iSepsis – Death by Fluids, Part 1

A recent study demonstrating the harm from aggressive fluid resuscitation of septic shock

EMCrit by Paul Marik.

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iSepsis – Death by Fluids, Part 1

A recent study demonstrating the harm from aggressive fluid resuscitation of septic shock

EMCrit by Paul Marik.

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Simulation-based education to ensure provider competency within the healthcare system

Abstract

The acquisition and maintenance of individual competency is a critical component of effective emergency care systems. This article summarizes consensus working group deliberations and recommendations focusing on the topic: “Simulation-based education to ensure provider competency within the healthcare system.” The authors presented this work for discussion and feedback at the 2017 Academic Emergency Medicine Consensus Conference on ‘‘Catalyzing System Change through Healthcare Simulation: Systems, Competency, and Outcomes,’’ held on May 16, 2017, in Orlando, FL. Although simulation-based training is a quality and safety imperative in other high-reliability professions such as aviation, nuclear power, and the military, health care professions still lag behind in applying simulation more broadly. This is likely a result of a number of factors, including cost, assessment challenges, and resistance to change. This consensus subgroup focused on identifying current gaps in knowledge and process related to the use of simulation for developing, enhancing, maintaining individual provider competency. The resulting product is a research agenda informed by expert consensus and literature review.

This article is protected by copyright. All rights reserved.

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Functional outcome and economic burden of operative management of patellar fractures: the pivotal role of onerous implants

Abstract

Objectives

The complication rate following operative treatment of patellar fractures remains high and is associated with a poor functional outcome. The primary goal of this study was to evaluate our functional outcome of patellar fracture osteosynthesis and define strategies to improve the outcome. The healthcare costs and utilization were calculated.

Methods

All demographic, clinical, radiographic variables and hospital-related costs of 111 patients with 113 surgically treated patellar fractures between January 2005 and December 2014 were analyzed. Fractures were grouped as either simple or complex. Functional outcome was assessed using Knee Injury and Osteoarthritis Outcome Score (KOOS).

Results

There were 67 simple fractures (59.3%) and 46 complex fractures (40.7%). The overall complication rate was 48.7%, including 19.5% implant-related complications. In 69 patients (61.1%), implants were removed. The outcome was rather poor, with considerable impairment in all KOOS subscales with the knee-related quality of life rated worst (median 62.5, IQR 37.5–81.25). Poor outcome correlated significantly with complex patellar fractures and extensive tension-band constructs.

Conclusions

The operative treatment of patellar fractures was associated with a high complication rate, functional impairment and reduced quality of life. Complex patellar fractures and extensive tension-band constructs were identified as the main determinants of poor outcome and increased economic burden due to higher reinterventions rates. Strategies to reduce complications and improve outcome should focus on less onerous implants.

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EM Nerd-The Case of the Divisive Tincture

  The guiding physiological principles of resuscitation have for so long been based off the restoration of normal macroscopic hemodynamics in the hopes that the reversal of such circulatory perturbations will correct the underlying cellular injustices. And yet time after time such strategies have failed to show definitive benefits when empirically tested. The simple practice […]

EMCrit by Rory Spiegel.

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EM Nerd-The Case of the Divisive Tincture

  The guiding physiological principles of resuscitation have for so long been based off the restoration of normal macroscopic hemodynamics in the hopes that the reversal of such circulatory perturbations will correct the underlying cellular injustices. And yet time after time such strategies have failed to show definitive benefits when empirically tested. The simple practice […]

EMCrit by Rory Spiegel.

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Norwegian Air Ambulance FW - Lufttransport THX For G o o d job.

After M a n n y years of safe operation, Norwegiann Gov. opted for an foreigain operator for ower Fixed-Wing ambulances... ( It`s a different storry to operate anny aicraft in Sweeden, compared to Norway... (-Cindergarden V.S Uni. ..! ) It shall be innteresting ... ExEMTNor

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Ideal Cricoid Pressure Is Biomechanically Impossible During Laryngoscopy

Abstract

Study Objective

A prospective, randomised controlled trial of Rapid Sequence Intubation (RSI) with Cricoid Pressure (CP) within the Emergency Department (ED). The primary aim of the study was to examine the link between ideal CP and the incidence of aspiration.

Method

Patients >18 years of age undergoing RSI in the ED of two hospitals in New South Wales, Australia, were randomly assigned to receive Measured CP using weighing scales to target the ideal CP range (3.060kg – 4.075kg) or Control CP where the weighing scales were used, but the CP operator was blinded to the amount of CP applied during the RSI. A data logger recorded all CP delivered during each RSI. Immediately after intubation, tracheal and oesophageal samples were taken and underwent pepsin analysis.

Results

Fifty four RSIs were analysed (25 Measured/29 Control). Macroscopic contamination of the larynx at RSI was observed in 14 patients (26%). During induction (0 – 50 seconds), both groups delivered in-range CP. During intubation (51 – 223 seconds), laryngoscopy was associated with a reduction in mean CP below 3.060 kg in both groups. When compared, there was no statistically significant difference between the groups. For eleven patients, pepsin was detected in the oropharyngeal sample, whilst 3 were positive for tracheal pepsin. Seven patients (4 Control / 3 Measured) were treated for clinical aspiration during hospitalisation. As a result of the finding that neither group could maintain ideal range CP during laryngoscopy, the trial was abandoned.

Conclusion

Laryngoscopy provides a counter force to CP which is negated in order to facilitate tracheal intubation. The concept that a static 3.060 kg- 4.075kg CP could be maintained during laryngoscopy and intubation was rejected by our study. Whether a lower CP range could prevent aspiration during RSI was not explored by this study.

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Point-of-care cognitive support technology in emergency departments: A scoping review of technology acceptance by clinicians

Abstract

Objective

Cognitive support technologies that support clinical decisions and practices in the emergency department (ED) have the potential to optimize patient care. However, limited uptake by clinicians can prevent successful implementation. A better understanding of acceptance of these technologies from the clinician perspective is needed. We conducted a scoping review to synthesize diverse, emerging evidence on clinicians’ acceptance of point-of-care (POC) cognitive support technology in the ED.

Method

We systematically searched 10 electronic databases and grey literature published from January 2006 to December 2016. Studies of any design assessing an ED-based POC cognitive support technology were considered eligible for inclusion. Studies were required to report outcome data for technology acceptance. Two reviewers independently screened studies for relevance and quality. Study quality was assessed using the Mixed Methods Appraisal Tool. A descriptive analysis of the features of POC cognitive support technology for each study is presented, illustrating trends in technology development and evaluation. A thematic analysis of clinician, technical, patient, and organizational factors associated with technology acceptance is also presented.

Results

Of the 1,563 references screened for eligibility, 24 met the inclusion criteria and were included in the review. Most studies were published from 2011 onwards (88%), scored high for methodological quality (79%) and examined POC technologies that were novel and newly introduced into the study setting (63%). Physician use of POC technology was the most commonly studied (67%). Technology acceptance was frequently conceptualized and measured by factors related to clinician attitudes and beliefs. Experience with the technology, intention to use, and actual use were also more common outcome measures of technology acceptance. Across studies, perceived usefulness was the most noteworthy factor impacting technology acceptance, and clinicians generally had positive perceptions of the use of POC cognitive support technology in the ED. However, the actual use of POC cognitive support technology reported by clinicians was low—use, by proportion of patient cases, ranged from 30% to 59%. Of the 24 studies, only 2 studies investigated acceptance of POC cognitive support technology currently implemented in the ED, offering ‘real world’ clinical practice data. All other studies focused on acceptance of novel technologies. Technical aspects such as an unfriendly user interface, presentation of redundant or ambiguous information, and required user effort had a negative impact on acceptance. Patient expectations were also found to have a negative impact, while patient safety implications had a positive impact. Institutional support was also reported to impact technology acceptance.

Conclusions

Findings from this scoping review suggest that while ED clinicians acknowledge the utility and value of using POC cognitive support technology, actual use of such technology can be low. Further, few studies have evaluated the acceptance and use of POC technologies in routine care. Prospective studies that evaluate how ED clinicians appraise and consider POC technology use in clinical practice are now needed with diverse clinician samples. While this review identified multiple factors contributing to technology acceptance, determining how clinician, technical, patient, and organizational factors mediate or moderate acceptance should also be a priority.

This article is protected by copyright. All rights reserved.

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Intranasal Fentanyl and Quality of Pediatric Acute Care

Publication date: Available online 28 September 2017
Source:The Journal of Emergency Medicine
Author(s): Kathleen M. Adelgais, Alison Brent, Joseph Wathen, Suhong Tong, Derrek Massanari, Sara Deakyne, Marion R. Sills
BackgroundChanges in the manner in which medications can be delivered can have significant effects on the quality of care in the acute care setting.ObjectiveThe objective of this study was to evaluate the change in three Institute of Medicine quality indicators (timeliness, safety, and effectiveness) in the pediatric emergency department (ED) after the introduction of the Mucosal Atomizer Device Nasal™ (MADn) for opioid analgesia.MethodsThis was a retrospective review of patients receiving opioid analgesia for certain conditions over a 5-year period. We compared patients receiving intravenous opioid (IVO) to those receiving intranasal fentanyl (INF). Timeliness outcomes include time from medication order to administration, time from dose to discharge, overall time to analgesia, and ED length of stay. Effectiveness outcomes include change in pain score and frequency of repeat dosing. Safety outcomes were the frequency of reversal agent administration or a documented oxygen desaturation of < 90%. Sensitivity analyses were performed to evaluate the effect of moderate sedation on all three outcomes.ResultsDuring the study period, 1702 patients received opioid analgesia, 744 before and 958 after MADn introduction, of whom, 233 (24%) received INF. After MADn introduction, patients receiving INF had a shorter time to discharge from dose (109 vs. 203 min; p < 0.05) and shorter ED length of stay (168 vs. 267 min; p < 0.05). There was no difference in pain score reduction; however, repeat dosing was less frequent for patients receiving INF (16% vs. 27%). There was no use of reversal medication and no difference in the frequency of oxygen desaturations. When patients undergoing moderate sedation were removed from the analysis, there was no difference in the direction of findings for all three outcomes.ConclusionsINF is associated with improved timeliness and equivalent effectiveness and safety when compared to IVO in the setting of the pediatric ED.



