imaging modalities permitted a prompt clinical diagnosis of an uncommon condition, which facilitated early operative management.

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Pyuria and Urine Cultures in Patients with Acute Renal Colic

Publication date: Available online 29 July 2016
Source:The Journal of Emergency Medicine
Author(s): Marc Dorfman, Shu B. Chan, Kevin Hayek, Collin Hill
BackgroundRenal colic caused by stone(s) is common in the emergency department. Often, urinalysis reveals white blood cells, but it is unknown how frequently pyuria is sterile or infectious.ObjectivesWe sought to determine the incidence of pyuria in patients with renal colic and to correlate the incidence with a positive urine culture.MethodsA 1-year retrospective review of adult patients with renal colic presenting to three community emergency departments was performed. Patients without confirmed renal stone(s) or completed urinalysis were excluded. Hematuria is defined as ≥5 red blood cells per high power field (RBC/HPF) and pyuria as >10 white blood cells per high power field (WBC/HPF). A positive urine culture is defined as >100,000 colony forming units per milliliter. Student's t-test, chi square, or Fisher's exact tests were performed as appropriate, with significance set at 0.05.ResultsThere were 339 patients who satisfied the inclusion and exclusion criteria, and 14.2% of these patients had associated pyuria. There were 153 (45.1%) urine cultures performed, and 16 (10.5%) were positive. Patients with pyuria were more likely to have a positive urine culture (36.4% vs. 3.3%, respectively; p < 0.001). The percentage of positive urine cultures increased (p < 0.001) with increasing pyuria from 9.1% (10–20 WBC/HPF) to 60.0% (>50 WBC/HPF). Positive cultures also increased (p < 0.001) with increased leukocyte esterase observed on macroscopic samples, from 1.6% (small or less leukocyte esterase) to 77.8% (large-volume leukocyte esterase).ConclusionPyuria was found in 14.2% of patients with renal colic. Patients with pyuria had 36.4% positive cultures compared to 3.3% of patients without pyuria. The degree of pyuria or leukocyte esterase was significantly associated with the risk of a positive culture. Urine cultures are recommended for all patients with renal colic and pyuria.

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Gas-forming Iliopsoas Abscess: A Klebsiella Pneumoniae–Mediated Invasive Syndrome

Publication date: Available online 29 July 2016
Source:The Journal of Emergency Medicine
Author(s): Shun-Ping Cheng, Wei-Wen Chang, Yu-Tzu Tsao

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Safely Managing Acute Osteoarthritis in the Emergency Department: An Evidence-Based Review

Publication date: Available online 29 July 2016
Source:The Journal of Emergency Medicine
Author(s): Scott E. Young, Jason D. Bothwell, Ryan M. Walsh
BackgroundJoint pain caused by acute osteoarthritis (OA) is a common finding in the emergency department. Patients with OA often have debilitating pain that limits their function and ability to complete their activities of daily living. In addition, OA has been associated with a high percentage of arthritis-related hospital admissions and an increased risk of all-cause mortality. Safely managing OA symptoms in these patients can present many challenges to the emergency provider.ObjectivesWe review the risks and benefits of available treatment options for acute OA-related pain in the emergency department. In addition, evidence-based recommendations will be made for safely managing pain and disability associated with OA in patients with comorbidities, including cardiovascular disease, renal insufficiency, and risk factors for gastrointestinal bleeding.DiscussionCommonly used treatments for OA include acetaminophen, oral nonsteroidal anti-inflammatory drugs, and opioids, each with varying degrees of efficacy and risk depending on the patient's underlying comorbidities. Effective alternative therapies, such as topical preparations, intra-articular corticosteroid injections, bracing, and rehabilitation are likely underused in this setting.ConclusionsEmergency providers should be aware of the risks and benefits of all treatment options available for acute OA pain, including oral medications, topical preparations, corticosteroid injections, bracing, and physical therapy.

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Endotracheal Intubation for Toxicologic Exposures: A Retrospective Review of Toxicology Investigators Consortium (ToxIC) Cases

Publication date: Available online 29 July 2016
Source:The Journal of Emergency Medicine
Author(s): Gillian A. Beauchamp, Robert G. Hendrickson, Benjamin W. Hatten
BackgroundEndotracheal intubation remains a cornerstone of early resuscitation of the poisoned patient, but little is known about which substances are associated with intubation.ObjectivesOur objective was to describe patient exposures to substances reported to the American College of Medical Toxicology (ACMT) Toxicology Investigators Consortium (ToxIC) that were managed with intubation between 2010 and 2014.MethodsWe performed a retrospective review of cases managed with endotracheal intubation in the ACMT ToxIC Registry from January 1, 2010 through December 31, 2014. Descriptive statistics were used to describe patient exposures.ResultsA total of 2724 exposures to substances were managed with endotracheal intubation. Intubated patients were 52% male and 82% adults. For all ages taken together, the most common known single-substance exposures managed with intubation were sedative hypnotics (9.8%), antidepressants (8.7%), and opioids (8.0%). The most common single ingestions associated with intubation in various age groups were: opioids (<2 years old), alpha-2 agonists (2–6 years old), antidepressants (7–18 years old), sedative-hypnotics (19–65 years old), and cardiac medications (>65 years old). Multiple substances were involved in 29.0% of exposures. Decontamination and elimination processes were used in 12.8% of patients.ConclusionsThe most common substances involved in single- and multiple-substance exposures managed with intubation varied by age group. Most patients were managed with supportive care. Knowledge of substances commonly involved in exposures managed with intubation may inform triage and resource planning in the emergency department resuscitation of critically ill poisoned patients.

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Funding Research in Emergency Department Shared Decision Making: a Summary of the 2016 Academic Emergency Medicine Consensus Conference Panel Discussion

Abstract

As part of the 2016 Academic Emergency Medicine consensus conference, “Shared Decision Making in the Emergency Department: Development of a Policy-Relevant Patient-Centered Research Agenda,” a panel of representatives from the Office of Emergency Care Research, the Patient Centered Outcomes Research Institute, the American Heart Association, the John A. Hartford Foundation, and the Emergency Care Coordination Center were assembled to discuss funding opportunities for future research in this field. This article summarizes their discussion of funding priorities and examples of successfully funded projects related to shared decision making in emergency medicine.

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Pittsburgh man looks for off-duty EMT who saved his life

PITTSBURGH — Paul and Marialana Bowser are searching for the mysterious stranger who came to their help the day Paul suffered a stroke outside the Eat N’ Park restaurant.

As they made their way inside the restaurant on July 17, Paul stood there clutching the door and could not move.

“That’s when he had said to me, ‘Hon, I’m having a stroke,’” Marialana Bowser told WTAE. (link here).

She had just asked a nearby customer to contact 911 when a stranger appeared at her husband’s side.

The stranger introduced himself as “Gary,” and told Marialana that he was an EMT. He was off-duty and happened to be eating at the restaurant when he saw Paul in distress.

The mysterious EMT took Paul’s pulse, and helped him remain seated in a chair while waiting for an ambulance to arrive.

The Bowsers told WTAE News that they would like to thank Gary in person for his assistance.

Paul said because of Gary’s quick reaction, he no longer feels numbness in his arm or leg.

“I would like to thank Gary for all his help,” Paul Bowser said. “How he took care of me during this crisis.”

“I feel good, thanks to Gary."

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Acute headache presentations to the emergency department: A state-wide cross-sectional study

Abstract

Objectives

The objective of this study was to describe demographic and clinical characteristics including features that were consistent with subarachnoid hemorrhage (SAH), use of diagnostic tests, emergency department (ED) discharge diagnoses, and disposition of adult patients presenting with an acute headache to EDs state-wide across Queensland, Australia. In addition, potential variations in the presentation and diagnostic work up between principal referral and city-regional hospitals were examined.

Methods

A prospective cross-sectional study was conducted over four weeks in September 2014. All patients ≥18 years presenting to one of 29 public and 5 private hospital EDs across the state with an acute headache were included. The headache had to be the principal presenting complaint and non-traumatic. The 34 study sites attend to about 90% of all ED presentations state-wide. The treating doctor collected clinical information at the time of the ED visit including the characteristics of the headache and investigations performed. A study coordinator retrieved results of investigations, ED discharge diagnoses, and disposition from state databases. Variations in presentation, investigations, and diagnosis between city-regional and principle referral hospitals were examined.

Results

There were 847 headache presentations. Median (range) age was 39 (18-92) years, 62% were female, and 31% arrived by ambulance. Headache peaked instantly in 18% and ≤1 hour in 44%. It was “worst ever” in 37%, 10/10 in severity in 23%, and associated with physical activity in 7.4%. Glasgow Coma Scale score was <15 in 4.1%. Neck stiffness was noted on examination in 4.8%. Neurological deficit persisting in the ED was found in 6.5%. A CT head scan was performed in 38% (318/841, 95%CI: 35-41%) and an LP in 4.7% (39/832, 95%CI: 3.4-6.3%). There were 18 SAH, six intra-parenchymal hemorrhages, one subdural hematoma, one newly diagnosed brain metastasis and two bacterial meningitis. Migraine was diagnosed in 23% and ‘primary headache not further specified’ in 45%.

CT head scans were more likely to be performed in principal-referral hospitals (41%) compared to city-regional hospitals (33%). The headache in patients presenting to the latter was less likely to be instantly peaking or associated with activity, but was no less severe in intensity and was more frequently accompanied by nausea and vomiting. Their diagnosis was more likely to be a benign primary headache. Variations in CT scanning could thus be due to differences in the case-mix. The median (interquartile range) ED length-of-stay was 3.1 (2.2-4.5 hours). Patients was discharged from the ED or admitted to the ED Short Stay Unit prior to discharge in 57% and 23% of cases respectively.

Conclusions

The majority of patients had a benign diagnosis, with intracranial hemorrhage and bacterial meningitis accounting for only 3% of the diagnoses. There are variations in the proportion of patients receiving CT head scans between city-regional and principle referral hospitals. As 38% of headache presentations overall underwent CT scanning, there is scope to rationalise diagnostic testing to rule out life-threatening conditions.

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Effectiveness of Interventions to Decrease Emergency Department Visits by Adult Frequent Users: A systematic review

Abstract

Introduction

Frequent emergency department (ED) users are high-risk and high-resource-utilizing patients. This systematic review evaluates effectiveness of interventions targeting adult frequent ED users in reducing visit frequency and improving patient outcomes.

Methods

An a priori protocol was published in PROSPERO. Two independent reviewers screened, selected, rated quality and extracted data. Third party adjudication resolved disagreements. Rate ratios of post- versus pre-intervention ED visits were calculated.

Data sources: A comprehensive search included seven databases and the grey literature.

Eligibility criteria for selecting studies:Experimental studies assessing the effect of interventions on frequent users’ ED visits and patient-oriented outcomes were included.

Results

6,865 citations were identified and 31 studies included. Designs were non-controlled (n=21) and controlled (n=4) before-after studies, and randomized controlled trials (n=6). Frequent user definitions varied considerably and risk of bias was moderate to high. Studies examined general frequent users or those with psychiatric co-morbidities, chronic disease, low socioeconomic status, or the elderly. Interventions included case management (n=18), care plans (n=8), diversion strategies (n=3), printout case notes (n=1), and social work visits (n=1). Post- versus pre-intervention rate ratios were calculated for 25 studies and indicated a significant visit decrease in 21 (84%) of these studies. The median rate ratio was 0.63 (IQR 0.41, 0.71), indicating that the general effect of the interventions described was to decrease ED visits post-intervention. Significant visit decreases were found for a majority of studies in subgroup analysis based on 6- or 12-month follow-up, definition thresholds, clinical frequent user subgroups and intervention types. Studies reporting homelessness found consistent improvements in stable housing. Overall, inter-study heterogeneity was high.

Conclusions

Interventions targeting frequent ED users appear to decrease ED visits and may improve stable housing. Future research should examine cost-effectiveness and adopt standardized definitions.

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Computed Tomography Use for Adults with Head Injury: Describing Likely Avoidable ED Imaging based on the Canadian CT Head Rule

Abstract

Background

Millions of head computed tomography (CT) scans are ordered annually, but the extent of avoidable imaging is poorly defined.

Objective

To determine the prevalence of likely avoidable CT imaging among adults evaluated for head injury in 14 community emergency departments (ED) in Southern California from 2008-2013.

Methods

We conducted an electronic health record (EHR) data-base and chart review of adult ED trauma encounters receiving a head CT from 2008-2013. The primary outcome was discordance with the Canadian CT Head Rule (CCHR) high-risk criteria; the secondary outcome was use of a neurosurgical intervention in the discordant cohort. We queried system-wide EHRs to identify CCHR discordance using criteria identifiable in discrete data fields. Explicit chart review of a subset of discordant CTs provided estimates of misclassification bias, and assessed the low-risk cases who actually received an intervention.

Results

Among 27,240 adult trauma head CTs, EHR data classified 11,432 (42.0%) discordant with CCHR recommendation. Subsequent chart review showed that the designation of discordance based on the EHR was inaccurate in 12.2% (95% CI 5.6-18.8%). Inter-rater reliability for attributing CCHR concordance was 95% (kappa=0.86). Thus we estimate that 36.8% of trauma head CTs were truly likely avoidable (95% CI 34.1-39.6%). Among the likely avoidable CT group identified by EHR, only 0.1% (n=13) received a neurosurgical intervention. Chart review showed none of these were actually “missed” by the CCHR, as all 13 were misclassified.

Conclusion

About 1/3 of head CTs currently performed on adults with head injury may be avoidable by applying the CCHR. Avoidance of CT in such patients is unlikely to miss any important injuries.

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NorwegianAirAmbulance shall operate all HEMS bases in Norway from 2018

NLA has been awarded contract for operation of all twelve HEMS-bases in Norway. It was announced by (The Gov`s.) National Air Ambulance Service ANS. Start 1 June 2018,-runs six years,-extension option =further four years.Patients will thus have an even more robust and modern air ambulance service, with increased capacity -availability.New helicopters, several spare helicopters. With this being air ambulance service among the world's best. Today NLA-AS operates nine of Norways twelve HEMS bases. In tender quality has been emphasized 60%-cost 40%. Because we as owner has a distinct purpose. NLA contributes to research, innovation and development. NLA has for nearly 40 years been a driving force to develop,expand the Norwegian Air Ambulance offer.The Foundation's role is primarily to provide research and development of new technologies that make HEMS service in Norway a world leader and ensures that more can be rescued by acute illness and injury far from the hospital. ExEMTN

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NorwegianAirAmbulance shall operate all HEMS bases in Norway from 2018

Παρασκευή 29 Ιουλίου 2016

A Randomized Controlled Comparison of the Internal Jugular Vein and the Subclavian Vein as Access Sites for Central Venous Catheterization in Pediatric Cardiac Surgery.