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Cystic Fibrosis Transmembrane Conductance Regulator Potentiation as a Therapeutic Strategy for Pulmonary Edema: A Proof-of-Concept Study in Pigs.

Objectives: To determine the feasibility of using a cystic fibrosis transmembrane conductance regulator potentiator, ivacaftor (VX-770/Kalydeco, Vertex Pharmaceuticals, Boston, MA), as a therapeutic strategy for treating pulmonary edema. Design: Prospective laboratory animal investigation. Setting: Animal research laboratory. Subjects: Newborn and 3 days to 1 week old pigs. Interventions: Hydrostatic pulmonary edema was induced in pigs by acute volume overload. Ivacaftor was nebulized into the lung immediately after volume overload. Grams of water per grams of dry lung tissue were determined in the lungs harvested 1 hour after volume overload. Measurements and Main Results: Ivacaftor significantly improved alveolar liquid clearance in isolated pig lung lobes ex vivo and reduced edema in a volume overload in vivo pig model of hydrostatic pulmonary edema. To model hydrostatic pressure-induced edema in vitro, we developed a method of applied pressure to the basolateral surface of alveolar epithelia. Elevated hydrostatic pressure resulted in decreased cystic fibrosis transmembrane conductance regulator activity and liquid absorption, an effect which was partially reversed by cystic fibrosis transmembrane conductance regulator potentiation with ivacaftor. Conclusions: Cystic fibrosis transmembrane conductance regulator potentiation by ivacaftor is a novel therapeutic approach for pulmonary edema. Copyright (C) by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Diagnostic Accuracy of Point-of-Care Ultrasound Performed by Pulmonary Critical Care Physicians for Right Ventricle Assessment in Patients With Acute Pulmonary Embolism.

Objectives: Risk stratification for acute pulmonary embolism using imaging presence of right ventricular dysfunction is essential for triage; however, comprehensive transthoracic echocardiography has limited availability. We assessed the accuracy and timeliness of Pulmonary Critical Care Medicine Fellow's performance of goal-directed echocardiograms and intensivists' interpretations for evaluating right ventricular dysfunction in acute pulmonary embolism. Design: Prospective observational study and retrospective chart review. Setting: Four hundred fifty bed urban teaching hospital. Patients: Adult in/outpatients diagnosed with acute pulmonary embolism. Interventions: Pulmonary critical care fellows performed and documented their goal-directed echocardiogram as normal or abnormal for right ventricular size and function in patients with acute pulmonary embolism. Gold standard transthoracic echocardiography was performed on schedule unless the goal-directed echocardiogram showed critical findings. Attending intensivists blinded to the clinical scenario reviewed these exams at a later date. Measurements and Main Results: Two hundred eighty-seven consecutive patients were evaluated for acute PE. Pulmonary Critical Care Medicine Fellows performed 154 goal-directed echocardiograms, 110 with complete cardiology-reviewed transthoracic echocardiography within 48 hours for comparison. Pulmonary Critical Care Medicine Fellow's area under the curve for size and function was 0.83 (95% CI, 0.75-0.90) and 0.83 (95% CI, 0.75-0.90), respectively. Intensivists' 1/2 area under the curve for size and function was (1) 0.87 (95% CI, 0.82-0.94), (1) 0.87 (95% CI, 0.80-0.93) and (2) 0.88 (95% CI, 0.82-0.95), (2) 0.88 (95% CI, 0.82-0.95). Median time difference between goal-directed echocardiogram and transthoracic echocardiography was 21 hours 18 minutes. Conclusions: This is the first study to evaluate pulmonary critical care fellows' and intensivists' use of goal-directed echocardiography in diagnosing right ventricular dysfunction in acute pulmonary embolism. Pulmonary Critical Care Medicine Fellows and intensivists made a timely and accurate assessment. Screening for right ventricular dysfunction using goal-directed echocardiography can and should be performed by pulmonary critical care physicians in patients with acute pulmonary embolism. Copyright (C) by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Return Visit Admissions May Not Indicate Quality of Emergency Department Care for Children

Abstract

Objective

To test the hypothesis that in-hospital outcomes are worse among children admitted during a return ED visit than among those admitted during an index ED visit.

Methods

Retrospective analysis of ED visits by children age 0-17 to hospitals in Florida and New York in 2013. Children hospitalized during an ED return visit within 7 days were classified as “ED return admissions” (discharged at ED index visit and admitted at return visit) or “readmissions” (admission at both ED index and return visits). In-hospital outcomes for ED return admissions and readmissions were compared to “index admissions without return admission” (admitted at ED index visit without 7-day return visit admission).

Results

Among 1,886,053 index ED visits to 321 hospitals, 75,437 were index admissions without return admission, 7,561 were ED return admissions and 1,333 were readmissions. ED return admissions had lower intensive care unit (ICU) admission rates (11.0% versus 13.6%; adjusted odds ratio (AOR) 0.78, 95% confidence interval (CI) 0.71-0.85), longer length of stay (LOS, 3.51 vs. 3.38 days; difference 0.13 days; incidence rate ratio (IRR) 1.04; 95% CI 1.02-1.07), but no difference in mean hospital costs (($7138 vs. $7331; difference -$193; 95% CI -$479 to 93) compared to index admissions without return admission.

Conclusions

Compared with children who experienced index admissions without return admission, children who are initially discharged from the ED who then have a return visit admission had lower severity and similar cost, suggesting that ED return visit admissions do not involve worse outcomes than do index admissions.

This article is protected by copyright. All rights reserved.

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City Memories

A city is not a city to me, It is a place of memories, A tapestry of faces, Souvenirs of residency. The coffee shop on Third, Shuttered and empty, It is Mayuri and Sarah, Whom I miss so dearly.

This article is protected by copyright. All rights reserved.

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EMR Stalking

Abstract

You arrived unannounced. I sloppily donned my protective costume while the hardened but tireless nurses ran out to fetch you from the driveway, as they had with hundreds of other police drop-offs before. I imagined your body being thrown from side to side, smearing blood onto the seat as you were sped through red lights to get to the hospital. Thrown onto a stretcher and rushed into the spotless and brightly lit trauma bay; it was there I that I reluctantly met you.

This article is protected by copyright. All rights reserved.

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Preventable dental problems land many in the emergency room

The University of British Columbia Health News

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Economics of open tibial fractures: The pivotal role of length-of-stay and infection

Health Economics Review

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Taking biotin may make biotinylated immunoassay results inaccurate

Reuters Health News

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A dose-response meta-analysis of chronic arsenic exposure and incident cardiovascular disease

International Journal of Epidemiology

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Senate GOP pulls Graham-Cassidy bill to avoid vote defeat

Healthcare Finance News

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People are reluctant to use public defibrillators to treat cardiac arrests

University of Warwick Health and Medicine News

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Ten-year experience of endocardial linear infarct exclusion technique for ischaemic cardiomyopathy

European Journal of Cardio-Thoracic Surgery

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Inhaled steroids linked to non-TB mycobacterial lung disease in elderly

Reuters Health News

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Preadmission statin use improves the outcome of less severe sepsis patients: A population-based propensity score matched cohort study

British Journal of Anesthesia

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The nature and burden of occupational injury among first responder occupations: A retrospective cohort study in Australian workers

Injury

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Risk factors for severe anaphylaxis in the United States

Annals of Allergy, Asthma, and Immunology

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Rural and urban differences in passenger-vehicle-occupant deaths and seat belt use among adults - United States, 2014

Morbidity and Mortality Weekly Report

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Undetectable haptoglobin is associated with major adverse kidney events in critically ill burn patients

Critical Care

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Hospital mortality rates after heart attack differ by age

Yale School of Medicine News

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Deprivation status and the hospital costs of an emergency medical admission

European Journal of Internal Medicine

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Failure after modern total knee arthroplasty: A prospective study of 18,065 knees

Journal of Arthroplasty

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Alternative Markers of Performance in Simulation: Where We Are and Where We Need To Go

Abstract

This article on alternative markers of performance in simulation is the product of a session held during the 2017 Academic Emergency Medicine Consensus Conference “Catalyzing System Change Through Health Care Simulation: Systems, Competency, and Outcomes.” There is a dearth of research on the use of performance markers other than checklists, holistic ratings, and behaviorally-anchored rating scales in the simulation environment. Through literature review, group discussion, and consultation with experts prior to the conference, the working group defined five topics for discussion: 1. establishing a working definition for alternative markers of performance; 2. defining goals for using alternative performance markers; 3. implications for measurement when using alternative markers; 4. identifying practical concerns related to the use of alternative performance markers; and 5. identifying potential for alternative markers of performance to validate simulation scenarios. Five research propositions also emerged, and are summarized in the paper.

This article is protected by copyright. All rights reserved.

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Association of vascular access flow with short-term and long-term mortality in chronic haemodialysis patients: A retrospective cohort study

BMJ Open

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FDA declines to approve Intellipharma's opioid painkiller

Reuters Health News

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Prediction of major osteoporotic and hip fractures in Australian men using FRAX scores adjusted with trabecular bone score

Osteoporosis International

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Novelion's Aegerion resolves US drug probes for $40 million

Reuters Health News

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Suicide attempts on the rise in US, finds study

Columbia University Medical Center

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Targeted temperature management using the "Esophageal Cooling Device" after cardiac arrest (The COOL Study): A feasibility and safety study

Resuscitation

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Vitamin D kinetics in the acute phase of critical illness: A prospective observational study

Journal of Critical Care

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Does a balanced transfusion ratio of plasma to packed red blood cells improve outcomes in both trauma and surgical patients? A meta-analysis of randomized controlled trials and observational studies

The American Journal of Surgery

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Timing to antibiotic therapy in septic oncologic patients presenting without hypotension

Supportive Care in Cancer

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Immunoproteasome in the of children with acute appendicitis, and its correlation with proteasome and UCHL1 measured by SPR imaging biosensors

Clinical and Experimental Immunology

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Cancer patients who use cannabis receive insufficient information

Reuters Health News

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Level of systemic inflammation and endothelial injury is associated with cardiovascular dysfunction and vasopressor support in post cardiac arrest patients

Resuscitation

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An increase in accident and emergency presentations for adverse events following immunisation after introduction of the group B meningococcal vaccine: An observational study

Archives of Diseases in Childhood

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Cerebral strokes in children on intracorporeal ventricular assist devices: Analysis of the EUROMACS Registry

European Journal of Cardio-Thoracic Surgery

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Clinical impact of KMT2C and SPRY4 expression levels in intensively treated younger adult acute myeloid leukemia patients

European Journal of Haematology

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Validation of the (Troponin-only) Manchester Acute Coronary Syndromes decision aid with a contemporary cardiac troponin I assay

The American Journal of Emergency Medicine

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Risks of road injuries in patients with bipolar disorder and associations with drug treatments: A population-based matched cohort study

Journal of Affective Disorders

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Military-related trauma is associated with eating disorder symptoms in male veterans

International Journal of Eating Disorders

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Challenges with implementation of a respiratory therapist-driven protocol of spontaneous breathing trials in the pediatric ICU

Respiratory Care

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Predictors of false negative diffusion-weighted MRI in clinically suspected central cause of vertigo

The American Journal of Emergency Medicine

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Health Systems Science

Medical school graduates are required to master basic science and clinical skills in order to deliver compassionate, high-quality, patient-centered care. Increasingly, however, physicians are expected to go beyond caring for an individual patient, and improve the health of communities and populations in a manner that is equitable, efficient, and cost-effective. Unfortunately, the current United States (US) health system is fragmented, complex, and unsustainably costly.

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Critical Care Resource Utilization and Outcomes of Children With Moderate Traumatic Brain Injury.

Objectives: To characterize admission patterns, critical care resource utilization, and outcomes in moderate pediatric traumatic brain injury. Design: Retrospective cohort study. Setting: National Trauma Data Bank. Patients: Children under 18 years old with a diagnosis of moderate traumatic brain injury (admission Glasgow Coma Scale score of 9-13) in the National Trauma Data Bank between 2007 and 2014. Measurement and Main Results: We examined clinical characteristics, critical care resource utilization, and discharge outcomes. Poor outcomes were defined as discharge to hospice, skilled nursing facility, long-term acute care, or death. We examined 20,010 patient records. Patients were 9 years old (interquartile range, 2-15 yr), male (64%) with isolated traumatic brain injury (81%), Glasgow Coma Scale score of 12, head Abbreviated Injury Scale score of 3, and Injury Severity Score of 10. Majority (34%) were admitted to nontrauma hospitals. Critical care utilization was 58.7% including 11.5% mechanical ventilation and 3.2% intracranial pressure monitoring. Compared to patients with Glasgow Coma Scale score of 13, admission Glasgow Coma Scale score of 9 was associated with greater critical care resource utilization, such as ICU admission (72% vs 50%), intracranial pressure monitoring (7% vs 1.8%), mechanical ventilation (21% vs 6%), and intracranial surgery (10% vs 5%). Most patients (70%) were discharged to home, but up to one third had poor outcomes. Older age group had a higher risk of poor outcomes (10-14 yr; adjusted relative risk, 1.32; 95% CI, 1.13-1.54; 15-17 yr; adjusted relative risk, 2.39; 95% CI, 2.12-2.70). Poor outcomes occurred with lower Glasgow Coma Scale (Glasgow Coma Scale score of 9 vs Glasgow Coma Scale score of 13: adjusted relative risk, 2.89; 95% CI, 2.47-3.38), higher Injury Severity Score (Injury Severity Score of >= 16 vs Injury Severity Score of

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When disaster strikes, will your community be prepared?

If a disaster hits your community, will you be prepared? Are your leaders asking the right questions and taking the right steps to make sure your community could recover quickly and completely? Learn more about the flexible and adaptable resources from NIST's Community Resilience program that will help put your community on the path toward greater resilience.

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PulmCrit: Large-bore suction for intubation: strategies & devices

The ideal suction tool for intubations is debatable, but it seems clear that the Yankauer is a poor choice.  Persistent use of the Yankauer suction catheter for airway management represents a profession-wide failure in our ability to manage large-volume regurgitation.

EMCrit by Josh Farkas.

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Retrospective evaluation of the impact of a Geriatric Trauma Institute on fragility hip fracture patient outcomes

Orthopaedic Nursing

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Acute peritoneal dialysis in patients with acute kidney injury

Peritoneal Dialysis International

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Resistance exercise linked to reduced anxiety

Reuters Health News

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UTHealth researchers discover how to train damaging inflammatory cells to promote repair after stroke

University of Texas Health Science Center at Houston News

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AMA president weighs the pros and cons of MACRA, MIPS

Healthcare Finance News

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Radial access protects from contrast media induced nephropathy after cardiac catheterization procedures

Clinical Research in Cardiology

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Intensive versus minimal standard dosage for peritoneal dialysis in acute kidney injury: A randomized pilot study

Peritoneal Dialysis International

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Etiology, diagnosis, and demographic analysis of maxillofacial trauma in elderly persons: A 10-year investigation

Journal of Cranio-Maxillofacial Surgery

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Novel therapies for angiotensin-converting enzyme inhibitor–induced angioedema: a systematic review of current evidence

The Journal of Emergency Medicine

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Fewer US women are seeing ob-gyns regularly

Reuters Health News

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Long-term risk of acute myocardial infarction, stroke, and death with outpatient use of clarithromycin: A retrospective cohort study

American Journal of Epidemiology

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Efficacy and safety of potent platelet P2Y12 receptor inhibitors in elderly vs. non-elderly patients with acute coronary syndrome: A systematic review and meta-analysis

American Heart Journal

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Continuous infusion vs. intermittent bolus injection of furosemide in acute decompensated heart failure: Systematic review and meta-analysis of randomised controlled trials

Anaesthesia

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Prognostic significance of spontaneous shockable rhythm conversion in adult out-of-hospital cardiac arrest patients with initial non-shockable heart rhythms: A systematic review and meta-analysis

Resuscitation

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Can a left ventricular assist device in individuals with advanced systolic heart failure improve or reverse frailty?

Journal of the American Geriatrics Society

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Reconnection to mechanical ventilation for 1 h after a successful spontaneous breathing trial reduces reintubation in critically ill patients: A multicenter randomized controlled trial

Intensive Care Medicine

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Effects of a transition home program on preterm infant emergency room visits within 90 days of discharge

Journal of Perinatology

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Particulate matter air pollution and the risk of incident CKD and progression to ESRD

Journal of the American Society of Nephrology

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Emergency department attendance following 4-component meningococcal B vaccination in infants

Archives of Diseases in Childhood

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First large scale study of cocaine users leads to breakthrough in drug testing

University of Surrey News

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Routine versus selective chest and abdominopelvic CT-scan in conscious blunt trauma patients: a randomized controlled study

Abstract

Purpose

CT-scan is increasingly used in blunt trauma, but the real impact on patient outcome is still unclear. This study was conducted to assess the effect of performing routine (versus selective) chest and abdominopelvic CT-scan on patient admission time and outcome in blunt trauma.

Methods

Conscious and hemodynamically stable high-energy trauma patients were included (n = 140). Routine chest and abdominopelvic CT-scan was requested in addition to the conventional radiography and ultrasound for the intervention group and selective CT-scan according to clinical presentation was done for the control group. Patient admission times in the emergency room and surgery ward, complications, and performed surgical procedures were assessed. “Unsuspected injuries” defined as additional findings on CT-scan, which were not expected before CT-scan, were evaluated.

Results

Admission time in the emergency ward and admission time in hospital were significantly shorter in the intervention group. Complications were similar in both groups. Abdominopelvic CT-scan in the intervention group revealed nine (7.8%) unsuspected injuries. All of these nine patients had also a positive clinical examination and injuries in other body regions. Chest CT-scan in the intervention group led to additional diagnoses in 17 patients (24.28%) leading to tube thoracostomy in 13 patients (18.57%).

Conclusion

Routine chest and abdominopelvic CT-scan in conscious blunt trauma patients decreases the hospitalization time, but has no impact on patient outcome and probably might lead to overtreatment of occult injuries. The option of using a selective approach should be further evaluated to decrease radiation exposure and facility overuse.

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Emotional Impact of End-of-Life Decisions on Professional Relationships in the ICU: An Obstacle to Collegiality?.

Objectives: End-of-life decisions are not only common in the ICU but also frequently elicit strong feelings among health professionals. Even though we seek to develop more collegial interprofessional approaches to care and health decision-making, there are many barriers to successfully managing complex decisions. The aim of this study is to better understand how emotions influence the end-of-life decision-making process among professionals working in ICU. Design: Qualitative study with clinical interviews. All interviews were transcribed verbatim and analyzed thematically using interpretative phenomenological analysis. Setting: Two independent ICUs at the "Centre Hospitalier de l'Universite de Montreal." Subjects: Ten physicians and 10 nurses. Interventions: None. Measurements and Main Results: During the end-of-life decision-making process, families and patients restructure the decision-making frame by introducing a strong emotional dimension. This results in the emergence of new challenges quite different from the immediacy often associated with intensive care. In response to changes in decision frames, physicians rely on their relationship with the patient's family to assist with advanced care decisions. Nurses, however, draw on their relationship and proximity to the patient to denounce therapeutic obstinacy. Conclusions: Our study suggests that during the end-of-life decision-making process, nurses' feelings toward their patients and physicians' feelings toward their patients' families influence the decisions they make. Although these emotional dimensions allow nurses and physicians to act in a manner that is consistent with their professional ethics, the professionals themselves seem to have a poor understanding of these dimensions and often overlook them, thus hindering collegial decisions. Copyright (C) by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017.