Objectives: To compare internal jugular vein and subclavian vein access for central venous catheterization in terms of success rate and complications. Design: A 1:1 randomized controlled trial. Setting: Baskent University Medical Center. Patients: Pediatric patients scheduled for cardiac surgery. Interventions: Two hundred and eighty children undergoing central venous catheterization were randomly allocated to the internal jugular vein or subclavian vein group during a period of 18 months. Measurements and Main Results: The primary outcome was the first-attempt success rate of central venous catheterization through either approach. The secondary outcomes were the rates of infectious and mechanical complications. The central venous catheterization success rate at the first attempt was not significantly different between the subclavian vein (69%) and internal jugular vein (64%) groups (p = 0.448). However, the overall success rate was significantly higher through the subclavian vein (91%) than the internal jugular vein (82%) (p = 0.037). The overall frequency of mechanical complications was not significantly different between the internal jugular vein (25%) and subclavian vein (31%) (p = 0.456). However, the rate of arterial puncture was significantly higher with internal jugular vein (8% vs 2%; p = 0.03) and that of catheter malposition was significantly higher with subclavian vein (17% vs 1%; p 0.05 for all). Conclusions: Central venous catheterization through the internal jugular vein and subclavian vein was not significantly different in terms of success at the first attempt. Although the types of mechanical complications were different, the overall rate was similar between internal jugular vein and subclavian vein access. The risk of infectious complications was significantly higher with internal jugular vein access. (C)2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Ketosis After Cardiopulmonary Bypass in Children Is Associated With an Inadequate Balance Between Oxygen Transport and Consumption.

Objectives: Hyperglycemia after cardiac surgery and cardiopulmonary bypass in children has been associated with worse outcome; however, causality has never been proven. Furthermore, the benefit of tight glycemic control is inconsistent. The purpose of this study was to describe the metabolic constellation of children before, during, and after cardiopulmonary bypass, in order to identify a subset of patients that might benefit from insulin treatment. Design: Prospective observational study, in which insulin treatment was initiated when postoperative blood glucose levels were more than 12 mmol/L (216 mg/dL). Setting: Tertiary PICU. Patients: Ninety-six patients 6 months to 16 years old undergoing cardiac surgery with cardiopulmonary bypass. Interventions: None. Measurements and Main Results: Metabolic tests were performed before anesthesia, at the end of cardiopulmonary bypass, at PICU admission, and 4 and 12 hours after PICU admission, as well as 4 hours after initiation of insulin treatment. Ketosis was present in 17.9% patients at the end of cardiopulmonary bypass and in 31.2% at PICU admission. Young age was an independent risk factor for this condition. Ketosis at PICU admission was an independent risk factor for an increased difference between arterial and venous oxygen saturation. Four hours after admission (p = 0.05). Insulin corrected ketosis within 4 hours. Conclusions: In this study, we found a high prevalence of ketosis at PICU admission, especially in young children. This was independently associated with an imbalance between oxygen transport and consumption and was corrected by insulin. These results set the basis for future randomized controlled trials, to test whether this subgroup of patients might benefit from increased glucose intake and insulin during surgery to avoid ketosis, as improving oxygen transport and consumption might improve patient outcome. (C)2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Platelet Transfusions in Pediatric Intensive Care.

Objectives: To characterize the determinants of platelet transfusion in a PICU and determine whether there exists an association between platelet transfusion and adverse outcomes. Design: Prospective observational single center study, combined with a self-administered survey. Setting: PICU of Sainte-Justine Hospital, a university-affiliated tertiary care institution. Patients: All children admitted to the PICU from April 2009 to April 2010. Intervention: None. Measurements and Main Results: Among 842 consecutive PICU admissions, 60 patients (7.1%) received at least one platelet transfusion while in PICU. In the univariate analysis, significant determinants for platelet transfusion were admission Pediatric Risk of Mortality Score greater than 10 (odds ratio, 6.80; 95% CI, 2.5-18.3; p

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Risk Factors of Acute Kidney Injury in Critically Ill Children.

Objectives: Acute kidney injury may be promoted by critical illness, preexisting medical conditions, and treatments received both before and during ICU admission. We aimed to estimate the frequency of acute kidney injury during ICU treatment and to determine factors, occurring both before and during the ICU stay, associated with the development of acute kidney injury. Design: Cohort study of critically ill children. Setting: University-affiliated PICU. Patients: Eligible patients were admitted to the ICU between January 2006 and June 2009. We excluded those admitted with known primary renal failure, chronic renal failure or postrenal transplant, conditions with known renal complications, or metabolic conditions treated with dialysis. Patients were also excluded if they had a short ICU stay (

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Clinical Impact of Accurate Point-of-Care Glucose Monitoring for Tight Glycemic Control in Severely Burned Children.

Objectives: The goal of this study was to retrospectively evaluate the clinical impact of an accurate autocorrecting blood glucose monitoring system in children with severe burns. Blood glucose monitoring system accuracy is essential for providing appropriate intensive insulin therapy and achieving tight glycemic control in critically ill patients. Unfortunately, few comparison studies have been performed to evaluate the clinical impact of accurate blood glucose monitoring system monitoring in the high-risk pediatric burn population. Design: Retrospective analysis of an electronic health record system. Setting: Pediatric burn ICU at an academic medical center. Patients: Children (aged = 20% total body surface area) receiving intensive insulin therapy guided by either a noncorrecting (blood glucose monitoring system-1) or an autocorrecting blood glucose monitoring system (blood glucose monitoring system-2). Measurements and Main Results: Patient demographics, insulin rates, and blood glucose monitoring system measurements were collected. The frequency of hypoglycemia and glycemic variability was compared between the two blood glucose monitoring system groups. A total of 122 patient charts from 2001 to 2014 were reviewed. Sixty-three patients received intensive insulin therapy using blood glucose monitoring system-1 and 59 via blood glucose monitoring system-2. Patient demographics were similar between the two groups. Mean insulin infusion rates (5.1 +/- 3.8 U/hr; n = 535 paired measurements vs 2.4 +/- 1.3 U/hr; n = 511 paired measurements; p

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Rapid Sequence Awake – An Awake Intubation Update

Rapid Sequencing of Awake Intubation

EMCrit by Scott Weingart.

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Rapid Sequence Awake – An Awake Intubation Update

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Rapid Sequencing of Awake Intubation

EMCrit by Scott Weingart.