Objective: To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients. Participants: A multispecialty task force of 16 international experts in critical care medicine, endocrinology, and guideline methods, all of them members of the Society of Critical Care Medicine and/or the European Society of Intensive Care Medicine. Design/Methods: The recommendations were based on the summarized evidence from the 2008 document in addition to more recent findings from an updated systematic review of relevant studies from 2008 to 2017 and were formulated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The strength of each recommendation was classified as strong or conditional, and the quality of evidence was rated from high to very low based on factors including the individual study design, the risk of bias, the consistency of the results, and the directness and precision of the evidence. Recommendation approval required the agreement of at least 80% of the task force members. Results: The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI, although delta cortisol (change in baseline cortisol at 60 min of = 3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy (conditional, low quality of evidence). We suggest not using corticosteroids in adult patients with sepsis without shock (conditional recommendation, moderate quality of evidence). We suggest the use of IV methylprednisolone 1 mg/kg/day in patients with early moderate to severe acute respiratory distress syndrome (PaO2/FiO2

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Critical Illness-Related Corticosteroid Insufficiency (CIRCI): A Narrative Review from a Multispecialty Task Force of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM).

Objective: To provide a narrative review of the latest concepts and understanding of the pathophysiology of critical illness-related corticosteroid insufficiency (CIRCI). Participants: A multi-specialty task force of international experts in critical care medicine and endocrinology and members of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. Data Sources: Medline, Database of Abstracts of Reviews of Effects (DARE), Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews. Results: Three major pathophysiologic events were considered to constitute CIRCI: dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, altered cortisol metabolism, and tissue resistance to glucocorticoids. The dysregulation of the HPA axis is complex, involving multidirectional crosstalk between the CRH/ACTH pathways, autonomic nervous system, vasopressinergic system, and immune system. Recent studies have demonstrated that plasma clearance of cortisol is markedly reduced during critical illness, explained by suppressed expression and activity of the primary cortisol-metabolizing enzymes in the liver and kidney. Despite the elevated cortisol levels during critical illness, tissue resistance to glucocorticoids is believed to occur due to insufficient glucocorticoid alpha-mediated anti-inflammatory activity. Conclusions: Novel insights into the pathophysiology of CIRCI add to the limitations of the current diagnostic tools to identify at-risk patients and may also impact how corticosteroids are used in patients with CIRCI. Copyright (C) by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Measuring Emergency Department Patient Population Acuity

Abstract

Background

Emergency department (ED) acuity is the general level of patient illness, urgency for clinical intervention, and intensity of resource use in an ED environment. The relative strength of commonly used measures of ED acuity is not well understood.

Methods

We performed a retrospective cross-sectional analysis of ED-level data to evaluate the relative strength of association between commonly used proxy measures with a full spectrum measure of ED acuity. Common measures included the percentage of patients with Emergency Severity Index (ESI) scores of 1 or 2, case mix index (CMI), academic status, annual ED volume, inpatient admission rate, percentage of Medicare patients, and patients-seen-per-attending-hour. Our reference standard for acuity is the percentage of high acuity charts (PHAC) coded and billed according to the Centers for Medicare and Medicaid Service's Ambulatory Payment Classification (APC) system. High acuity charts included those APC 4, 5 or critical care. PHAC was represented as a fractional response variable. We examined the strength of associations between common acuity measures and PHAC using Spearman's rank correlation coefficients (r_s) and regression models including a quasi-binomial generalized linear model and linear regression.

Results

In our univariate analysis, the percentage of patients ESI 1or 2, CMI, academic status and annual ED volume had statistically significant associations with PHAC. None explained more than 16% of PHAC variation. For regression models including all common acuity measures, academic status was the only variable significantly associated with PHAC.

Conclusion

ESI had the strongest association with PHAC followed by CMI and annual ED volume. Academic status captures variability outside of that explained by ESI, CMI, annual ED volume, percentage Medicare patients, or patients-per-attending-per-hour. All measures combined only explained only 42.6% of PHAC variation.

This article is protected by copyright. All rights reserved.

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Decision Making in Orthopaedic Trauma

Abstract

The first edition of Decision Making in Orthopaedic Trauma, is a uniquely formatted textbook intended to guide medical students, resident physicians-in-training, and practicing clinicians in the acute management of a comprehensive range of orthopedic emergencies. The authors of the individual algorithms are members of the faculty at the University of California, San Francisco (UCSF) / Zuckerberg San Francisco General (ZSFG) Orthopaedic Trauma Institute. Relying on their extensive professional experience and relevant evidence based publications, they created an easy to access format that provides a quick, simple to use reference for the critical decision points for a variety of traumatic orthopedic conditions. Using an algorithm-based approach, clinicians are guided through critical decision trees to assist decision making in the evaluation and treatment of a wide variety of orthopedic emergencies, from simple fractures through complex life and limb threatening conditions. The text includes 80 chapters, each composed of a 1-page, beautifully styled and easy to follow flow diagram for decision making, followed by a page listing relevant evidence-based references.

This article is protected by copyright. All rights reserved.

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Body Composition Changes in Severely Burned Children During ICU Hospitalization.

Objectives: Prolonged hospitalization due to burn injury results in physical inactivity and muscle weakness. However, how these changes are distributed among body parts is unknown. The aim of this study was to evaluate the degree of body composition changes in different anatomical regions during ICU hospitalization. Design: Retrospective chart review. Setting: Children's burn hospital. Patients: Twenty-four severely burned children admitted to our institution between 2000 and 2015. Interventions: All patients underwent a dual-energy x-ray absorptiometry within 2 weeks after injury and 2 weeks before discharge to determine body composition changes. No subject underwent anabolic intervention. We analyzed changes of bone mineral content, bone mineral density, total fat mass, total mass, and total lean mass of the entire body and specifically analyzed the changes between the upper and lower limbs. Measurements and Main Results: In the 24 patients, age was 10 +/- 5 years, total body surface area burned was 59% +/- 17%, time between dual-energy x-ray absorptiometries was 34 +/- 21 days, and length of stay was 39 +/- 24 days. We found a significant (p

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Feasibility and Safety of Controlled Active Hypothermia Treatment During Transport in Neonates With Hypoxic-Ischemic Encephalopathy.

Objectives: To evaluate the feasibility and safety of controlled active hypothermia versus standard intensive care during neonatal transport in patients with hypoxic-ischemic encephalopathy. Design: Cohort study with a historic control group. Setting: All infants were transported by Neonatal Emergency & Transport Services to a Level-III neonatal ICU. Patients: Two hundred fourteen term newborns with moderate-to-severe hypoxic-ischemic encephalopathy. An actively cooled group of 136 newborns were compared with a control group of 78 newborns. Interventions: Controlled active hypothermia during neonatal transport. Measurements and Main Results: Key measured variables were timing of hypothermia initiation, temperature profiles, and vital signs during neonatal transport. Hypothermia was initiated a median 2.58 hours earlier in the actively cooled group compared with the control group (median 1.42 [interquartile range, 0.83-2.07] vs 4.0 [interquartile range, 2.08-5.79] hours after birth, respectively; p

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Discussing Benefits and Risks of Tracheostomy: What Physicians Actually Say.

Objectives: When contemplating tracheostomy placement in a pediatric patient, a family-physician conference is often the setting for the disclosure of risks and benefits of the procedure. Our objective was to compare benefits and risks of tracheostomy presented during family-physician conferences to an expert panel's recommendations for what should be presented. Design: We conducted a retrospective review of 19 transcripts of audio-recorded family-physician conferences regarding tracheostomy placement in children. A multicenter, multidisciplinary expert panel of clinicians was surveyed to generate a list of recommended benefits and risks for comparison. Primary analysis of statements by clinicians was qualitative. Setting: Single-center PICU of a tertiary medical center. Subjects: Family members who participated in family-physician conferences regarding tracheostomy placement for a critically ill child from April 2012 to August 2014. Measurements and Main Results: We identified 300 physician statements describing benefits and risks of tracheostomy. Physicians were more likely to discuss benefits than risks (72% vs 28%). Three broad categories of benefits were identified: 1) tracheostomy would limit the impact of being in the PICU (46%); 2) perceived obstacles of tracheostomy can be overcome (34%); and 3) tracheostomy optimizes respiratory health (20%). Risks fell into two categories: tracheostomy involves a big commitment (71%), and it has complications (29%). The expert panel's recommendations were similar to risks and benefits discussed during family conferences; however, they suggested physicians present an equal balance of discussion of risks and benefits. Conclusions: When discussing tracheostomy placement, physicians emphasized benefits that are shared by physicians and families while minimizing the risks. The expert panel recommended a balanced approach by equally weighing risks and benefits. To facilitate educated decision making, physicians should present a more extensive range of risks and benefits to families making this critical decision. (C)2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Urinary protein profiles in ketorolac-associated acute kidney injury in patients undergoing orthopedic day surgery

International Journal of Nephrology and Renovascular Disease

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How clinicians can communicate better with adult cancer patients - ASCO

Reuters Health News

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Many drug companies fail to conduct timely safety checks on medicines after FDA approval

Reuters Health News

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Study of fall-risk-increasing drugs in elderly patients before and after a bone fracture

Postgraduate Medical Journal

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Study: Healthcare demands taking toll on physician health, patient care

Healthcare Finance News

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End-tidal carbon dioxide and defibrillation success in out-of-hospital cardiac arrest

Resuscitation

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Outcomes of emergency department anaphylaxis visits from 2005 to 2014

The Journal of Allergy and Clinical Immunology: In Practice

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Rapid response team patients triaged to remain on ward despite deranged vital signs: Missed opportunities?

Acta Anaesthesiologica Scandinavica

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Minocycline and matrix metalloproteinase inhibition in acute intracerebral hemorrhage: A pilot study

European Journal of Neurology

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Fatal yellow fever in a traveler returning from Peru - New York, 2016

Morbidity and Mortality Weekly Report

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Heart failure in young adults is associated with high mortality: A contemporary population-level analysis

Canadian Journal of Cardiology

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Effects of intra-operative fluoroscopic 3D-imaging on peri-operative imaging strategy in calcaneal fracture surgery

Archives of Orthopaedic and Trauma Surgery

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Kinect-based real-time audiovisual feedback device improves cardiopulmonary resuscitation quality of lower-body-weight rescuers

The American Journal of Emergency Medicine

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Thermal stability of mafenide and amphotericin B topical solution

Burns

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Early decrease of oxidative stress by non-invasive ventilation in patients with acute respiratory failure

Internal and Emergency Medicine

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Posterior vitreous detachment - Prevalence of and risk factors for retinal tears

Clinical Ophthalmology

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Impact of discharge anticoagulation education by emergency department pharmacists at a tertiary academic medical center

The Journal of Emergency Medicine

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Emergency medicine evaluation of community-acquired pneumonia: History, examination, imaging and laboratory assessment, and risk scores

The Journal of Emergency Medicine

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Effect of access site choice on acute kidney injury after percutaneous coronary intervention

The American Journal of Cardiology

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Immune cells may heal bleeding brain after strokes

NIH News

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Validation of a Dispatch Protocol with Continuous Quality Control for Cardiac Arrest: A Before-and-After Study at a City Fire Department-Based Dispatch Center

Publication date: Available online 21 September 2017
Source:The Journal of Emergency Medicine
Author(s): Chien-Hsiung Huang, Hsuan-Jui Fan, Cheng-Yu Chien, Chen-June Seak, Chan-Wei Kuo, Chip-Jin Ng, Wen-Cheng Li, Yi-Ming Weng
BackgroundAn optimized protocol to help dispatchers identify potential cases of cardiac arrest and provide phone instructions for cardiopulmonary resuscitation (CPR) may increase the provision of bystander CPR, further improving the survival rate and neurological outcomes.ObjectiveWe assessed a revised dispatcher-assisted (DA)-CPR protocol with a continuous quality-improvement feature in a county fire department-based emergency medical services system.MethodsThis was a before-and-after intervention prospective study conducted in Taoyuan City, Taiwan. The participants were out-of-hospital cardiac arrest (OHCA) patients from November 2014 to February 2016. Interventional quality control started in August 2015. Approximately 10% of the telephone calls from these OHCA patients were reviewed.ResultsIn total, 66 and 64 cases were included in the before- and after-intervention groups, respectively. No significant differences were observed in sex, age, day, and time of events, or languages spoken by the callers. After the intervention, we found significant improvements in the rates at which cardiac arrests were recognized (54.5% vs. 68.8%; p = 0.007) and normal breathing was checked (51.5% vs. 76.6%, p = 0.003). Moreover, the frequency with which DA-CPR was provided by the dispatchers improved significantly (50.0% vs. 72.7%; p = 0.046). Significant improvement in patient outcomes was observed with regard to 24-h survival (7.6% vs. 20.3%, p = 0.036) but not with regard to survival to discharge (3.0% vs. 10.9%, p = 0.076).ConclusionsThe study found this DA-CPR protocol, which includes continuous quality control, is promising as it improved the successful recognition of cardiac arrests.



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Time Course of Septic Shock in Immunocompromised and Nonimmunocompromised Patients.

Objectives: To address the impact of underlying immune conditions on the course of septic shock with respect to both mortality and the development of acute infectious and noninfectious complications. Design: An 8-year (2008-2015) monocenter retrospective study. Setting: A medical ICU in a tertiary care center. Patients: Patients diagnosed for septic shock within the first 48 hours of ICU admission were included. Patients were classified in four subgroups with respect to their immune status: nonimmunocompromised and immunocompromised distributed into hematologic or solid malignancies and nonmalignant immunosuppression. Outcomes were in-hospital death and the development of ischemic and hemorrhagic complications and ICU-acquired infections. The determinants of death and complications were addressed by multivariate competing risk analysis. Interventions: None. Measurements and Main Results: Eight hundred one patients were included. Among them, 305 (38%) were immunocompromised, distributed into solid tumors (122), hematologic malignancies (106), and nonmalignant immunosuppression (77). The overall 3-day, in-ICU, and in-hospital mortality rates were 14.1%, 37.3%, and 41.3%, respectively. Patients with solid tumors displayed increased in-hospital mortality (cause-specific hazard, 2.20 [95% CI, 1.64-2.96]; p

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The Impact of Fluid Overload on Outcomes in Children Treated With Extracorporeal Membrane Oxygenation: A Multicenter Retrospective Cohort Study.

Objective: To characterize the epidemiology of fluid overload and its association with mortality and duration of extracorporeal membrane oxygenation in children treated with extracorporeal membrane oxygenation. Design: Retrospective cohort study. Setting: Six tertiary children's hospital ICUs. Patients: Seven hundred fifty-six children younger than 18 years old treated with extracorporeal membrane oxygenation for greater than or equal to 24 hours from January 1, 2007, to December 31, 2011. Interventions: None. Measurements and Main Results: Overall survival to extracorporeal membrane oxygenation decannulation and hospital discharge was 74.9% (n = 566) and 57.7% (n = 436), respectively. Median fluid overload at extracorporeal membrane oxygenation initiation was 8.8% (interquartile range, 0.3-19.2), and it differed between hospital survivors and non survival, though not between extracorporeal membrane oxygenation survivors and non survivors. Median peak fluid overload on extracorporeal membrane oxygenation was 30.9% (interquartile range, 15.4-54.8). During extracorporeal membrane oxygenation, 84.8% had a peak fluid overload greater than or equal to 10%; 67.2% of patients had a peak fluid overload of greater than or equal to 20% and 29% of patients had a peak fluid overload of greater than or equal to 50%. The median peak fluid overload was lower in patients who survived on extracorporeal membrane oxygenation (27.2% vs 44.4%; p

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Factors influencing on-scene time in a rural Norwegian helicopter emergency medical service: a retrospective observational study

Critically ill patients need to be immediately identified, properly managed, and rapidly transported to definitive care. Extensive prehospital times may increase mortality in selected patient groups. The on-sc...

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Acute pancreatitis: is early CT necessary?

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Cool it or not but based on what?

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The impact of teach-back method on retention of key domains of emergency department discharge instructions

The Journal of Emergency Medicine

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Christmas berry derivative shows promise in mouse asthma models

Reuters Health News

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Moderate sensitivity and high specificity of emergency department administrative data for transient ischemic attacks

BMC Health Services Research

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Physicians, patients blame insurance, drug companies for rising health care costs

Healthcare Finance News

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What can studies tell us about whole grains and the heart?

Reuters Health News

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Accuracy of Shock Index versus ABC score to predict need for massive transfusion in trauma patients

Injury

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Prognostic value of serum biomarkers of cerebral injury in classifying neurological outcome after paediatric resuscitation

Resuscitation

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Intra- and inter-rater agreement of the Genital Injury Severity Scale

Journal of Forensic and Legal Medicine

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Snakebite envenoming

Liverpool School of Tropical Medicine News

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Nasal injury and comfort with jet versus bubble continuous positive airway pressure delivery systems in preterm infants with respiratory distress

European Journal of Pediatrics

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Predictors of epinephrine dispensing and allergy follow-up after emergency department visit for anaphylaxis

Annals of Allergy, Asthma, and Immunology

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Management of comminuted fractures of the distal humerus: Clinical outcome after primary external fixation versus immediate fixation with locking plates

Archives of Orthopaedic and Trauma Surgery

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The validation of the Dutch SF-Qualiveen, a questionnaire on urinary-specific quality of life, in spinal cord injury patients

BMC Urology

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Laboratory markers of cardiac and metabolic complications after generalized tonic-clonic seizures

BMC Neurology

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Clinical criteria for tracheostomy decannulation in subjects with acquired brain injury

Respiratory Care

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Lung injury etiology and other factors influencing the relationship between dead-space fraction and mortality in ARDS

Respiratory Care

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Links between deprivation and risk of violence-related injury

Cardiff University News

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Risk factors for severe hypoglycemia in black and white adults with diabetes: The Atherosclerosis Risk in Communities (ARIC) study

Diabetes Care

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Canadian youth have poor access to mental health and addictions care according to first pan-provincial study

Simon Fraser University News

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Variability of Capillary Refill Time among Physician Measurements

Publication date: Available online 21 September 2017
Source:The Journal of Emergency Medicine
Author(s): David C. Sheridan, Steven D. Baker, Susan A. Kayser, David Jones, Matthew L. Hansen
BackgroundThe assessment of capillary refill time (CRT) is a common physical examination technique. However, despite its importance and its widespread use, there is little standardization, which can lead to inaccurate assessments.ObjectiveIn this article, we assessed how different physicians estimate CRT. We hypothesized that when different physicians are presented with the same recordings of CRT, clinicians will, on average, provide different CRT estimates.MethodsUsing recordings of different fingertip compressions, physicians assessed and documented when capillary refill had returned to normal. Videos were recorded of the fingertips only, with no other identifying markers or subject characteristics provided. Videos were shown at one-quarter speed to allow time for recognition and response to the capillary refill. The primary outcome was physician estimates of CRT for each video recording.ResultsAn analysis of variance regression revealed significant differences in physician estimates of CRT when examining the same CRT videos from 34 subjects. Further regression analyses reveal the importance of controlling for the physician that is examining the patient when predicting a patient's CRT.ConclusionsResults indicate that some physicians gave, on average, slower CRT estimates, whereas others gave, on average, faster CRT estimates. Objective approaches and innovations in assessment of capillary refill have the potential to increase the diagnostic accuracy of this important clinical examination finding.



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The Impact of Teach-Back Method on Retention of Key Domains of Emergency Department Discharge Instructions

Publication date: Available online 20 September 2017
Source:The Journal of Emergency Medicine
Author(s): Becky Ann Slater, Yinjiang Huang, Preeti Dalawari
BackgroundStudies have shown that patient understanding and recall of their emergency department (ED) discharge instructions is limited. The teach-back method involves patients repeating back what they understand, in their own words, so that discharge providers can confirm comprehension and correct misunderstandings.ObjectiveThe objective of this study was to determine if the teach-back method would increase retention of post ED discharge instructions.MethodsA before-and-after study design (pre and post teach-back method) was used at an academic Midwestern institution. After discharge, patients were asked a set of standardized questions regarding their discharge instructions via telephone interview. Answers were compared with the participant's discharge instructions in the electronic medical record. A composite score measuring mean percent recall correct was calculated in four categories: diagnosis, medication reconciliation, follow-up instructions, and return precautions. Data were collected for 1 week prior to and 1 week post intervention. One additional week between the pre- and postintervention phases included training and practice behavior adoption. The primary outcome was mean percent recall correct between the two groups assessed by a Mann-Whitney U test, and adjusted for confounders with an analysis of covariance model.ResultsThe mean percent recall correct in the teach-back phase was 79.4%, or 15 percentage points higher than the preintervention group. After adjusting for age and education, the adjusted model showed a recall rate of 70.0% pre vs. 82.1% (p < 0.005) post intervention.ConclusionsThe teach-back method had a positive association on retention of discharge instructions in the ED regardless of age and education.