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Using topic coding to understand the nature of change language in a motivational intervention to reduce alcohol and sex risk behaviors in emergency department patients

Patient Education and Counselling

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A survival case of tension gastrothorax due to hiatal hernia, the key of life-saving is thoracotomy: A case report and review of literature

The American Journal of Emergency Medicine

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Is pain really undertreated? Challenges of addressing pain in trauma patients during prehospital transport and trauma resuscitation

Injury

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Role of ultrasonography for testicular injuries in penetrating scrotal trauma

Urology

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Subacute posttraumatic complaints and psychological distress in trauma patients with or without mild traumatic brain injury

Injury

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Bio-engineered molecule shows promise for quick control of bleeding

The Children's Hospital of Philadelphia

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Outcomes 2 years after traumatic spinal cord injury in Botswana: A follow-up study

Spinal Cord

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Early surgery within 2 days for hip fracture is not reliable as healthcare quality indicator

Injury

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A combination of three-dimensional printing and computer-assisted virtual surgical procedure for preoperative planning of acetabular fracture reduction

Injury

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A review of existing trauma and musculoskeletal impairment (TMSI) care capacity in East, Central, and Southern Africa

Injury

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Increase in moped injuries requiring emergency care

The American Journal of Emergency Medicine

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Severe diabetic ketoacidosis presenting with negative serum ketones: First case report and a review of the mechanism

The American Journal of Emergency Medicine

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Healthcare costs and productivity costs of hand and wrist injuries by external cause

Injury

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AMGA 2016 survey reports average increase in physician compensation at 3.1%

American Medical Group Association News

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Emergency department-based interventions for women suffering domestic abuse: a critical literature review.

Domestic abuse represents a serious public health and human rights concern. Interventions to reduce the risk of abuse include staff training and standardized documentation improving detection and adherence to referral pathways. Interventional studies have been conducted in primary care, maternity and outpatient settings. Women disclosing abuse in emergency departments differ from women attending other healthcare settings, and it is unclear whether these interventions can be transferred to the emergency care setting. This review examines interventional studies to evaluate the effectiveness of emergency department-based interventions in reducing domestic abuse-related morbidity. Medline, EMBASE, CINAHL, PsycINFO and Cochrane Library were searched, according to prespecified selection criteria. Study quality was assessed using the Jadad scale. Of 273 search results, nine were eligible for review. Interventions involving staff training demonstrated benefits in subjective measures, such as staff knowledge regarding abuse, but no changes in clinical practice, based on detection and referral rates. When staff training was implemented in conjunction with supporting system changes - for example, standardized documentation for assessment and referral - clinically relevant improvements were noted. Interventions centred around staff training are insufficient to bring about improvements in the management and, thus, outcome of patients suffering abuse. Instead, system changes, such as standardized documentation and referral pathways, supported by training, may bring about beneficial changes. It remains uncertain whether surrogate outcomes employed by most studies translate to changes in abuse-related morbidity: the ultimate goal. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Optimizing Team Dynamics: An Assessment of Physician Trainees and Advanced Practice Providers Collaborative Practice.

Objectives: The presence of advanced practice providers has become increasingly common in many ICUs. The ideal staffing model for units that contain both advanced practice providers and physician trainees has not been described. The objectives of this study were to evaluate ICU staffing models that include physician trainees and advanced practice providers and their effects on patient outcomes, resident and fellow education, and training experience. A second aim was to assess strategies to promote collaboration between team members. Data Sources: PubMed, CINAHL, OVID MEDLINE, and Cochrane Review from 2002 to 2015. Study Selection: Experimental study designs conducted in an ICU setting. Data Extraction: Two reviewers screened articles for eligibility and independently abstracted data using the identified search terms. Data Synthesis: We found 21 articles describing ICU team structure and outcomes. Four articles were found describing the impact of advanced practice providers on resident or fellow education. Two articles were found discussing strategies to promote collaboration between advanced practice providers and critical care fellows or residents. Conclusions: Several articles were identified describing the utilization of advanced practice providers in the ICU and the impact of models of care on patient outcomes. Limited data exist describing the impact of advanced practice providers on resident and fellow education and training experience. In addition, there are minimal data describing methods to enhance collaboration between providers. Future research should focus on determining the optimal ICU team structure to improve patient outcomes, education of trainees, and job satisfaction of team members and methods to promote collaboration between advanced practice providers and physicians in training. (C)2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Survey of Sedation and Analgesia Practice Among Canadian Pediatric Critical Care Physicians.

Background: Despite the fact that almost all critically ill children experience some degree of pain or anxiety, there is a lack of high-quality evidence to inform preferred approaches to sedation, analgesia, and comfort measures in this environment. We conducted this survey to better understand current comfort and sedation practices among Canadian pediatric intensivists. Methods: The survey was conducted after a literature review and initial focus groups. The survey was then pretested and validated. The final survey was distributed by email to 134 intensivists from 17 PICUs across Canada using the Research Electronic Data Capture system. Results: The response rate was 73% (98/134). The most commonly used sedation scores are Face, Legs, Activity, Cry, and Consolability (42%) and COMFORT (41%). Withdrawal scores are commonly used (65%). In contrast, delirium scores are used by only 16% of the respondents. Only 36% of respondents have routinely used sedation protocols. The majority (66%) do not use noise reduction methods, whereas only 23% of respondents have a protocol to promote day/night cycles. Comfort measures including music, swaddling, soother, television, and sucrose solutions are frequently used. The drugs most commonly used to provide analgesia are morphine and acetaminophen. Midazolam and chloral hydrate were the most frequent sedatives. Conclusion: Our survey demonstrates great variation in practice in the management of pain and anxiety in Canadian PICUs. Standardized strategies for sedation, delirium and withdrawal, and sleep promotion are lacking. There is a need for research in this field and the development of evidence-based, pediatric sedation and analgesia guidelines. (C)2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Treatment of Coagulopathy Related to Hepatic Insufficiency.

Objectives: To provide a concise review of the medical management of coagulopathy related to hepatic insufficiency. This review will focus on prevention and management of bleeding episodes in patients with hepatic insufficiency. The treatment and prevention of thromboembolic complications will also be addressed. Data Sources: Electronic search of PubMed database using relevant search terms, including hepatic coagulopathy, hemorrhage, liver diseases, blood coagulation disorders, blood transfusion, disseminated intravascular coagulation, and liver failure. Subsequent searches were done on specific issues. Study Selection: Articles considered include original articles, review articles, guidelines, consensus statements, and conference proceedings. Data Extraction: A detailed review of scientific, peer-reviewed data was performed. Relevant publications were included and summarized. Data Synthesis: Available evidence is used to describe and summarize currently available tests of hemostasis, utilization of prohemostatic agents, transfusion strategies, use of prophylactic anticoagulation and treatment of thromboembolic events in patients with hepatic insufficiency. Conclusions: Dynamic changes to hemostasis occur in patients with hepatic insufficiency. Routine laboratory tests of hemostasis are unable to reflect these changes and should not be used exclusively to evaluate coagulopathy. Newer testing methods are available to provide data on the entire spectrum of clotting but are not validated in acute bleeding. Prohemostatic agents utilized to prevent bleeding should only be considered when the risk of bleeding outweighs the risk of thrombotic complications. Restrictive transfusion strategies may avoid exacerbation of acute bleeding. Prophylaxis against and treatment of thromboembolic events are necessary and should consider patient specific factors. Copyright (C) by 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Dynamic Measures to Determine Volume Responsiveness: Logical, Biologically Plausible, and Unproven.

No abstract available

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Πέμπτη 28 Ιουλίου 2016

PulmCrit Wee – Pragmatic comparison of 33C vs. 36C after cardiac arrest

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A post last year discussed the top 10 reasons to stop cooling to 33C. It was based largely on the Nielsen trial, which showed similar outcomes between therapeutic hypothermia (TH33) and therapeutic temperature management (TTM36). However, this trial left some questions about how these protocols would perform outside the context of a RCT (external validity). Last year's post speculated that since TTM36 is easier to achieve, it would out-perform TH33 in real-world conditions.

EMCrit by Josh Farkas.