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National Survey of Emergency Physicians Concerning Home-Based Care Options as Alternatives to Emergency Department–Based Hospital Admissions

Publication date: Available online 20 September 2017
Source:The Journal of Emergency Medicine
Author(s): Amy R. Stuck, Christopher Crowley, James Killeen, Edward M. Castillo
BackgroundEmergency departments (EDs) in the United States play a prominent role in hospital admissions, especially for the growing population of older adults. Home-based care, rather than hospital admission from the ED, provides an important alternative, especially for older adults who have a greater risk of adverse events, such as hospital-acquired infections, falls, and delirium.ObjectiveThe objective of the survey was to understand emergency physicians' (EPs) perspectives on home-based care alternatives to hospitalization from the ED. Specific goals included determining how often EPs ordered home-based care, what they perceive as the barriers and motivators for more extensive ordering of home-based care, and the specific conditions and response times most appropriate for such care.MethodsA group of 1200 EPs nationwide were e-mailed a six-question survey.ResultsParticipant response was 57%. Of these, 55% reported ordering home-based care from the ED within the past year as an alternative to hospital admission or observation, with most doing so less than once per month. The most common barrier was an “unsafe or unstable home environment” (73%). Home-based care as a “better setting to care for low-acuity chronic or acute disease exacerbation” was the top motivator (79%). Medical conditions EPs most commonly considered for home-based care were cellulitis, urinary tract infection, diabetes, and community-acquired pneumonia.ConclusionsResults suggest that EPs recognize there is a benefit to providing home-based care as an alternative to hospitalization, provided they felt the home was safe and a process was in place for dispositioning the patient to this setting. Better understanding of when and why EPs use home-based care pathways from the ED may provide suggestions for ways to promote wider adoption.



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The Emergency Medicine−Focused Review of Cholangitis

Publication date: Available online 20 September 2017
Source:The Journal of Emergency Medicine
Author(s): Rachel Ely, Brit Long, Alex Koyfman
BackgroundCholangitis is a life-threatening infection of the biliary tract. Historically, the mortality secondary to cholangitis approached 100%. However, with early recognition, antibiotics, resuscitation, and surgical or endoscopic intervention, patient outcomes have significantly improved, although there is still progress to be made.Objective of ReviewThe objective of this review is to provide an emergency medicine−centered approach to the risk factors, presentations, and various diagnostic and treatment modalities in cholangitis.DiscussionEarly recognition and treatment of cholangitis in the emergency department is instrumental in ensuring a favorable outcome for patients. Recognition of acute cholangitis can be challenging, as many patients do not present with the classic symptoms of Charcot's triad. This article reviews the risk factors in cholangitis, as well as the typical presentations and necessary diagnostic studies. Furthermore, once diagnosis is made, distinguishing those requiring emergent biliary decompression from those who may tolerate a delayed procedure can also be difficult. Scoring systems that attempt to identify patients who may tolerate a delayed approach have yet to be validated. This review discusses the appropriate antibiotic therapy based on most common pathogens, as well as the options for achieving biliary decompression.ConclusionsCholangitis is a life-threatening infection that carries a high likelihood of poor outcomes if not treated early and aggressively in the emergency department. Appropriate recognition, early broad-spectrum antibiotics, and fluid resuscitation are paramount, and in patients with severe disease, early biliary decompression will significantly reduce mortality.



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Novel Therapies for Angiotensin-Converting Enzyme Inhibitor–Induced Angioedema: A Systematic Review of Current Evidence

Publication date: Available online 20 September 2017
Source:The Journal of Emergency Medicine
Author(s): Heidi M. Riha, Bryant B. Summers, Jessica V. Rivera, Megan A. Van Berkel
BackgroundAngiotensin-converting enzyme inhibitor (ACEI)–induced angioedema can occur at any point during therapy and, when severe, can require mechanical ventilation. Standard agents for anaphylactic reactions have limited efficacy for bradykinin-mediated angioedema and, therefore, agents approved for hereditary angioedema are increasingly prescribed for these patients.Objective of the ReviewThis systematic review critically evaluates evidence describing the off-label use of fresh frozen plasma (FFP), prothrombin complex concentrate (PCC), complement 1 esterase inhibitor (C1-INH), icatibant, and ecallantide for treatment of ACEI-induced angioedema.DiscussionA PubMed search was conducted and articles were cross-referenced for additional citations. All full-text clinical trials, case series, and case reports published in the English language describing pharmacologic treatment of ACEI-induced angioedema were included. Thirty-seven publications detailing FFP, PCC, and regimens approved for hereditary angioedema, including icatibant, ecallantide, and C1-INH, are reviewed extensively.ConclusionsWhile findings of decreased time to symptom resolution or a cessation in symptom progression have been reported with each of these therapies, additional data showing clinically relevant implications, such as reduced intensive care unit length of stay or avoidance of mechanical ventilation, are warranted, especially when taking cost into consideration. FFP has limited evidence demonstrating a benefit for treatment of ACEI-induced angioedema without consistent dosing strategies. However, given its wide availability and low potential for adverse reactions, FFP therapy may be reasonable. Of the novel agents traditionally used for hereditary angioedema, icatibant has the highest level of evidence and has been reported to be successful in limiting the progression of angioedema.



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Impact of Discharge Anticoagulation Education by Emergency Department Pharmacists at a Tertiary Academic Medical Center

Publication date: Available online 21 September 2017
Source:The Journal of Emergency Medicine
Author(s): Elizabeth G. Zdyb, D. Mark Courtney, Sanjeev Malik, Michael J. Schmidt, Abbie E. Lyden
BackgroundAlthough pharmacists commonly provide patient education and help manage high-risk anticoagulant medications in inpatient and outpatient settings, the evidence for these interventions in the emergency department (ED) is less established, especially in the era of direct-acting oral anticoagulants. In 2013, a formal program was initiated whereby patients discharged with a new prescription for any anticoagulant receive education from an ED pharmacist when on-site. In addition, they received follow-up phone calls from an ED pharmacist within 72 hours of discharge.ObjectiveWe sought to identify the impact of pharmacist education, defined as the need for intervention on callback, versus physician and nursing-driven discharge measures on patient understanding and appropriate use of anticoagulant medications.MethodsA single-center retrospective analysis included patients discharged from the ED between May 2013 and May 2016 with a new anticoagulant prescription. Electronic callback records were reviewed to assess patients' adherence and understanding of discharge instructions as well as for an anticoagulant-related hospital readmission within 90 days.ResultsOne hundred seventy-four patients were evaluated in a per protocol analysis. Patients who did not receive pharmacist education prior to discharge required an increased need for intervention during callback versus those who did (36.4% vs. 12.9%, p = 0.0005) related to adherence, inappropriate administration, and continued use of interacting medications or supplements, among other concerns. In addition, patients who had not received pharmacist counseling were more likely to be readmitted to a hospital or return to the ED within 90 days after their initial visit for an anticoagulation-related problem versus patients who had (12.12% vs. 1.85%, p = 0.0069).ConclusionDischarge education by ED pharmacists leads to improved patient understanding and appropriate use of anticoagulants.



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Subgaleal Hematoma at the Contralateral Side of Scalp Trauma in an Adult

Publication date: Available online 20 September 2017
Source:The Journal of Emergency Medicine
Author(s): Ching-En Chen, Zen-Zhon Liao, Yen-Heng Lee, Cheng-Chieh Liu, Chi-Kao Tang, Yi-Rong Chen
BackgroundSubgaleal hematoma (SGH), an abnormal accumulation of blood under the galeal aponeurosis of the scalp, is more commonly observed in newborns and children. According to previous cases, the etiology of SGH includes mild head trauma, vacuum-assisted vaginal delivery, contusion, and hair braiding or pulling.Case ReportA 39-year-old healthy worker came to our emergency department (ED) due to scalp lacerations from an accident that caused severe twisting of his hair. He denied head contusion and was conscious upon arrival. Physical examination showed three lacerations over his right temporal area. The wounds depth extended to the skull, with a 10-cm subperiosteal pocket beneath the lacerations. Primary sutures were performed immediately under local anesthesia, not only for wound closure but also for hemostasis. However, he returned to our ED 3 h after the first visit for a newly developed soft lump over the left side of his forehead. Computed tomography scan of brain illustrated a huge and diffuse SGH in the left temporal region with extension to periorbital region. Although the option of incision and drainage was discussed with a neurosurgeon and a search for some case reports was done, most of the hematoma could be self-limited. Conservative management with non-elastic bandage packing direct compression was applied. The patient was then admitted for close observation and conservative treatment for 1 week. There was no recurrence of SGH in the following 3 months.Why Should an Emergency Physician Be Aware of This?SGH is an uncommon phenomenon that is caused by tearing of the emissary veins in the loose areolar tissue located beneath the galeal aponeurosis. Conservative treatment with bandage compression is recommended for SGH. Surgery is reserved for cases where non-invasive management fails or severe complications.



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Emergency Medicine Evaluation of Community-Acquired Pneumonia: History, Examination, Imaging and Laboratory Assessment, and Risk Scores

Publication date: Available online 20 September 2017
Source:The Journal of Emergency Medicine
Author(s): Brit Long, Drew Long, Alex Koyfman
BackgroundPneumonia is a common infection, accounting for approximately one million hospitalizations in the United States annually. This potentially life-threatening disease is commonly diagnosed based on history, physical examination, and chest radiograph.ObjectiveTo investigate emergency medicine evaluation of community-acquired pneumonia including history, physical examination, imaging, and the use of risk scores in patient assessment.DiscussionPneumonia is the number one cause of death from infectious disease. The condition is broken into several categories, the most common being community-acquired pneumonia. Diagnosis centers on history, physical examination, and chest radiograph. However, all are unreliable when used alone, and misdiagnosis occurs in up to one-third of patients. Chest radiograph has a sensitivity of 46–77%, and biomarkers including white blood cell count, procalcitonin, and C-reactive protein provide little benefit in diagnosis. Biomarkers may assist admitting teams, but require further study for use in the emergency department. Ultrasound has shown utility in correctly identifying pneumonia. Clinical gestalt demonstrates greater ability to diagnose pneumonia. Clinical scores including Pneumonia Severity Index (PSI); Confusion, blood Urea nitrogen, Respiratory rate, Blood pressure, age 65 score (CURB-65); and several others may be helpful for disposition, but should supplement, not replace, clinical judgment. Patient socioeconomic status must be considered in disposition decisions.ConclusionThe diagnosis of pneumonia requires clinical gestalt using a combination of history and physical examination. Chest radiograph may be negative, particularly in patients presenting early in disease course and elderly patients. Clinical scores can supplement clinical gestalt and assist in disposition when used appropriately.



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Neurologic and Functional Morbidity in Critically Ill Children With Bronchiolitis.

Objectives: Neurologic and functional morbidity occurs in ~30% of PICU survivors, and young children may be at particular risk. Bronchiolitis is a common indication for PICU admission among children less than 2 years old. Two single-center studies suggest that greater than 10-25% of critical bronchiolitis survivors have neurologic and functional morbidity but those estimates are 20 years old. We aimed to estimate the burden of neurologic and functional morbidity among more recent bronchiolitis patients using two large, multicenter databases. Design: Analysis of the Pediatric Health Information System and the Virtual Pediatric databases. Setting: Forty-eight U.S. children's hospitals (Pediatric Health Information System) and 40 international (mostly United States) children's hospitals (Virtual Pediatric Systems). Patients: Previously healthy PICU patients less than 2 years old admitted with bronchiolitis between 2009 and 2015 who survived and did not require extracorporeal membrane oxygenation or cardiopulmonary resuscitation. Interventions: None. Neurologic and functional morbidity was defined as a Pediatric Overall Performance Category greater than 1 at PICU discharge (Virtual Pediatric Systems subjects), or a subsequent hospital encounter involving developmental delay, feeding tubes, MRI of the brain, neurologist evaluation, or rehabilitation services (Pediatric Health Information System subjects). Measurements and Main Results: Among 3,751 Virtual Pediatric Systems subjects and 9,516 Pediatric Health Information System subjects, ~20% of patients received mechanical ventilation. Evidence of neurologic and functional morbidity was present at PICU discharge in 707 Virtual Pediatric Systems subjects (18.6%) and more chronically in 1,104 Pediatric Health Information System subjects (11.6%). In both cohorts, neurologic and functional morbidity was more common in subjects receiving mechanical ventilation (27.5% vs 16.5% in Virtual Pediatric Systems; 14.5% vs 11.1% in Pediatric Health Information System; both p

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Variability in Usual Care Mechanical Ventilation for Pediatric Acute Respiratory Distress Syndrome: Time for a Decision Support Protocol?.

Objectives: Although pediatric intensivists philosophically embrace lung protective ventilation for acute lung injury and acute respiratory distress syndrome, we hypothesized that ventilator management varies. We assessed ventilator management by evaluating changes to ventilator settings in response to blood gases, pulse oximetry, or end-tidal CO2. We also assessed the potential impact that a pediatric mechanical ventilation protocol adapted from National Heart Lung and Blood Institute acute respiratory distress syndrome network protocols could have on reducing variability by comparing actual changes in ventilator settings to those recommended by the protocol. Design: Prospective observational study. Setting: Eight tertiary care U.S. PICUs, October 2011 to April 2012. Patients: One hundred twenty patients (age range 17 d to 18 yr) with acute lung injury/acute respiratory distress syndrome. Measurements and Main Results: Two thousand hundred arterial and capillary blood gases, 3,964 oxygen saturation by pulse oximetry, and 2,757 end-tidal CO2 values were associated with 3,983 ventilator settings. Ventilation mode at study onset was pressure control 60%, volume control 19%, pressure-regulated volume control 18%, and high-frequency oscillatory ventilation 3%. Clinicians changed FIO2 by +/-5 or +/-10% increments every 8 hours. Positive end-expiratory pressure was limited at ~10 cm H2O as oxygenation worsened, lower than would have been recommended by the protocol. In the first 72 hours of mechanical ventilation, maximum tidal volume/kg using predicted versus actual body weight was 10.3 (8.5-12.9) (median [interquartile range]) versus 9.2 mL/kg (7.6-12.0) (p

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Temporal Changes in Prescription of Neuropharmacologic Drugs and Utilization of Resources Related to Neurologic Morbidity in Mechanically Ventilated Children With Bronchiolitis.

Objectives: Critically ill children with bronchiolitis may require neuropharmacologic medications and support for neuro-functional sequelae, but current practices are not well described. We aimed to describe recent trends in neuropharmacology and utilization of neuro-rehabilitation resources in mechanically ventilated children with bronchiolitis. Design: Analysis of the multicenter Pediatric Health Information System database. Setting: Forty-seven U.S. children's hospitals. Patients: PICU patients less than 2 years old with bronchiolitis undergoing mechanical ventilation between 2006 and 2015. Interventions: None. Annual rates of utilization of neuropharmacologic medications (sedatives, analgesics, etc) and of neuro-rehabilitation services (physical therapy, neurologic consultation, etc) over the 10-year study period were compared. Measurements and Main Results: Neuropharmacologic medications prescribed on greater than or equal to 2 days were extracted. Utilization of MRI of the brain, neurologic consultation, swallow evaluation, occupational therapy, and physical therapy was also extracted. Among 12,508 subjects, the median age was 2.8 months, ~50% had comorbid conditions, and the median duration of mechanical ventilation was 7 days. The percentage of children prescribed greater than or equal to five drugs/drug classes increased over the study period from 36.5% to 55.8% (p

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In Reply

Abstract

We appreciate the comments and concerns raised by members of SAEM‘s Academy of Diversity and Inclusion in Emergency Medicine¹ regarding the findings of our article, “A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making.”² We agree with Samuels et al.¹ that there are notable methodological limitations of earlier studies examining the influence of physician implicit bias on clinical decision making that must be considered when interpreting the findings of our systematic review.

This article is protected by copyright. All rights reserved.

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The use of CT-scan in foreign body aspiration in children: A 6 years' experience

International Journal of Pediatric Otorhinolaryngology

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National Early Warning Score (NEWS) at ICU discharge can predict early clinical deterioration after ICU transfer

Journal of Critical Care

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Schools should stock epinephrine, train more staff to administer it - experts

Reuters Health News

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Return to sports after multiple trauma: Which factors are responsible? — Results from a 17-year follow-up

Clinical Journal of Sport Medicine

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Almost all large employers plan to offer telehealth in 2018, but will employees use it?

Healthcare Finance News

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Oral glucose lowering with linagliptin and metformin compared with linagliptin alone as initial treatment in Asian patients with newly diagnosed type 2 diabetes and marked hyperglycemia: Subgroup analysis of a randomized clinical trial

Journal of Diabetes Investigation

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Impact of percutaneous drainage on outcome of intra-abdominal infection associated with pediatric perforated appendicitis

The Pediatric Infectious Disease Journal

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Impact of hypothyroidism on occurrence and outcome of acute coronary syndrome from the National Inpatient Sample

The American Journal of Cardiology

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Qualitative and quantitative radiological analysis of non-contrast CT is a strong indicator in patients with acute pyelonephritis

The American Journal of Emergency Medicine

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Statin use tied to lower mortality in alcoholic cirrhosis

Reuters Health News

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Intramuscular tendon involvement on MRI has limited value for predicting time to return to play following acute hamstring injury

British Journal of Sports Medicine

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Efficacy of hemostatic powder in preventing bleeding after gastric endoscopic submucosal dissection in high-risk patients

Journal of Gastroenterology and Hepatology

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Randomized controlled feasibility trial of intranasal ketamine compared to intranasal fentanyl for analgesia in children with suspected extremity fractures

Academic Emergency Medicine

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Myasthenia gravis and crisis: evaluation and management in the emergency department

The Journal of Emergency Medicine

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Evolution and bad prognostic value of advanced glycation end products after acute heart failure: Relation with body composition

Cardiovascular Diabetology

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Aversion to ambiguity and willingness to take risks affect therapeutic decisions in managing atrial fibrillation for stroke prevention: Results of a pilot study in family physicians

Patient Preference and Adherence

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Reductions in alexithymia and emotion dysregulation after training emotional self-awareness following traumatic brain injury: A phase I trial

Journal of Head Trauma Rehabilitation

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Implementation and preliminary clinical outcomes of a pharmacist-managed venous thromboembolism clinic for patients treated with rivaroxaban post emergency department discharge

Academic Emergency Medicine

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Experiences of surviving a cardiac arrest after therapeutic hypothermia treatment. An interview study

International Emergency Nursing

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High Levels of Morbidity and Mortality Among Pediatric Hematopoietic Cell Transplant Recipients With Severe Sepsis: Insights From the Sepsis PRevalence, OUtcomes, and Therapies International Point Prevalence Study.