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Dangerously Hot: As mercury rises, so do fire hazards, health risks

By Jill Harmacinski
The Eagle Tribune

ANDOVER, Mass. — As temperatures soared into the 90s again Wednesday, locals stuck by fans and air conditioning and dipped in pools and ponds trying to ride out the latest wave of sweltering heat.

Some professions are shown no mercy, however.

Late Wednesday morning as the mercury just touched 90 degrees, a fire on a South Lawrence porch was reported when residents smelled smoke and dialed 911.

Crews raced to 90-92 Jamaica St., where the single-alarm blaze in a two-story, two-family house was quickly knocked down. Fire investigators quickly determined the fire was caused by careless disposal of cigarettes. While there were no injuries, porches on the first and second floors were scorched.

"This is what we call a good stop," said Fire Chief Brian Moriarty. "These guys don't goof off. They come to work to fight fires."

They also wear 75 pounds of protective gear, so numerous Lawrence General Hospital paramedics were on standby as the firefighters worked on Jamaica Street in the sun at the top of a hill.

North of Boston paramedic Bill Kinch explained it's imperative to monitor the vital signs and temperatures of rescuers who work day after day in such oppressive heat.

If a firefighter's temperature rises above 100 degrees, heart rate goes over 120, or blood pressure exceeds 140 over 90, Kinch said he or she is immediately pulled away from the fire.

"We will literally keep them out of the fire until their vital signs drop," said Kinch, a paramedic for the past 25 years.

While body heat escapes from the head quickly, a person also can rapidly cool down if a cold towel is draped over the head. Kinch regularly does this while rehabbing firefighters in hot weather.

The healing power of water
Bottled water is also an ally to rescuers, as well as regular folks just trying to go about their business on a hot and humid day, Kinch noted.

The thing is, he explained, by the time you feel thirsty you are already dehydrated.

Those who are most at risk of dehydration are the very young and very old because their bodies aren't good at regulating heat.

"As you get older, your body becomes much worse at regulating temperature and hydration," he said.

With a prediction of a high of 94 degrees Thursday, Kinch urged people to keep an eye on their families and neighbors to make sure everyone is staying cool and hydrated.

Helping others is something the Salvation Army in Haverhill is dedicated to.

Members drove around Wednesday in their personal cars handing out ice-cold bottled water.

"We go down by the river behind the thrift store on Merrimack Street, by the Post Office in Washington Square, the public library on Main Street and other areas where homeless congregate and where we might encounter senior citizens," said Salvation Army Capt. Mari Hardy.

"We probably average six to eight cases of water per day and Wednesday is the third day in a row we've been doing this," Hardy said.

The goal is to help people keep hydrated, particularly the homeless and elderly who might not feel they need to have a drink but may be at risk of heat exhaustion.

Christina Sierra, a working mother from Methuen, joked this week that she was going to serve her family popsicles for dinner.

On Wednesday, Sierra took the day off and brought her two children to a friend's pool to cool off. Again, her daily menu plan had an icy feel.

"There is truth to ice cream for breakfast, lunch and dinner," she said.

'People are heeding the warnings'
The temperatures have been consistently high in New Hampshire, too, but officials said they've been experiencing few heat-related problems.

"I'm going to curse myself by saying we haven't had anything recently," said Lt. Anthony Rossignol of the Derry Fire Department. "We did respond to (a brush fire) a few shifts ago that was in Candia. ... When I came on, the guys were kind of expecting to go back to it because of the potential hot spots. ... But we haven't really seen anything — knock on wood — elaborate here in town."

Derry residents have been taking to public spots like Gallien's Beach and the splash pad at the Don Ball Park to cool off.

"Definitely, we've seen an increase in attendance," said Eric Bodenrader, director of Derry Parks and Recreation, who attributed the above-average patronage to the heat.

"Fortunately, we have not had any issues. ... We're staffed at both locations with supervisors, concessions attendants and lifeguards, and they're trained to look out for situations where someone may be experiencing a medical (issue)."

Plaistow Fire Chief John McArdle said he's noticed many people outside to jog or bike have been doing so earlier in the morning or later in the evening.

"I think people are heeding the warnings that we're seeing in the media to be careful and not overexert themselves," McArdle said.

Battalion Chief Randall Young of the Salem Fire Department also described the town as being fortunate, given the weather.

"We've actually been lucky. Typically when we have this type of ... long, dry, hot weather, we usually do have a lot of issues, but we've been fortunate," he said. "We haven't had a lot of problems — nothing big and not a large quantity."

Young did say, however, that the department has been fielding more medical calls than usual due to the heat and people becoming dehydrated.

"We have had a small uptick in that," Young said.

Londonderry also has experienced just a few problems related to the heat, but Battalion Chief Kevin Zins said the department, like many in the area, is "trying to be proactive, keeping guys hydrated and cool and ready so they can perform a little better when they get out in the heat."

A cooling center and mosquitoes
Vincent Ouellette, director of human services for Haverhill, said the city has been offering residents an opportunity to keep cool at the Citizens Center.

"If we get calls we would remain open at night, but we have not received any calls," he said. "I've not heard of any issues with people not having a place to be cool. But we are open on an as-needed basis."

Visits to the Plug Pond recreation area in Haverhill are also up, with crowds reaching the 200 person capacity. Ouellette said people will go the pond for an hour or so and then leave so there is a constant turn over.

"We've also seen consistent crowds at the spray park at Swasey Field," he said.

Starting Thursday morning in Lawrence, cooling centers will open at the city's senior center at 155 Haverhill St. and at Oasis Senior Day Care, a private facility located at 120 Broadway.

The senior center will be open from 8 a.m. to 7 p.m. and folks can cool day at Oasis from 9 a.m. to 4 p.m., officials said.

In Methuen, the heat coincided with spraying overnight to drastically reduce the mosquito population.

The spraying was done using truck-mounted, ultra-low volume equipment that dispenses a very fine mist of pesticides, officials said.

North Andover officials also this week issued a voluntary water ban and a simultaneous drought watch.

The town's Board of Selectmen asked residents to conserve water, including doing lawn watering between 8 p.m. to 6 a.m. They asked residents only to water their lawns every third day and to limit outside water use for washing cars and paved surfaces.

The main Lawrence Public Library got so hot that it was closed at 3:45 p.m., an hour and 15 minutes earlier than the regular 5 p.m.

The temperature was 89 degrees on the second floor and 92 degrees on the third, said Acting Director Kemal Bozkurt, who conferred with library trustees on the decision.

The excessive heat was a danger to patrons and staff, he said. The union contract provides for the closing of the library if the temperature rises above 86 degrees.

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Norsk Luftambulanse CampEurope

International training on the permanent trainingbase owned by Norwegian Air Ambulance ( Dedikated trainig helo ) -So the pilot, HEMS Tec and Anesthesiologist can train w.o. reducing the responsetime around contry, and train advanced prosedures undisturbed. CampEurope = Inviting other services to base, for learning from other services / Rising level of HEMS around Europe. In the Norwegian Air Ambulance the doc. must be able to do water-rescue, and work from Long-rope. Normally he/she operate as "Rope-man", innstructing pilote during rope-jobs. This year it was pilots, HEMS-tec`s and physicians from Austria, Switzerland, Finland and Denmark who trained with Norwegian crews. ( Norwegian Air Ambulance fund Europes largest research environment on EMS, More then 20 projects now. ) ( NLA operates the 3 bases in Denmark ) http://ift.tt/1rSwYVH ExEMTNor

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Norsk Luftambulanse CampEurope

Stiftelsen Norsk Luftambulanse CampEurope

L’incidence de l’hypotension post-intubation endotrachéale chez des patients en salle de réanimation: impact des définitions

Research Articles
Marie-Claire Lévesque, Natalie Le Sage, Simon Berthelot, Valérie Boucher, Éric Mercier, Marcel Émond
Canadian Journal of Emergency Medicine,FirstView Article(s), 9 pages

Abstract

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Street Norco looks like the real thing but really, really isn't

American College of Emergency Physicians News

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The physician-as-stakeholder: An exploratory qualitative analysis of physicians’ motivations for using shared decision-making in the emergency department

Academic Emergency Medicine

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Usefulness of hospital emergency department records to explore access to injury care in Nepal

International Journal of Emergency Medicine

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Sex differences in hip fracture surgery: Preoperative risk factors for delirium and postoperative outcomes

Journal of the American Geriatrics Society

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Injury characteristics and outcomes in elderly trauma patients in Sub-Saharan Africa

World Journal of Surgery

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Interventions for managing weight change following paediatric acquired brain injury: A systematic review

Developmental Medicine & Child Neurology

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Acute toxicity associated with use of 5F-derivations of synthetic cannabinoid receptor agonists with analytical confirmation

Journal of Medical Toxicology

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Posttraumatic stress disorder, overweight, and obesity: A systematic review and meta-analysis

Harvard Review of Psychiatry

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Interprofessional collaboration to improve discharge from skilled nursing facility to home: Preliminary data on postdischarge hospitalizations and emergency department visits

Journal of the American Geriatrics Society

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Disaster radio for communication of vital messages and health-related information: Experiences from the Haiyan Typhoon, the Philippines

Disaster Medicine and Public Health Preparedness

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The dominance of the private sector in the provision of emergency obstetric care: Studies from Gujarat, India

BMC Health Services Research

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The bariatric patient in the intensive care unit: Pitfalls and management

Current Atherosclerosis Reports

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A rare case of multiple spinal epidural abscesses and cauda equina syndrome presenting to the emergency department following acupuncture

International Journal of Emergency Medicine

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Preparedness of Finnish emergency medical services for chemical emergencies

Prehospital and Disaster Medicine

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Female smokers face greatest risk for brain bleeds

American Heart Association News

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Obesity and trauma mortality: Sizing up the risks in motor vehicle crashes

Obesity Research & Clinical Practice

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Calls to Central Ohio Poison Center about lamp oil increase 80 percent

Nationwide Children's Hospital

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Τετάρτη 27 Ιουλίου 2016

Palliative Care in the Emergency Department

As the geriatric population increases in the United States, there is an increase in number of visits to emergency departments for end-of-life and palliative care. This provides the emergency physician with a unique opportunity to alleviate and prevent further suffering in this vulnerable population. Competency in communication strategies that support shared decision making and familiarity with medicolegal terminology increase physician confidence about addressing complaints at the end of life. Familiarity with evidence-based recommendations for symptom management of pain at the end of life aids the emergency physician in creating a positive experience for the patient and their loved ones.

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Neurologic Emergencies in the Elderly

Neurologic diseases are a major cause of death and disability in elderly patients. Due to the physiologic changes and increased comorbidities that occur as people age, neurologic diseases are more common in geriatric patients and a major cause of death and disability in this population. This article discusses the elderly patient presenting to the emergency department with acute ischemic stroke, transient ischemic attack, intracerebral hemorrhage, subarachnoid hemorrhage, chronic subdural hematoma, traumatic brain injury, seizures, and central nervous system infections. This article reviews the subtle presentations, difficult workups, and complicated treatment decisions as they pertain to our older patients.”

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Geriatric Resuscitation

The geriatric population makes up a large portion of the emergency patient population. Geriatric patients have less reserve and more comorbid diseases. They are frequently on multiple medications and are more likely to require aggressive treatment during acute illness. Although it may not be obvious, it is important to recognize the signs of shock as early as possible. Special care and monitoring should be used when resuscitating the elderly. The use of bedside ultrasound and monitoring for coagulopathies are discussed. Clinicians should be constantly vigilant and reassess throughout diagnosis and treatment. Ethical considerations in this population need to be considered on an individual basis.

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Index

Note: Page numbers of article titles are in boldface type.

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Sepsis and Other Infectious Disease Emergencies in the Elderly

Waning immunity and declining anatomic and physiologic defenses render the elder vulnerable to a wide range of infectious diseases. Clinical presentations are often atypical and muted, favoring global changes in mental status and function over febrile responses or localizing symptoms. This review encompasses early recognition, evaluation, and appropriate management of these common infections specifically in the context of elders presenting to the emergency department. With enhanced understanding and appreciation of the unique aspects of infections in the elderly, emergency physicians can play an integral part in reducing the morbidity and mortality associated with these often debilitating and life-threatening diseases.

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Forthcoming Issues

Neurologic Emergencies

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The Geriatric Emergency Department

This article presents an overview of the complex needs of older patients presenting to the emergency department for care. Discussion points for hospital communities considering emergency services to accommodate the aging population are highlighted. The essential components of a geriatric emergency department, including transition of care strategies, are reviewed.

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Amal Mattu

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Dyspnea in the Elderly

This article discusses the evaluation and management of stable and unstable elderly patients with dyspnea. Several of the changes in the elderly that alter cardiopulmonary physiology are discussed. A review of common presenting illnesses and their evaluation and management are highlighted. The reader should be left with a better understanding of this unique population and the overall evaluation and treatment.

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Contributors

AMAL MATTU, MD, FAAEM, FACEP

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Pharmacology in the Geriatric Patient

The aging population of the United States creates pharmaceutical challenges for the practicing emergency physician. Polypharmacy, drug-drug and drug-disease interactions, and other pharmaceutical complications from the pathophysiologic changes associated with aging need to be recognized in order to optimize outcomes in the elderly. Effective strategies that improve patients outcomes include a better understanding of the physiologic and pharmacologic changes that occur with aging, integrated use of clinical emergency department pharmacists, and choosing nonpharmacologic treatment options when possible.

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Copyright

ELSEVIER

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Altered Mental Status and Delirium

Older patients who present to the emergency department frequently have acute or chronic alterations of their mental status, including their level of consciousness and cognition. Recognizing both acute and chronic changes in cognition are important for emergency physicians. Delirium is an acute change in attention, awareness, and cognition. Numerous life-threatening conditions can cause delirium; therefore, prompt recognition and treatment are critical. The authors discuss an organized approach that can lead to a prompt diagnosis within the time constraints of the emergency department.

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Geriatric Emergencies

EMERGENCY MEDICINE CLINICS OF NORTH AMERICA

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Evaluation of Syncope in Older Adults

The older adult patient with syncope is one of the most challenging evaluations for the emergency physician. It requires clinical skill, patience, and knowledge of specific older adult issues. It demands care in the identification of necessary resources, such as medication review, and potential linkage with several multidisciplinary follow-up services. Excellent syncope care likely requires reaching out to ensure institutional resources are aligned with emergency department patient needs, thus asking emergency physicians to stretch their administrative talents. This is likely best done as preset protocols prior to individual patient encounters. Emergency physicians evaluate elders with syncope every day and should rise to the challenge to do it well.