Objectives: Pediatric severe sepsis is a major cause of morbidity and mortality worldwide, and hematopoietic cell transplant patients represent a high-risk population. We assessed the epidemiology of severe sepsis in hematopoietic cell transplant patients, describing patient outcomes compared with children with no history of hematopoietic cell transplant. Design: Secondary analysis of the Sepsis PRevalence, OUtcomes, and Therapies point prevalence study, comparing demographics, sepsis etiology, illness severity, organ dysfunction, and sepsis-related treatments in patients with and without hematopoietic cell transplant. The primary outcome was hospital mortality. Multivariable logistic regression models were used to determine adjusted differences in mortality. Setting: International; 128 PICUs in 26 countries. Patients: Pediatric patients with severe sepsis prospectively identified over a 1-year period. Interventions: None. Measurements and Main Results: In patients with severe sepsis, 37/567 (6.5%) had a history of hematopoietic cell transplant. Compared with patients without hematopoietic cell transplant, hematopoietic cell transplant patients had significantly higher hospital mortality (68% vs 23%; p

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Potential Acceptability of a Pediatric Ventilator Management Computer Protocol.

Objectives: To examine issues regarding the granularity (size/scale) and potential acceptability of recommendations in a ventilator management protocol for children with pediatric acute respiratory distress syndrome. Design: Survey/questionnaire. Setting: The eight PICUs in the Collaborative Pediatric Critical Care Research Network. Participants: One hundred twenty-two physicians (attendings and fellows). Interventions: None. Measurements and Main Results: We used an online questionnaire to examine attitudes and assessed recommendations with 50 clinical scenarios. Overall 80% of scenario recommendations were accepted. Acceptance did not vary by provider characteristics but did vary by ventilator mode (high-frequency oscillatory ventilation 83%, pressure-regulated volume control 82%, pressure control 75%; p = 0.002) and variable adjusted (ranging from 88% for peak inspiratory pressure and 86% for FIO2 changes to 69% for positive end-expiratory pressure changes). Acceptance did not vary based on child size/age. There was a preference for smaller positive end-expiratory pressure changes but no clear granularity preference for other variables. Conclusions: Although overall acceptance rate for scenarios was good, there was little consensus regarding the size/scale of ventilator setting changes for children with pediatric acute respiratory distress syndrome. An acceptable protocol could support robust evaluation of ventilator management strategies. Further studies are needed to determine if adherence to an explicit protocol leads to better outcomes. (C)2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Barriers and facilitators towards implementing the Sepsis Six care bundle (BLISS-1): a mixed methods investigation using the theoretical domains framework

The ‘Sepsis 6’, a care bundle of basic, but vital, measures (e.g. intravenous fluid, antibiotics) has been implemented to improve sepsis treatment. However, uptake has been variable. Tools from behavioral scie...

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Randomized Controlled Feasibility Trial of Intranasal Ketamine Compared to Intranasal Fentanyl for Analgesia in Children with Suspected Extremity Fractures

Abstract

Objective

We compared the tolerability and efficacy of intranasal sub-dissociative ketamine to intranasal fentanyl for analgesia of children with acute traumatic pain and investigated the feasibility of a larger non-inferiority trial that could investigate the potential opioid sparing effects of intranasal ketamine.

Methods

This randomized controlled trial compared intranasal ketamine 1 mg/kg to intranasal fentanyl 1.5 μg/kg in children 4–17 years old with acute pain from suspected, isolated extremity fractures presenting to an urban level II pediatric trauma center from December 2015 to November 2016. Patients, parents, treating physicians, and outcome assessors were blinded to group allocation. The primary outcome, a tolerability measure, was the frequency of cumulative side effects and adverse events within 60 minutes of drug administration. The secondary outcomes included the difference in mean pain score reduction at 20 minutes, the proportion of patients achieving a clinically significant reduction in pain in 20 minutes, total dose of opioid pain medication in morphine equivalents/kg/hour (excluding study drug) required during the emergency department (ED) stay, and the feasibility of enrolling children presenting to the ED in acute pain into a randomized trial conducted under US regulations. All patients were monitored until 6 hours after their last dose of study drug, or until admission to the hospital ward or operating room.

Results

Of 629 patients screened, 87 received the study drug and 82 had complete data for the primary outcome (41 patients in each group). The median age (interquartile range) was 8 (3) years and 62% were male. Baseline pain scores were similar among patients randomized to receive ketamine (73 ± 26) and fentanyl (69 ± 26) [mean difference (95% CI): 4 (-7 to 15)]. The cumulative number of side effects was 2.2 times higher in the ketamine group, but there were no serious adverse events and no patients in either group required intervention. The most common side effects of ketamine were bad taste in the mouth (37; 90.2%), dizziness (30; 73.2%), and sleepiness (19; 46.3%). The most common side effects of fentanyl were sleepiness (15; 36.6%), bad taste in the mouth (9; 22%), and itchy nose (9; 22%). No patients experienced respiratory side effects. At 20 minutes, the mean pain scale score reduction was 44 ± 36 for ketamine and 35 ± 29 for fentanyl [mean difference: 9 (95% CI: -4 to 23)]. Procedural sedation with ketamine occurred in 28 ketamine patients (65%) and 25 fentanyl patients (57%) prior to completing the study.

Conclusions

Intranasal ketamine was associated with more minor side effects than intranasal fentanyl. Pain relief at 20 minutes was similar between groups. Our data support the feasibility of a larger, non-inferiority trial to more rigorously evaluate the safety, efficacy, and potential opioid sparing benefits of intranasal ketamine analgesia for children with acute pain.

This article is protected by copyright. All rights reserved.

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Test-retest reliability of traumatic brain injury outcome measures: A Traumatic Brain Injury Model Systems study

Journal of Head Trauma Rehabilitation

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Validation of prognostic scores to predict short-term mortality in patients with acute-on-chronic liver failure

Journal of Gastroenterology and Hepatology

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Do the risks of sotagliflozin outweigh benefits for type 1 diabetes?

Reuters Health News

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Management of atrial fibrillation with rapid ventricular response in the intensive care unit: A secondary analysis of electronic health record data

Shock

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Young adults with autism face additional health concerns

Reuters Health News

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The relations of cognitive, behavioral, and physical activity variables to depression severity in traumatic brain injury: Reanalysis of data from a randomized controlled trial

Journal of Head Trauma Rehabilitation

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Definitive airway management after pre-hospital supraglottic airway insertion: Outcomes and a management algorithm for trauma patients

The American Journal of Emergency Medicine

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Increasing number of children addicted to opioids

Reuters Health News

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Inter-observer agreement in pediatric cervical spine injury assessment between prehospital and emergency department providers

Academic Emergency Medicine

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Impact of weekend admission on mortality and other outcomes among patients with burn injury: A nationwide analysis

Burns

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Transfusion requirement in burn care evaluation (TRIBE): A multicenter randomized prospective trial of blood transfusion in major burn injury

Annals of Surgery

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Association of mineralocorticoid receptor antagonist use and in-hospital outcomes in patients with acute heart failure

Clinical Research in Cardiology

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Three-dimensional strut plate for the treatment of mandibular fractures: A systematic review

International Journal of Oral and Maxillofacial Surgery

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Follow-up trends after Emergency Department discharge for acutely symptomatic hernias

The American Journal of Surgery

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Effect of antibiotics administered via the respiratory tract in the prevention of ventilator-associated pneumonia: A systematic review and meta-analysis

Journal of Critical Care

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Diagnosing concussions with voice research

Michigan State University Health News

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Human factors and simulation in emergency medicine

Abstract

This consensus group from the 2017 Academic Emergency Medicine Consensus Conference “Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes” held in Orlando, Florida on May 16, 2017 focused on the use of human factors and simulation in the field of emergency medicine. The human factors discipline is often underutilized within emergency medicine but has significant potential in improving the interface between technologies and individuals in the field. The discussion explored the domain of human factors, its benefits in medicine, how simulation can be a catalyst for human factors work in emergency medicine, and how emergency medicine can collaborate with human factors professionals to affect change. Implementing human factors in emergency medicine through healthcare simulation will require a demonstration of clinical and safety outcomes, advocacy to stakeholders and administrators, and establishment of structured collaborations between human factors professionals and emergency medicine, such as in this breakout group.

This article is protected by copyright. All rights reserved.

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Lessons Learned from the Development and Parameterization of a Computer Simulation Model to Evaluate Task Modification for Healthcare Providers

Abstract

Computer simulation is a highly advantageous method for understanding and improving healthcare operations with a wide variety of possible applications. Most computer-simulation studies in emergency medicine have sought to improve allocation of resources to meet demand, or to assess the impact of hospital and other system policies on emergency department (ED) throughput. These models have enabled essential discoveries that can be used to improve the general structure and functioning of EDs. Theoretically, computer simulation could also be used to examine the impact of adding or modifying specific provider tasks. Doing so involves a number of unique considerations, particularly in the complex environment of acute-care settings. In this paper, we describe conceptual advances and lessons learned during the design, parameterization, and validation of a computer-simulation model constructed to evaluate changes in ED provider activity. We illustrate these concepts using examples from a study focused on the operational effects of HIV-screening implementation in the ED. Presentation of our experience should emphasize the potential for application of computer simulation to study changes in healthcare-provider activity and facilitate the progress of future investigators in this field.

This article is protected by copyright. All rights reserved.

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Interstitial pneumonia with autoimmune features: an additional risk factor for ARDS?

Interstitial pneumonia with autoimmune features (IPAF) identifies a recently recognized autoimmune syndrome characterized by interstitial lung disease and autoantibodies positivity, but absence of a specific c...

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Mother, Jugs, Speed stretcher scene

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EMCrit Podcast 208 – Felipe Teran on Why We are Doing CPR Wrong

You are doing CPR wrong

EMCrit by Scott Weingart.

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EMCrit Podcast 208 – Felipe Teran on Why We are Doing CPR Wrong

You are doing CPR wrong

EMCrit by Scott Weingart.

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Cross-validation of a classification system for persons with traumatic brain injury in the posthospital period

Journal of Head Trauma Rehabilitation

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Prosecutors identify Insys founder as unindicted co-conspirator in opioid case

Reuters Health News

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The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: A systematic review

Human Resources for Health

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Providers and payers both win when they share population health data

Healthcare Finance News

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Life-saving post-ER suicide prevention strategies are cost effective

NIH News

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Sertraline for major depression during the year following traumatic brain injury: A randomized controlled trial

Journal of Head Trauma Rehabilitation

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Seasonal patterns of acute and recurrent idiopathic pericarditis

Clinical Cardiology

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