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CME Accreditation Page

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Abdominal Pain in the Geriatric Patient

With an aging population, emergency department clinicians can expect an increase in geriatric patients presenting with abdominal pain. Compared with younger patients, this patient population is less likely to present with classic symptoms, physical examination findings, and laboratory values of abdominal disease. However, the morbidity and mortality associated with elderly patients presenting with abdominal pathologic conditions are significant. For this reason, the clinician must be familiar with some subtle and not so subtle differences when caring for the geriatric patient with abdominal pain to ensure timely diagnosis and appropriate treatment.

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Geriatric Emergencies

The elderly patient is becoming an increasingly larger demographic who seeks care in the emergency department (ED). According to the Census Bureau, in 2010, there were 40.3 million people aged 65 and above in the United States, comprising 13% of the overall population. By 2050, projections indicate the population over 65 will comprise 20.9% of the population. The elderly ED patient represents 43% of all admissions and just under 50% of intensive care unit admissions. This patient population is often quite complex, requires longer ED visits compared with their younger counterparts, undergoes far more testing, and often challenges us with ethical questions when they present with life-threatening disease.

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Evaluation and Management of Chest Pain in the Elderly

Geriatric patients are at increased risk for serious morbidity and mortality from life-threatening causes of chest pain. This article covers 5 life-threatening causes of chest pain in the elderly: acute coronary syndrome, aortic dissection, pulmonary embolism, pneumothorax, and esophageal rupture. Atypical presentations, frailty, and significant comorbidities that characterize the elderly make the diagnosis and treatment of these already complicated conditions even more complicated. The emergency provider must be vigilant and maintain a low threshold to test. When a diagnosis is made, treatment must be aggressive. The elderly benefit from optimal care.

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Current Trends in Geriatric Emergency Medicine

The number of geriatric visits to United States emergency departments continues to rise. This article reviews demographics, statistics, and future projections in geriatric emergency medicine. Included are discussions of US health care spending, geriatric emergency departments, prehospital care, frailty of geriatric patients, delirium, geriatric trauma, geriatric screening and prediction tools, medication safety, long-term care, and palliative care.

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How to apply a direct pressure wrap to control severe extremity bleeding

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A CPR educator tells his own bystander CPR story

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How to apply a direct pressure wrap to control severe extremity bleeding

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A CPR educator tells his own bystander CPR story

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How to apply a direct pressure wrap to control severe extremity bleeding

from EMS via xlomafota13 on Inoreader http://ift.tt/2aropL7

A CPR educator tells his own bystander CPR story

from EMS via xlomafota13 on Inoreader http://ift.tt/2aaN1Xw

How to apply a direct pressure wrap to control severe extremity bleeding

from EMS via xlomafota13 on Inoreader http://ift.tt/2aropL7

A CPR educator tells his own bystander CPR story

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6 EMS questions for the next U.S. president

Our two major political parties have officially nominated their candidates. Hillary Clinton and Donald Trump, mostly in broad brushstrokes, are painting their differences on policy and regulatory issues to voters.

Healthcare, one of the dominant political issues of the past eight years and likely a top issue for years to come, is of great interest to voters. The different facets of healthcare are a focus of lobbyists representing different groups like retirees and veterans, political action committees funded by mega-donors, and insurance, pharmaceutical and hospital conglomerates.

I don't expect EMS issues to be specifically addressed by either candidate in the final months of the campaign, but if I was given the opportunity to speak with either candidate one-on-one, these are the questions I would ask.

1. How will you permanently fix reimbursement for Medicare and Medicaid transports?
Ambulance services often lose money when transporting patients with Medicare or Medicaid, because the cost of transport can exceed what is actually reimbursed to them. In addition, no reimbursement is made for transporting patients to alternate destinations, such as mental health facilities or sobriety centers, which are better suited to treating certain sets of problems.

How will you ensure our nation's ambulance services, many run by volunteers or municipal fire departments, are properly reimbursed for the services they provide to citizens on Medicare or Medicaid?

2. What steps will you take to resolve the the fatal opioid overdose epidemic?
Opioid overdoses now kill as many or more Americans than motor vehicle collisions. In some areas of the United States, opioid addiction and deaths are at epidemic levels.

What is the role of the Federal government in reducing the availability of illegal narcotics, and better regulating the distribution of legal narcotics? Where can we find the resources to transport patients to facilities with addiction treatment expertise? What steps will you take to change the focus of EMS, law enforcement and public health efforts from reversing overdoses with naloxone — which has increased in price by 1000 percent — to preventing addiction from starting in the first place?

3. Will you call on congress to pass the Field EMS Bill in your first 100 days?
EMS does not have a specific home in the federal government. The Department of Health and Human Services, Department of Homeland Security, the National Highway Transportation Safety Administration, and the Centers for Disease Control and Prevention all have interests in and initiatives for EMS, but no single agency has the needs and interests of EMS as its core mission.

Where does EMS belong in the federal government, and will you call on the U.S. Congress to pass the Field EMS Modernization and Innovation Act as a priority accomplishment for your first 100 days in office?

4. What is your plan for Obamacare?
Though Obamacare has increased the number of Americans with health insurance, it does not seem to have addressed the underlying issues preventing millions from accessing primary care. Since many patients lack access to primary care physicians and are either unable or unwilling to find non-emergent care, emergency services are being tied up with patients requesting aid for minor aches, pains and maladies.

If you do intend to repeal Obamacare, what will you put in its place to ensure health care access for our seniors, our veterans, our disabled and our vulnerable children? Alternatively, if you plan to let Obamacare stand, what will you ask the Congress to revise or add?

5. What actions will you champion to reduce chronic disease care costs?
The costs of treating chronic diseases like obesity, diabetes, hypertension, COPD and heart failure are an enormous strain on our nation's economy, and often crushing to every model of ambulance transport. As you barnstorm the U.S. from now to election day, you will regularly see and hear from voters suffering from these illnesses, and observe firsthand how chronic diseases can be a tremendous obstacle between personal productivity and the pursuit of happiness.

As president, how will you lead our nation to better personal health, reduce the incidence of chronic disease and regulate tobacco, alcohol, sugar, sodium and other food additives known to directly worsen health?

6. How will you make sure EMS is ready for the next national disaster?
Paramedics, along with their firefighter and law enforcement officer colleagues, are on the frontlines responding to terrorist attacks, active shooters and natural disasters. Most EMS agencies, already operating at or near the capacity of their personnel and equipment, are hard-pressed to respond to an unexpected surge in service.

As we near the 15^th anniversary of the September 11^th attacks, we regularly receive news of departments who are unable to communicate with one another, chiefs who are unable to put political squabbles aside to develop regional response plans, a lack of equipment for paramedics responding to active shooter incidents, and failures to implement the incident command system and collaborate through a unified command. Most recently, the Ebola scare exposed our inability to transport highly infectious patients between the few hospitals actually capable of receiving those patients.

Billions of dollars have been spent on preparedness — equipment, training and staffing — but only a fraction of that money has been directed to EMS and disaster health care. What will you do to make sure our nation's first responders are equipped and trained to respond to disasters as significant or greater than 9/11 or Hurricane Katrina?

Exercise your right as a citizen to vote
In the final months of the campaign season, research each candidate's positions on EMS and health care issues, as well as the other policy issues important to you. Then make sure to cast your vote for national, state and local candidates this fall.

Many state and national EMS organizations, like the National Association of EMTs and the American Ambulance Association, have advocacy efforts to represent and lobby on the behalf of their members. Add your voice by becoming a member.

Finally, if you find yourself on ambulance standby for a political candidate's campaign stop in your response area this political season, perhaps you will have a chance to ask the candidate how they will support EMS. If you do, let me know what they have to say.

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6 EMS questions for the next U.S. president

1. How will you permanently fix reimbursement for Medicare and Medicaid transports"
Ambulance services often lose money when transporting patients with Medicare or Medicaid, because the cost of transport can exceed what is actually reimbursed to them. In addition, no reimbursement is made for transporting patients to alternate destinations, such as mental health facilities or sobriety centers, which are better suited to treating certain sets of problems.

How will you ensure our nation's ambulance services, many run by volunteers or municipal fire departments, are properly reimbursed for the services they provide to citizens on Medicare or Medicaid"

2. What steps will you take to resolve the the fatal opioid overdose epidemic"
Opioid overdoses now kill as many or more Americans than motor vehicle collisions. In some areas of the United States, opioid addiction and deaths are at epidemic levels.

What is the role of the Federal government in reducing the availability of illegal narcotics, and better regulating the distribution of legal narcotics" Where can we find the resources to transport patients to facilities with addiction treatment expertise" What steps will you take to change the focus of EMS, law enforcement and public health efforts from reversing overdoses with naloxone — which has increased in price by 1000 percent — to preventing addiction from starting in the first place"

3. Will you call on congress to pass the Field EMS Bill in your first 100 days"
EMS does not have a specific home in the federal government. The Department of Health and Human Services, Department of Homeland Security, the National Highway Transportation Safety Administration, and the Centers for Disease Control and Prevention all have interests in and initiatives for EMS, but no single agency has the needs and interests of EMS as its core mission.

Where does EMS belong in the federal government, and will you call on the U.S. Congress to pass the Field EMS Modernization and Innovation Act as a priority accomplishment for your first 100 days in office"

4. What is your plan for Obamacare"
Though Obamacare has increased the number of Americans with health insurance, it does not seem to have addressed the underlying issues preventing millions from accessing primary care. Since many patients lack access to primary care physicians and are either unable or unwilling to find non-emergent care, emergency services are being tied up with patients requesting aid for minor aches, pains and maladies.

If you do intend to repeal Obamacare, what will you put in its place to ensure health care access for our seniors, our veterans, our disabled and our vulnerable children" Alternatively, if you plan to let Obamacare stand, what will you ask the Congress to revise or add"

5. What actions will you champion to reduce chronic disease care costs"
The costs of treating chronic diseases like obesity, diabetes, hypertension, COPD and heart failure are an enormous strain on our nation's economy, and often crushing to every model of ambulance transport. As you barnstorm the U.S. from now to election day, you will regularly see and hear from voters suffering from these illnesses, and observe firsthand how chronic diseases can be a tremendous obstacle between personal productivity and the pursuit of happiness.

6. How will you make sure EMS is ready for the next national disaster"
Paramedics, along with their firefighter and law enforcement officer colleagues, are on the frontlines responding to terrorist attacks, active shooters and natural disasters. Most EMS agencies, already operating at or near the capacity of their personnel and equipment, are hard-pressed to respond to an unexpected surge in service.

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What does it feel like to do CPR?

Nearly everyone in EMS has thought about being thrust into a situation where they’re required to use their knowledge of CPR to save a life in dramatic fashion. A user on Quora recently asked, “How does it feel to perform CPR on a real person?” A few answers stood out to us, especially one by an ALS instructor named Lou Davis. You can read her reply below:

It feels as though you are holding someone's life in your hands.

Because for the time that you are compressing the chest, you are the one thing that is, potentially, keeping that person's brain oxygenated.

You' are standing between them and death.

I could tell you how it feels physically - but in truth it isn't markedly different from the mannequin.

You may feel ribs breaking - particularly in older patients where the ribs have lost the elasticity of youth.

But the overwhelming feeling is that of responsibility - it may be the most important thing you have ever done.

I have performed CPR many, many times, on patients ranging in age from mere days, to those who have already had their 'four score years'. I have rhythmically compressed the chest of those who I know will be taken before their time. Each and every time it feels as hard as the first time.

Their life in your hands. That's what it feels like.

Do you remember the first time you performed CPR on a patient? Was it what you expected or how was it different? Let us know in the comments below, and be sure to check out our Facebook page.

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What does it feel like to do CPR?

Nearly everyone in EMS has thought about being thrust into a situation where they’re required to use their knowledge of CPR to save a life in dramatic fashion. A user on Quora recently asked, “How does it feel to perform CPR on a real person"” A few answers stood out to us, especially one by an ALS instructor named Lou Davis. You can read her reply below:

It feels as though you are holding someone's life in your hands.

Because for the time that you are compressing the chest, you are the one thing that is, potentially, keeping that person's brain oxygenated.

You' are standing between them and death.

I could tell you how it feels physically - but in truth it isn't markedly different from the mannequin.

You may feel ribs breaking - particularly in older patients where the ribs have lost the elasticity of youth.

But the overwhelming feeling is that of responsibility - it may be the most important thing you have ever done.

Their life in your hands. That's what it feels like.

Do you remember the first time you performed CPR on a patient" Was it what you expected or how was it different" Let us know in the comments below, and be sure to check out our Facebook page.

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Recovering from Orlando: The role of a critical incident stress team

By Leischen Stelter, editor of In Public Safety

The June 12 massacre inside an Orlando nightclub left 49 people dead and 53 wounded. After police killed the gunman, officers, firefighters and medical professionals entered the building to provide aid to the wounded. According to news reports, the scene inside was absolute carnage with bodies scattered across the dance floor and in the restrooms. The trauma of the event affected not only those who were in the nightclub that night, but also those who responded.

The Role of a Critical Incident Stress Team
American Military University’s criminal justice program director, Dr. Chuck Russo, lives in Central Florida and was a founding member of his agency’s Critical Incident Stress Team (CIST). He is also the team leader for Florida’s Regional Disaster Behavioral Health Assessment Team. In that role, he oversees psychologists, psychiatrists and social workers, as well as specially trained volunteers, who provide services to first responders following a traumatic incident. Russo was on call for several days following the Orlando incident, ready to provide support to the police officers, firefighters, medical personnel and other first responders who assisted with the gruesome scene.

[Related: Critical Incident Stress Management Interventions Help Heal First Responders]

While Russo’s team was not deployed to assist in Orlando, he has spoken with several colleagues who were involved. “Most people hadn’t seen anything like it before – the only ones who had seen anything similar had been in war,” he said. There’s no level of training as intense as actually responding to a mass casualty incident. “If you’re a police officer long enough, you’re going to come across bodies and the results of violence. Most officers can deal with a certain level of blood and gore, but this exceeded everyone’s normal,” he said.

Full story: Recovering from Orlando: The role of a critical incident stress team

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Πληροφορίες

Κυριακή 31 Ιουλίου 2016

Σάββατο 30 Ιουλίου 2016

Abstract

Abstract

Objectives

Methods

Results

Conclusions

Abstract

Introduction

Methods

Results

Conclusions

Abstract

Background

Objective

Methods

Results

Conclusion

Παρασκευή 29 Ιουλίου 2016

Πέμπτη 28 Ιουλίου 2016

Τετάρτη 27 Ιουλίου 2016

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